Rate of Synthetic Oligosaccharide Degradation as a Novel Measure of Amylase Activity in Peritoneal Dialysis Patients

Background

Plasma α–amylase activity is elevated in uremic patients but lower in peritoneal dialysis (PD) patients using icodextrin in comparison to healthy controls. We studied the rate by which an exogenous oligosaccharide (maltoheptaose; G7) is degraded ex vivo by amylase in plasma from PD patients treated with glucose or icodextrin PD solutions.

Methods

Plasma amylase (pancreatic and total) activity and concentration were measured in 11 controls and in PD patients treated with glucose ( n = 11) and icodextrin ( n = 19). The plasma was spiked with G7 and/or synthetic amylase and the metabolites formed were measured by HPLC following incubation at 37°C for 4 hours.

Results

The relationship between amylase activity and amylase concentration was similar in all patients and controls. The G7 degradation rate was slower in plasma from icodextrin patients but it was also reduced in patients using glucose compared with the controls, in spite of the higher amylase activity in the glucose group. Normalization (by spiking) of patient plasma with porcine amylase increased but did not normalize the speed of G7 degradation. At a given endogenous amylase activity level, the efficiency of G7 degradation was similar for both patient groups.

Conclusions

An ex vivo model to study the relationship between amylase activity and the actual rate of carbohydrate (represented by G7) breakdown was developed and showed that PD patients using glucose and icodextrin degrade G7 at a slower speed than controls. This suggests that amylase-mediated carbohydrate metabolism is reduced in PD patients. Further clinical studies are needed to confirm if these findings hold true also in other groups of uremic patients with varying degrees of kidney failure, as well as in patients undergoing hemodialysis.

Protective effect of mycophenolate mofetil on residual renal function in peritoneal dialysis patients: An open label feasibility study

AIM

This study aims to evaluate the safety of mycophenolate mofetil (MMF) and its effect on residual renal function (RRF) during peritoneal dialysis (PD).

METHODS

This is a prospective, randomized study comprising 60 PD patients. The patients were assigned either to the MMF group (MMF dosage: 1.0-1.5 g/day in two divided doses for 6 months, followed by a dose of 0.5-0.75 g/day for another 6 months) or to the control group. The patients close monitoring for 1 year. Variables related to residual renal function, including urine volume, measured glomerular filtration rate (GFR), and renal Kt/V, were measured at four time points.

RESULTS

There were no significant changes in urinary protein excretion in either group (P > 0.05). The MMF group showed a significantly higher urine volume than the control group (955.38 ± 243.54 vs 786.15 ± 279.62 mL/day, P = 0.024). The renal kt/V was also significantly higher in the MMF group (0.59 ± 0.11 in MMF vs 0.50 ± 0.19 in control group, P = 0.032). There was significant difference in the renal measured GFR between the two groups at 6, 9 and 12 months (MMF vs control at 6 months, 6.14 ± 0.66 vs 5.58 ± 0.65 mL/min per 1.73m² , P = 0.003; at 9 months, 5.68 ± 0.80 vs 4.78 ± 0.75, P < 0.001; at 12 months, 5.44 ± 0.91 vs 4.43 ± 0.93, P < 0.001). MMF was well tolerated without any serious complications.

CONCLUSION

The use of MMF in PD patients tends to better preserve RRF.

Rate of Decline of Residual Kidney Function Before and After the Start of Peritoneal Dialysis

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BACKGROUND

There is a paucity of information on whether peritoneal dialysis (PD) slows the decline of residual kidney function (RKF) compared to the natural slope of RKF decline prior to dialysis start. Our aim was to analyze the RKF decline before and after initiating PD, and to determine the principal factors affecting this decline during the PD period. ♦

METHODS

We determined individual glomerular filtration rates (GFR) for approximately 12 months before and after PD in 77 new PD patients in a large academic medical center (2008 - 2012). The GFR was estimated by the Modification of Diet in Renal Disease (MDRD) equation in the predialysis period and by averaging 24-hour urine creatinine and urea clearances in the PD period. The rate of RKF decline was calculated using unadjusted linear regression analysis. Wilcoxon signed rank test was used to compare RKF decline before and after PD initiation. Multivariate linear regression was used to identify independent risk factors for RKF decline in the PD phase. ♦

RESULTS

A significantly slower mean rate of RKF decline was observed in the PD period compared with the predialysis period (-0.21 ± 0.30 vs -0.59 ± 0.55 mL/min/1.73 m(2)/month, p < 0.01). Higher baseline RKF, higher serum phosphate, and older age were independently associated with faster decline of RKF (all p < 0.01). ♦

CONCLUSIONS

In patients with advanced chronic kidney disease, initiating PD was associated with a slower rate of RKF decline compared to the rate in the predialysis period.

