Icodextrin Dosage for Peritoneal Dialysis
For adult and pediatric patients on peritoneal dialysis, use a single daily exchange of 7.5% icodextrin solution (typically 2.0-2.5 L in adults, 1,000-1,100 mL/m² in children) for the long dwell period of 10-16 hours. 1
Standard Dosing Parameters
Adults
- Concentration: 7.5% icodextrin solution
- Volume: 2.0-2.5 L per exchange 1, 2, 3
- Dwell time: 10-16 hours for the long dwell 4, 5
- Frequency: Once daily only 1
Pediatrics
- Concentration: 7.5% icodextrin solution
- Volume: 1,000-1,100 mL/m² body surface area 6, 7
- Dwell time: 12 hours 4, 6
- Frequency: Once daily only
Clinical Application Strategy
When to Prescribe Icodextrin
Use icodextrin for the long dwell in patients who:
- Are high/rapid peritoneal transporters unable to achieve adequate ultrafiltration with standard glucose solutions 4
- Have persistent fluid overload despite optimization of glucose-based exchanges 4
- Require glucose sparing due to metabolic complications 8
- Are anuric or have minimal residual kidney function 9
Timing of the Long Dwell
- CAPD patients: Use for the nocturnal (overnight) dwell 4
- APD patients: Use for the daytime dwell 4, 5
Ultrafiltration Expectations
Icodextrin provides sustained ultrafiltration of approximately 300-450 mL per exchange over the long dwell period 5, 6, 2. Importantly, ultrafiltration does not increase significantly beyond 10 hours of dwell time 5, so there is no benefit to extending dwells beyond this duration solely for ultrafiltration purposes.
The ultrafiltration achieved with icodextrin is:
- Superior to 1.36% glucose solutions 6
- Comparable to 3.86% hypertonic glucose solutions 6
- Sustained throughout the entire dwell without the reabsorption seen with glucose 4
Critical Dosing Considerations
Do NOT Exceed One Daily Exchange
Current evidence supports only one icodextrin exchange per 24 hours 1, 10. Using more than one daily dwell increases the risk of:
- Accumulation of icodextrin metabolites (particularly maltose) 3
- False elevation of capillary glucose readings 10
- Increased plasma osmolality 3
- Potential for excessive ultrafiltration 10
Pediatric-Specific Considerations
Start icodextrin early (within the first year of PD initiation) in children 11. Early-start icodextrin (within 1 year) versus late-start provides:
- Five-fold reduction in technique failure or death risk 11
- Better blood pressure control 11
- Preservation of residual kidney function 11
- Improved outcomes even in children younger than 5 years 11
However, be aware that icodextrin ultrafiltration may correlate with age in very young children, with potentially less effective ultrafiltration in the youngest patients 4, though this finding requires confirmation.
Monitoring and Adjustments
What to Monitor
- Net ultrafiltration volume with each exchange
- Blood pressure and volume status (more important than ultrafiltration volume alone) 4
- Residual kidney function 11
- Plasma glucose levels (note: some glucose meters may give falsely elevated readings due to maltose cross-reactivity) 10
When Icodextrin May Be Less Effective
- Males and high transporters tend to achieve higher ultrafiltration 5
- Patients with very low baseline peritoneal ultrafiltration may benefit most 2
- Age and transport characteristics affect response, but these should not preclude use 5
Common Pitfalls to Avoid
- Do not use icodextrin for short dwells - It requires 10+ hours to achieve optimal ultrafiltration 5
- Do not drain the icodextrin dwell early - Unlike glucose solutions, there is no benefit to early drainage for ultrafiltration optimization 4
- Do not use multiple icodextrin exchanges daily - Stick to once-daily dosing 1, 10
- Do not delay initiation in appropriate patients - Early use (especially in pediatrics) provides superior outcomes 11
- Be aware of glucose meter interference - Maltose metabolites can cause falsely elevated glucose readings with some meters 10
Route of Administration
Intraperitoneal administration only - Never use intravenously 1. The solution should be warmed to body temperature before instillation, and the bag should be inspected for leaks and clarity before use 1.