Icodextrin as salvage therapy in peritoneal dialysis patients with refractory fluid overload

BACKGROUND: Icodextrin is a high molecular weight, starch-derived glucose polymer, which is capable of inducing sustained ultrafiltration over prolonged (12–16 hour) peritoneal dialysis (PD) dwells. The aim of this study was to evaluate the ability of icodextrin to alleviate refractory, symptomatic fluid overload and prolong technique survival in PD patients. METHODS: A prospective, open-label, pre-test/post-test study was conducted in 17 PD patients (8 females/9 males, mean age 56.8 ± 2.9 years) who were on the verge of being transferred to haemodialysis because of symptomatic fluid retention that was refractory to fluid restriction, loop diuretic therapy, hypertonic glucose exchanges and dwell time optimisation. One icodextrin exchange (2.5 L 7.5%, 12-hour dwell) was substituted for a long-dwell glucose exchange each day. RESULTS: Icodextrin significantly increased peritoneal ultrafiltration (885 ± 210 ml to 1454 ± 215 ml, p < 0.05) and reduced mean arterial pressure (106 ± 4 to 96 ± 4 mmHg, p < 0.05), but did not affect weight, plasma albumin concentration, haemoglobin levels or dialysate:plasma creatinine ratio. Diabetic patients (n = 12) also experienced improved glycaemic control (haemoglobin Alc decreased from 8.9 ± 0.7% to 7.9 ± 0.7%, p < 0.05). Overall PD technique survival was prolonged by a mean of 11.6 months (95% CI 6.0–17.3 months). On multivariate Cox proportional hazards analysis, extension of technique survival by icodextrin was only significantly predicted by baseline net daily peritoneal ultrafiltration (adjusted HR 2.52, 95% CI 1.13–5.62, p < 0.05). CONCLUSIONS: Icodextrin significantly improved peritoneal ultrafiltration and extended technique survival in PD patients with symptomatic fluid overload, especially those who had substantially impaired peritoneal ultrafiltration

Evaluation of a novel vitamin E coated cellulosic membrane hollow fiber dialyzer

Adverse physiologic effects accompany hemodialysis. Biocompatible dialyzer membranes may both limit oxidative stress and decrease beta (2)-microglobulin production, thereby reducing patient morbidity. We compared standard solute clearance, lipid, and antioxidant effects of a novel cellulosic membrane dialyzer modified with covalently bonded vitamin E (Excebrane Clirans E15, Terumo Australia) with standard cellulosic and polysulphone membrane dialyzers. Stable adult hemodialysis patients taking no lipid lowering or antioxidant therapy (n = 17; 9 male, 8 female) were recruited into a 10 week, prospective, unblinded study. Measurements were made at baseline on their usual dialyzer and after 2, 4, and 10 weeks of Excebrane use. Excebrane demonstrated good in vivo clearance of standard solutes relative to surface area. Predialysis beta (2)-microglobulin levels were unchanged with time and were significantly lower postdialysis than with cellulose acetate (p 0.05). Total antioxidant status fell during dialysis (p < 0.0005), but plasma vitamin A and E concentrations increased (p = 0.007 and p = 0.02, respectively). Baseline vitamin A levels were high in all patients and, along with vitamin E, total antioxidant status and lipid profiles did not change over time with Excebrane use. Excebrane is an efficient, biocompatible membrane with no deleterious effects on (2)-microglobulin or lipids. More long-term study is merited