Icodextrin decreases technique failure and improves patient survival in peritoneal dialysis patients

AIM

It remains unclear whether long-term daily icodextrin use can decrease technique failure and improve survival in peritoneal dialysis (PD) patients. The aim of the present study was to investigate whether icodextrin use, once daily, can decrease technique failure and prolong patient survival in incident PD patients.

METHODS

Incident PD patients who survived more than 90 days were recruited from the China Medical University Hospital, Taiwan, between 1 January 2007 and 31 December 2011. All patients were followed until transfer to haemodialysis (HD), renal transplantation, transfer to another centre, death, or 31 December 2011.

RESULTS

A total of 306 incident PD patients (89 icodextrin users, 217 icodextrin non-users) were recruited during the study period. Icodextrin users were more likely to have hypertension, diabetes and high or high-average peritoneal transport compared with non-users. During the follow-up period, 43 patients were transferred to HD: seven (7.87%) of the icodextrin group, and 36 (16.59%) of the non-icodextrin group. Thirty-two patients died during the follow-up period: five (5.62%) of the icodextrin group, and 27 (12.44%) of the non-icodextrin group. Icodextrin use was significantly associated with a better prognosis, in terms of technique failure (adjusted HR = 0.32; 95% CI = 0.14-0.72). With regard to patient survival, icodextrin use (adjusted HR = 0.33; 95% CI = 0.12-0.87) was associated with a significantly lower risk of death.

CONCLUSION

The use of icodextrin once daily may decrease technique failure and improve survival in incident PD patients.

Strategies for preserving residual renal function in peritoneal dialysis patients

Although there have been many advancements in the treatment of patients with chronic kidney disease (CKD) over the last 50 years, in terms of reducing cardiovascular risk, mortality remains unacceptably high, particularly for those patients who progress to stage 5 CKD and initiate dialysis (CKD5d). As mortality risk increases exponentially with progressive CKD stage, the question arises as to whether preservation of residual renal function once dialysis has been initiated can reduce mortality risk. Observational studies to date have reported an association between even small amounts of residual renal function and improved patient survival and quality of life. Dialysis therapies predominantly provide clearance for small water-soluble solutes, volume and acid-base control, but cannot reproduce the metabolic functions of the kidney. As such, protein-bound solutes, advanced glycosylation end-products, middle molecules and other azotaemic toxins accumulate over time in the anuric CKD5d patient. Apart from avoiding potential nephrotoxic insults, observational and interventional trials have suggested that a number of interventions and treatments may potentially reduce the progression of earlier stages of CKD, including targeted blood pressure control, reducing proteinuria and dietary intervention using combinations of protein restriction with keto acid supplementation. However, many interventions which have been proven to be effective in the general population have not been equally effective in the CKD5d patient, and so the question arises as to whether these treatment options are equally applicable to CKD5d patients. As strategies to help preserve residual renal function in CKD5d patients are not well established, we have reviewed the evidence for preserving or losing residual renal function in peritoneal dialysis patients, as urine collections are routinely collected, whereas few centres regularly collect urine from haemodialysis patients, and haemodialysis dialysis patients are at risk of sudden intravascular volume shifts associated with dialysis treatments. On the other hand, peritoneal dialysis patients are exposed to a variety of hypertonic dialysates and episodes of peritonitis. Whereas blood pressure control, using an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), and low-protein diets along with keto acid supplementation have been shown to reduce the rate of progression in patients with earlier stages of CKD, the strategies to preserve residual renal function (RRF) in dialysis patients are not well established. For peritoneal dialysis patients, there are additional technical factors that might aggravate the rate of loss of residual renal function including peritoneal dialysis prescriptions and modality, bio-incompatible dialysis fluid and over ultrafiltration of fluid causing dehydration. In this review, we aim to evaluate the evidence of interventions and treatments, which may sustain residual renal function in peritoneal dialysis patients.

