Early-Start Versus Late-Start Icodextrin for Children Receiving Chronic Peritoneal Dialysis

Key Points Early icodextrin use preserved residual kidney function and improved BP versus glucose dialysate in pediatric peritoneal dialysis patients. Starting icodextrin within 1 year of commencing peritoneal dialysis reduced the risk of technique failure or death nearly five-fold versus later start. 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. Podcast This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.www.asn-online.org/media/podcast/CJASN/2025_12_18_CJASNDecember.20.12.mp3