The efficacy and safety of icodextrin has been well established. In this paper, we will discuss the pharmacokinetics and biocompatibility of icodextrin and its clinical effect on fluid management in peritoneal dialysis patients. Novel strategies for its prescription for peritoneal dialysis patients with inadequate ultrafiltration are reviewed. 1. Introduction The use of icodextrin (ico) has been characterized as one of the major achievements in peritoneal dialysis (PD) [1]. Ico-based peritoneal dialysis solutions have been used successfully by PD practitioners for two decades. Ico is an isoosmolar alternative osmotic agent that induces ultrafiltration (UF) in peritoneal dialysis by colloid osmosis. Peritoneal absorption of ico is limited and occurs by convection via the lymphatics of the peritoneum [2]. As a result, the net pressure gradient is relatively constant, sustaining UF for the long dwell. Many clinical benefits of ico have been described, such as a reduction in total glucose load [3], equivalent or higher UF than that provided by hypertonic glucose solutions [4], and better control of fluid balance [5]. Ico is recommended for patients with poor UF and those with a high or high/high-average pattern in the peritoneal equilibrium test (PET). It is well known that UF volume correlates with patient and technique survival [6]. Glucose degradation products (GDPs) and the products of advanced glycosylation end products (AGEs) induce inflammation and fibrosis of the peritoneal membrane [7]. Minimizing dextrose exposure by using ico for the long dwell may prevent long-term detrimental changes of the peritoneal membrane. In addition, there is a growing concern about the total amount of absorbed glucose and so there is interest in the use of new alternative glucose-sparing osmotic agents. The use of a “bimodal” solution composed of glucose and ico, in order to increase sodium and fluid removal, is a promising approach [8]. Ico was used initially during the long night dwell in continuous ambulatory peritoneal dialysis (CAPD) and during the day dwell in continuous cyclic peritoneal dialysis (CCPD). Recently, the daily use of two ico exchanges has been suggested in order to minimize the glucose load and/or to increase the UF rate [9–12]. The biocompatibility of ico has been investigated; however, it should be noted that there are data suggesting that those who use icodextrin are still vulnerable to develop encapsulating peritoneal sclerosis (EPS) [13]. 2. Pharmacokinetics of Icodextrin Ico consists of a complex mixture of starch-derived water-soluble glucose
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