Strategies for the preservation of residual renal function in pediatric dialysis patients

In adults with end-stage renal disease (ESRD), the preservation of residual renal function (RRF) has been shown to be associated with decreased mortality and improved control of complications of chronic kidney disease. However, less is known on the benefits of RRF in the pediatric dialysis population. The purpose of this article is to review the clinical significance of RRF and to discuss strategies for the preservation of RRF in children with ESRD.

Effect of peritoneal dialysis modality on the 1-year rate of decline of residual renal function

PURPOSE

The effect of different peritoneal dialysis (PD) modalities on the decline in residual renal function (RRF) is unclear due to inconsistencies among studies. In particular, the effect of automated peritoneal dialysis (APD) modalities [continuous cyclic peritoneal dialysis (CCPD) and nightly intermittent peritoneal dialysis (NIPD)] on RRF has not been examined in a large cohort.

MATERIALS AND METHODS

We conducted a single-center retrospective study to investigate the association between PD modalities and decline in RRF in 142 incident PD patients [34 on CCPD, 36 on NIPD, and 72 on continuous ambulatory peritoneal dialysis (CAPD)]. RRF was measured within 2 months from PD start and at 1 year after PD initiation.

RESULTS

The RRF at 1 year after PD initiation was 1.98±2.20 mL/min/1.73 m² in CCPD patients and 3.63±3.67 mL/min/1.73 m² in NIPD patients, which were moderately lower than 4.23±3.51 mL/min/1.73 m² in CAPD patients (p=0.064). Moreover, there was no significant difference in the 1-year rate of decline of RRF between CCPD and NIPD patients, although APD patients had a faster 1-year RRF decline rate than CAPD patients (CCPD and NIPD vs. CAPD: -45.68 and -36.69 vs. 1.17%/year, p=0.045). APD was associated with a more rapid decline in RRF in patients with end-stage renal disease undergoing PD, although multivariate analysis attenuated the significance of this finding (β=-31.50; 95% CI, -63.61 to 0.62; p=0.052).

CONCLUSION

Our results suggest that CAPD might be more helpful than APD for preserving RRF during the first year of dialysis therapy, although there was no significant difference in the 1-year rate of decline of RRF between the two APD modalities.

Residual renal function in children treated with chronic peritoneal dialysis

Residual renal function (RRF) in patients with end-stage renal disease (ESRD) receiving renal replacement therapy is defined as the ability of native kidneys to eliminate water and uremic toxins. Preserved RRF improves survival and quality of life in adult ESRD patients treated with peritoneal dialysis. In children, RRF was shown not only to help preserve adequacy of renal replacement therapy but also to accelerate growth rate, improve nutrition and blood pressure control, reduce the risk of adverse myocardial changes, facilitate treatment of anemia and calcium-phosphorus balance abnormalities, and result in reduced serum and dialysate fluid levels of advanced glycation end-products. Factors contributing to RRF loss in children treated with peritoneal dialysis include the underlying renal disease such as hemolytic-uremic syndrome and hereditary nephropathy, small urine volume, severe proteinuria at the initiation of renal replacement therapy, and hypertension. Several approaches can be suggested to decrease the rate of RRF loss in pediatric patients treated with chronic peritoneal dialysis: potentially nephrotoxic drugs (e.g., aminoglycosides), episodes of hypotension, and uncontrolled hypertension should be avoided, urinary tract infections should be treated promptly, and loop diuretics may be used to increase salt and water excretion.

Successful treatment of icodextrin-single peritoneal dialysis for refractory nephrotic syndrome induced by idiopathic membranous nephropathy

