Early-Start vs. Late-Start Icodextrin for Children Receiving Chronic Peritoneal Dialysis: Findings from the International Pediatric Peritoneal Dialysis Network

Abstract

Background: Experience with icodextrin use in children on long-term peritoneal dialysis is limited. We describe international icodextrin prescription practices and their impact on clinical outcomes: ultrafiltration, blood pressure control, residual kidney function (RKF), technique and patient survival.

Methods: We included patients under 21 years enrolled in the International Pediatric Peritoneal Dialysis Network (IPPN) between 2007 and 2024, on automated PD with a daytime dwell. Outcome analysis was restricted to patients with six months or greater follow-up. We used propensity score matching to balance baseline differences between icodextrin and glucose groups. Long-term outcomes and survival were analyzed by longitudinal linear mixed-effects models and Cox proportional hazards models, respectively, adjusting for key covariates. Sensitivity analyses addressed the impact of missing data.

Results: Icodextrin was prescribed in 724 of 3573 (20.3%) patients, varying widely across world regions. Only 'early-start' icodextrin (within one-year of PD start) was associated with a significant decline in diastolic blood pressure standard deviation score (SDS; β=-1.31, P<0.001) and a slower decline in RKF (β=0.11, P=0.002) compared to glucose use alone. 'Late-starters' (starting icodextrin after ≥1 year on PD) compared to 'early-starters' had more uncontrolled hypertension (38% vs. 20%; P<0.001), a higher anti-hypertensive agent requirement (68% vs. 55%; P=0.03) and an higher dialytic glucose exposure from baseline (5.4 vs. 4.8 gm/kg/d; P=0.05). Icodextrin use, both early and late, was independently associated with a positive linear increase in ultrafiltration sustained during follow-up compared to glucose use (β=0.27 and β=0.33, respectively; both P<0.01). Peritonitis rates and dialysate leaks were similar between icodextrin and glucose groups. 'Late-starters' had significantly increased risk of technique failure/death compared to 'early-starters' (HR 5.16, 95% CI 1.57 to 17.0, P=0.007).

Conclusion: Icodextrin use improves ultrafiltration, but only early compared to delayed initiation conferred a five-fold higher likelihood of technique survival, better blood pressure control and preservation of RKF.