Effect of icodextrin on heart rate variability in diabetic patients on peritoneal dialysis.

INTRODUCTION: Spectral analysis of heart rate variability is a noninvasive method for evaluating autonomic cardiovascular dysfunction under various clinical conditions, such as in dialysis patients, in whom an imbalance between the sympathetic and parasympathetic nervous system appears to be an important risk factor for sudden cardiovascular death and arrhythmia. ♢ OBJECTIVE: We compared the effect of icodextrin-based dialysis solution, an option that allows for better metabolic and fluid overload control, with that of glucose-based dialysis fluid on sympathetic and parasympathetic activity in the heart, as assessed by heart rate variability, in diabetic patients on peritoneal dialysis (PD). ♢ METHODS: This secondary analysis uses data from a randomized controlled trial in diabetic PD patients with high or high-average peritoneal transport using icodextrin-based (ICO group, n = 30) or glucose-based (GLU group, n = 29) solutions for the long dwell. All patients underwent 24-hour electrocardiographic Holter monitoring at baseline, and at 6 and 12 months of follow-up. ♢ RESULTS: We observed no significant differences between the groups in most of the variables analyzed, although values were, in general, below reference values. In the ICO group, total power and both low- and high-frequency power in normalized units increased, but the percentage of RR intervals with variation of more than 50 ms declined over time; in the GLU group, all those values declined. Plasma catecholamine levels were higher at baseline and declined over time. ♢ CONCLUSIONS: These results indicate a partial recovery of sympathetic activity in the ICO group, probably because of better extracellular fluid control and lower exposure to glucose with the use of icodextrin-based dialysis solutions.

Icodextrin improves metabolic and fluid management in high and high-average transport diabetic patients.

BACKGROUND: Icodextrin-based solutions (ICO) have clinical and theoretical advantages over glucose-based solutions (GLU) in fluid and metabolic management of diabetic peritoneal dialysis (PD) patients; however, these advantages have not yet been tested in a randomized fashion. OBJECTIVE: To analyze the effects of ICO on metabolic and fluid control in high and high-average transport diabetic patients on continuous ambulatory PD (CAPD). PATIENTS AND METHODS: A 12-month, multicenter, open-label, randomized controlled trial was conducted to compare ICO (n = 30) versus GLU (n = 29) in diabetic CAPD patients with high-average and high peritoneal transport characteristics. The basic daily schedule was 3 x 2 L GLU (1.5%) and either 1 x 2 L ICO (7.5%) or 1 x 2 L GLU (2.5%) for the long-dwell exchange, with substitution of 2.5% or 4.25% for 1.5% GLU being allowed when clinically necessary. Variables related to metabolic and fluid control were measured each month. RESULTS: Groups were similar at baseline in all measured variables. More than 66% of the patients using GLU, but only 9% using ICO, needed prescriptions of higher glucose concentration solutions. Ultrafiltration (UF) was higher (198 +/- 101 mL/day, p < 0.05) in the ICO group than in the GLU group over time. Changes from baseline were more pronounced in the ICO group than in the GLU group for extracellular fluid volume (0.23 +/- 1.38 vs -1.0 +/- 1.48 L, p < 0.01) and blood pressure (systolic 1.5 +/- 24.0 vs -10.4 +/- 30.0 mmHg, p < 0.01; diastolic 1.5 +/- 13.5 vs -6.2 +/- 14.2 mmHg, p < 0.01). Compared to baseline, patients in the ICO group had better metabolic control than those in the GLU group: glucose absorption was more reduced (-17 +/- 44 vs -64 +/- 35 g/day) as were insulin needs (3.6 +/- 3.4 vs - 9.1 +/- 4.7 U/day, p < 0.01), fasting serum glucose (8.3 +/- 36.5 vs -37 +/- 25.8 mg/dL, p < 0.01), triglycerides (54.5 +/- 31.9 vs -54.7 +/- 39.9 mg/dL, p < 0.01), and glycated hemoglobin (0.79% +/- 0.79% vs -0.98% +/- 0.51%, p < 0.01). Patients in the ICO group had fewer adverse events related to fluid and glucose control than patients in the GLU group. CONCLUSION: Icodextrin represents a significant advantage in the management of high transport diabetic patients on PD, improving peritoneal UF and fluid control and reducing the burden of glucose overexposure, thereby facilitating metabolic control.

Inflammation and extracellular volume expansion are related to sodium and water removal in patients on peritoneal dialysis.

BACKGROUND: Inflammation is an important risk for mortality in dialysis patients. Extracellular fluid volume (ECFv) expansion, a condition commonly seen in peritoneal dialysis (PD) patients, may be associated with inflammation. However, published support for this relationship is scarce. OBJECTIVES: To quantify the proportion of patients on PD with inflammation and to analyze the role of ECFv expansion and the factors related to these conditions. DESIGN: A prospective, multicenter cross-sectional study in six hospitals with a PD program. PATIENTS AND METHODS: Adult patients on PD were studied. Clinical data, body composition, and sodium and fluid intake were recorded. Biochemical analysis, C-reactive protein (CRP), and peritoneal and urinary fluid and sodium removal were also measured. RESULTS: CRP values positive (>or=3.0 mg/L) for inflammation were found in 147 (80.3%) and negative in 36 patients. Patients with positive CRP had higher ECFv/total body water (TBW) ratio (women 47.69 +/- 0.69 vs 47.36 +/- 0.65, men 43.15 +/- 1.14 vs 42.84 +/- 0.65; p < 0.05), higher serum glucose (125.09 +/- 81.90 vs 103.28 +/- 43.30 mg/dL, p < 0.03), and lower serum albumin (2.86 +/- 0.54 vs 3.17 +/- 0.38 g/dL, p < 0.001) levels. They also had lower ultrafiltration (1003 +/- 645 vs 1323 +/- 413 mL/day, p < 0.005) and total fluid removal (1260 +/- 648 vs 1648 +/- 496 mL/day, p < 0.001), and less peritoneal (15.59 +/- 162.14 vs 78.11 +/- 110.70 mEq/day, p < 0.01) and total sodium removal (42.06 +/- 142.49 vs 118.60 +/- 69.73 mEq/day, p < 0.001). In the multivariate analysis, only ECFv/TBW was significantly (p < 0.04) and independently associated with inflammation. ECFv/TBW was correlated with fluid removal (r = 0.16, p < 0.03) and renal sodium removal (r = 0.2, p < 0.01). CONCLUSION: The data suggest that ECFv expansion may have a significant role as an inflammatory stimulus. The results disclose a relationship between the two variables, ECFv expansion and inflammation, identified as independent risk factors for mortality in PD patients.