The patient was a 76-year-old male who developed nephrotic syndrome. Idiopathic membranous nephropathy was diagnosed by renal biopsy and clinical findings. The patient had been refractory to predonisolone and cyclosporine A therapies, and overhydration recurred repeatedly during the clinical course. One year after an initial hospitalization, he had to be hospitalized a second time because of overhydration. During the hospitalization, he underwent fluid removal by the extracorporeal ultrafiltration method (ECUM), as his response to diuretics was too weak to permit the control of cardiac insufficiency. The ECUM alleviated his overhydration, but no remission of nephrotic syndrome was achieved. The patient was then discharged temporarily, but overhydration developed again 2 months later. Peritoneal dialysis (PD) using an overnight dwell of a single dose of icodextrin was initiated to obtain stable fluid removal. This promptly alleviated the refractory subcutaneous edema, and type I incomplete remission of nephrotic syndrome was achieved about 2 weeks after the start of PD. The patient could be withdrawn from the PD therapy 4 months later. Subsequently, the urinary volume was maintained and the serum creatinine level was stabilized at about 2 mg/dl. In our patient, the protein leakage into the drainage was small enough to permit remission of the nephrotic syndrome with stable fluid removal. On this basis, we believe that PD using icodextrin is considered as one of the options for the treatment of refractory nephrotic syndrome with poor water control.

Safety issues of long-term glucose load in patients on peritoneal dialysis--a 7-year cohort study

BACKGROUND

Effects of long-term glucose load on peritoneal dialysis (PD) patient safety and outcomes have seldom been reported. This study demonstrates the influence of long-term glucose load on patient and technique survival.

METHODS

We surveyed 173 incident PD patients. Long-term glucose load was evaluated by calculating the average dialysate glucose concentration since initiation of PD. Risk factors were assessed by fitting Cox's models with repeatedly measured time-dependent covariates.

RESULTS

We noted that older age, higher glucose concentration, and lower residual renal function (RRF) were significantly associated with a worse patient survival. We found that female gender, absence of diabetes, lower glucose concentration, use of icodextrin, higher serum high density lipoprotein cholesterol, and higher RRF were significantly associated with a better technique survival.

CONCLUSIONS

Long-term glucose load predicted mortality and technique failure in chronic PD patients. These findings emphasize the importance of minimizing glucose load in PD patients.

Effects of icodextrin on patient survival and technique success in patients undergoing peritoneal dialysis

BACKGROUND

Many studies have suggested clinical benefits of icodextrin in peritoneal dialysis (PD) patients regarding fluid management, glycaemic control and metabolic improvement. However, reports on whether icodextrin can improve patient and technique survival is sparse.

METHODS

A total of 2163 patients from 54 centres in Korea who initiated PD from July 2003 to December 2006 were enrolled. Outcomes data were retrieved retrospectively from the Baxter Korea database. Among these patients, 641 patients who had been prescribed icodextrin for >50% of their PD duration were defined as the 'icodextrin' group and the remaining 1522 patients as the 'non-icodextrin' group. Propensity score matching yielded 640 matched pairs of patients. We compared all-cause mortality and technique failure rates between the two groups.

RESULTS

There were no significant differences in age, gender, diabetes, cardiovascular comorbidity, socioeconomic status, biocompatible solution use in short dwells or centre experience between the two groups. Death occurred in 92 (14.4%) patients in the icodextrin group compared with 128 (20.0%) in the non-icodextrin group [hazard ratio (HR), 0.69; 95% confidence interval (CI), 0.53-0.90; P = 0.006]. In addition, icodextrin use was associated with a significantly lower risk of technique failure (HR, 0.60; 95% CI, 0.40-0.92; P = 0.018). The icodextrin group had fewer technique failures due to non-compliance compared with the non-icodextrin group whereas peritonitis- or ultrafiltration failure-related technique failure was not different between the two groups.

CONCLUSION

This study further supports previous findings of long-term utilization of icodextrin solution improving patient and technique survival in PD patients. To confirm these results, a large randomized prospective study is warranted.

Icodextrin increases technique survival rate in peritoneal dialysis patients with diabetic nephropathy by improving body fluid management: a randomized controlled trial

BACKGROUND AND OBJECTIVES

There are still controversies whether peritoneal dialysis (PD) with icodextrin preserves residual renal and peritoneal membrane functions in patients with diabetes. However, there are no randomized controlled and long-term clinical trials in newly started PD patients with diabetic nephropathy.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Forty-one patients with diabetic nephropathy with ESRD were enrolled and randomly assigned to the glucose group (GLU) treated with 8 L of 1.5% or 2.5% glucose or an icodextrin group (ICO) treated with 1.5 or 2.0 L of 7.5% icodextrin-containing solutions. Technique failure, body fluid management, glucose and lipid metabolism, and residual renal and peritoneal functions and were evaluated over 2 years.

