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

Abstract

Key Points:

1. Early icodextrin use preserved residual kidney function and improved BP versus glucose dialysate in pediatric peritoneal dialysis patients.

2. Starting icodextrin within 1 year of commencing peritoneal dialysis reduced the risk of technique failure or death nearly five-fold versus later start.

3. Children younger than 5 years on icodextrin had similar ultrafiltration and BP control with superior kidney function preservation versus older children.

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

Methods: We included patients younger than 21 years enrolled in the International Pediatric Peritoneal Dialysis Network between 2007 and 2024, on automated PD with a daytime dwell. Outcome analysis was restricted to patients with 6 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 effect of missing data.

Results: Icodextrin was prescribed in 724 of 3573 (20.3%) patients, varying widely across world regions. Only “early-start” icodextrin (within 1 year of PD start) was associated with a significant decline in diastolic BP standard deviation score (β=−1.31, P < 0.001) and a slower decline in RKF (β=0.11, P = 0.002) compared with glucose use alone. “Late-starters” (starting icodextrin after ≥1 year on PD) compared with “early-starters” had more uncontrolled hypertension (38% versus 20%; P < 0.001), a higher antihypertensive agent requirement (68% versus 55%; P = 0.03) and an higher dialytic glucose exposure from baseline (5.4 versus 4.8 gm/kg per day; P = 0.05). Icodextrin use, both early and late, was independently associated with a positive linear increase in ultrafiltration sustained during follow-up compared with 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 with “early-starters” (hazard ratio, 5.16; 95% confidence intervals, 1.57 to 17.0; P = 0.007).

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

Keywords: chronic dialysis; pediatric nephrology; peritoneal dialysis.