RESULTS

The technique survival rate was 71.4% in ICO and 45.0% in GLU, with most of the technique failure due to volume overload. ICO showed significantly better cumulative technique survival. Net ultrafiltration volume was significantly higher in ICO throughout the study period. There were no beneficial effects of icodextrin on hemoglobin A1c, glycoalbumin, and lipid profile at 24 months. Urine volume and residual renal function declined faster in ICO, but there were no significant differences between the two groups. For peritoneal function, no differences were observed in dialysis-to-plasma creatinine ratios during the observation.

CONCLUSIONS

In PD therapy for diabetic nephropathy, the use of icodextrin-containing solutions has a beneficial effect on technique survival, but there are no apparent benefits or disadvantages in residual renal and peritoneal functions compared with conventional PD with glucose solution.

Decline in residual renal function in automated compared with continuous ambulatory peritoneal dialysis

BACKGROUND AND OBJECTIVES

We compared the decline of RRF in patients starting dialysis on APD with those starting on CAPD, because a faster decline on APD has been suggested.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

NECOSAD patients starting dialysis on APD or CAPD with RRF at baseline were included and followed for 3 years. Residual GFR (rGFR) was the mean of urea and creatinine clearances. Differences in yearly decline of rGFR were estimated in analyses with linear repeated measures models, whereas the risk of complete loss of RRF was estimated by calculating hazard ratios (HRs) for APD compared with CAPD. As-treated (AT) and intention-to-treat (ITT) designs were used. All of the analyses were adjusted for age, gender, comorbidity, and primary kidney disease and stratified according to follow-up and mean baseline GFR.

RESULTS

The 505 CAPD and 78 APD patients had no major baseline differences. No differences were found in the analyses on yearly decline of rGFR. APD patients did have a higher risk of losing RRF in the first year (ITT crude HR 2.43 [confidence interval 95%, 1.48 to 4.00], adjusted 2.66 [1.60 to 4.44]; AT crude 1.89 [1.04 to 3.45], adjusted 2.15 [1.16 to 3.98]). The higher risk of losing all RRF was most pronounced in patients with the highest rGFR at baseline (ITT; crude 3.91 [1.54 to 9.94], adjusted 1.85 to 14.17).

CONCLUSIONS

The risk of losing RRF is higher for patients starting dialysis on APD compared with those starting on CAPD, especially in the first year.

Risk factors for high dialysate glucose use in PD patients--a retrospective 5-year cohort study

BACKGROUND

Use of high concentrations of glucose for peritoneal dialysis (PD) may produce unfavorable results. Our previous study showed that high initial glucose load is associated with poor PD technique survival.

OBJECTIVE

This retrospective cohort study at a medical center in Taiwan aimed to understand the factors associated with high glucose load in long-term PD patients.

PATIENTS AND METHODS

We reviewed 90 newly started PD patients over 5 years. We determined glucose load by calculating annual glucose weight and dialysate volume administered. Multiple linear regression analyses with time-dependent covariates were used to determine factors that influence the annual average dialysate glucose concentration.

RESULTS

The study group included 47 men and 43 women with a mean age of 53.4 +/- 13.9 years. Technique survival rates were 91.0%, 84.1%, and 77.6% at the beginning of the second, third, and fourth year of PD therapy respectively. The presence of diabetes mellitus (DM), high body mass index (BMI), and low weekly renal Kt/V were significantly correlated with high average dialysate glucose concentration during the first, second, and third years. For patients undergoing PD for more than 3 years, residual renal function (RRF) deteriorated, and only DM significantly affected higher dialysate glucose concentration in the fourth year.

CONCLUSIONS

Patients with DM, high BMI, and low RRF were more likely to require a high glucose load for PD therapy, especially during the first 3 years. After those 3 years of PD, DM was the only significant factor in the need for higher glucose load. To reduce the glucose load in chronic PD patients, alternative osmotic agents such as icodextrin or amino acids should be considered in the daily PD regimen.

A patient with refractory nephrotic syndrome withdrawn from peritoneal dialysis

A 67-year-old woman was admitted to our hospital because of anasarca due to refractory nephrotic syndrome and chronic renal insufficiency. Laboratory data indicated serum total protein of 4.8 g/dl, albumin of 1.5 g/dl, creatinine of 1.9 mg/dl and BUN of 17 mg/dl. Urinary protein excretion was 7.8 g/day. Because of severe atrophy of both kidneys, neither renal biopsy nor immunosuppressive treatment was performed. Since conservative management including bed rest, diet therapy, limitation of water intake and administration of diuretics was not effective, peritoneal dialysis therapy using icodextrin only at night was started. The amount of water removal was steadily secured without progressing renal dysfunction or decreasing urine volume. From day 290 onward, the urinary protein excretion was decreased to show complete remission and urine volume increased. On day 528, peritoneal dialysis was discontinued, and thereafter only peritoneal lavage was performed. On day 858, the catheter was removed from the abdominal cavity, and thereafter diuretics could be discontinued. The reason for the dramatic reduction of urinary protein in this patient is unclear. However, it is possible that the primary disease such as membranous nephritis showed remission while the patient was undergoing icodextrin peritoneal dialysis, which preserves renal function but not extracorporeal ultrafiltration or hemodialysis. Icodextrin peritoneal dialysis may be an alternative to hemodialysis for refractory fluid overload in patients with nephrotic syndrome and may have the advantage of preserving renal function.

An update on renal replacement therapy in Europe: ERA-EDTA Registry data from 1997 to 2006

BACKGROUND

Recent studies have indicated a stabilization in the incidence rates of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in a number of European countries. The aim of this study was to provide an update on the incidence, prevalence and outcomes of RRT in Europe over the past decade.

METHODS

Nineteen European national or regional renal registries with registry data from 1997 to 2006 participated in the study. Incidence and prevalence trends were analysed with Poisson and Joinpoint regression. Cox regression methods were used to examine patient survival.

RESULTS

The total adjusted incidence rate of RRT for ESRD increased from 109.9 per million population (pmp) in 1997 to 119.7 pmp in 2000, i.e. an average annual percentage change (AAPC) of 2.9% (95% CI 2.1-3.8%). Thereafter, the incidence increased at a much lower rate to 125.4 pmp in 2006 [AAPC 0.6% (95% CI 0.3-0.8%)]. This change in the trend of the incidence of RRT was largely due to a stabilization in the incidence rates of RRT for females aged 65-74 years, males aged 75-84 years and patients receiving RRT for ESRD due to hypertension/renal vascular disease. The overall adjusted prevalence in Europe continued to increase linearly at 2.7% per year. Between the periods 1997-2001 and 2002-2006, the risk of death decreased for all treatment modalities, with the most substantial improvement in patients starting peritoneal dialysis [19% (95% CI 15-22%)] and in patients receiving a kidney transplant [17% (95% CI 11-23%)].

CONCLUSION

This European study shows that the annual rise of the overall incidence rate of RRT for ESRD has diminished and that in several age groups the incidence rates have now stabilized. The survival of dialysis patients and kidney transplant recipients has continued to improve.

Icodextrin does not impact infectious and culture-negative peritonitis rates in peritoneal dialysis patients: a 2-year multicentre, comparative, prospective cohort study

Background. Icodextrin is a glucose polymer derived by hydrolysis of cornstarch. The different biocompatibility profile of icodextrin-containing peritoneal dialysis (PD) solutions may have a positive influence on peritoneal host defence. Furthermore, cases of sterile peritonitis potentially associated with icodextrin have been reported.

Methods. The primary objective of this multicentre, longitudinal, observational, non-interventional, prospective cohort study, which included 722 PD patients, was to evaluate the incidence of overall peritonitis in patients treated with icodextrin-containing PD solutions (Extraneal™) used during one long-dwell exchange/day compared with those treated with non-icodextrin-containing PD solutions. The secondary objective was to determine if culture-negative peritonitis rates differed between patients treated with icodextrin from two independent manufacturers. All peritonitis episodes were assessed by a Steering Committee in a blind manner.

Results. There was no significant difference between icodextrin-treated and control patients in the adjusted overall, culture-positive or culture-negative peritonitis rates. When stratified by the icodextrin supplier, there was no significant difference in the adjusted rate of culture-negative peritonitis episodes between groups.

Conclusion. Subjects receiving icodextrin as part of their PD regimen experienced neither a higher rate of culture-negative peritonitis nor a lower rate of infectious peritonitis compared with non-icodextrin users. There was no significant influence of the icodextrin raw material supplier on peritonitis rates.