Background and Objectives
There are controversies whether icodextrin (ICO)-use can improve patient survivals in incident peritoneal dialysis (PD) patients.
This Asian study from Taiwan compared the risk of death between ICO-users (study group) and a group of propensity score
matched non-ICO-users (control group). Icodextrins was first introduced to Taiwan PD market since January 1st, 2004.
Aim 1: To investigate if once-daily-ICO-use has survival benefit to certain high-risk Asian PD patients.
Aim 2: To investigate if there is a difference of survival benefit between different gender.
Aim 3: To investigate if there is a beneficial effect upon patient survivals in diabetic and non-diabetic patients.
Once-daily-use of Icodextrin Improved Survivals of Asian Peritoneal Dialysis Patients, Particularly in Female Population
- A Propensity Score Matched Nationwide Population Study
Chiu-Ching Huang
1,2, Wen-Yin Kuo
3, I.-Kuan Wang
1,2, Wen-Chen Tsai
3,41
Kidney Institute and Division of Nephrology, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
2
College of Medicine, China Medical University, Taichung 40402, Taiwan
3
Department of Health Services Administration, China Medical University, Taichung 40402, Taiwan
4
Biostatistics Center, China Medical University, Taichung 40402, Taiwan
Methods
From January 1st, 2004 to June 30th, 2009 ; all incident PD patients who survived more than 3 months on PD in Taiwan National Health Insurance Research Database were included. ICOs were prescribed once daily for high risk patients, e.g. (1) diabetics with HbA1C > 7%, or (2) high transporters, or (3) those used high-glucose containing dialysates. Patients were followed until death or transfer to hemodialysis or renal transplantation or loss to follow up or Dec 31st, 2009. Patient survivals were compared between ICO users and propensity score matched controls. The multivariate Cox regression models were used to calculate the impact of ICO-use on mortality and to plot survival curves.
Results
A total of 1627 incident PD patients were identified. Among them, 524 ICO-users were matched with 1:1 ratio to 524 non-ICO-users for age, gender, income and comorbidities (Table 1). All ICO-users had used ICO for at least 3 months. ICO-users had better patient survivals than control cohort (HR 0.6 for ICO vs non-ICO users, 95% CI: 0.37-0.99, p=0.045)(Fig1)(Table 2). Female ICO users had significantly better patient survivals than non-ICO users (HR 0.48, 95% CI: 0.25-0.94, p=0.032), but it is not significant in male patients (HR 0.79, 95% CI 0.35-1.79, p=0.575) (Fig 2). In both diabetic and non-diabetic populations, ICO user appeared to have lower HR for all-cause mortality, but the difference was not significant (DM: HR 0.62, 95% CI 0.34-1.13, p= 0.117; Non-DM: HR 0.59, 95% CI 0.18-1.54, p=0.243).
Conclusions
Compared to a propensity score matched control cohort, once-daily-use of ICO in high risk Asian PD patients is beneficial to patient survival, particularly in female population. Further randomized controlled studies are necessary to confirm our observation.
Figure 1. ICO-users had better patient survivals than non-ICO users.
N= 524 in each group P= 0.045
Figure 2. Female ICO users had better patient survivals than non-ICO users, but no difference observed in male patients
Female P= 0.032
Male
P= 0.575
Table 1.Baseline characteristics of study cohort (ICO-users) and control patients (non-ICO users)
Icodextrin use No (N=524) Yes (N=524) n % n % P Gender 0.354 Female 268 51.15 252 48.09 Male 256 48.85 272 51.91 Age (years) 0.674 ≦54 246 46.95 256 48.85 55～64 119 22.71 122 23.28 ≧65 159 30.34 146 27.86
Monthly income (USD) 0.516
<600 47 8.97 50 9.54 600-1000 330 62.98 310 59.16 1000-1500 84 16.03 101 19.27 ＞1500 63 12.02 63 12.02 Comorbidity CAD 126 24.05 120 22.90 0.716 CHF 146 27.86 136 25.95 0.531 DM 238 45.42 235 44.85 0.901 Hypertension 442 84.35 441 84.16 1.000 Malignancy 118 22.52 110 20.99 0.600 AMI 10 1.91 6 1.15 0.450 Chronic hepatitis 177 33.78 176 33.59 1.000 CVA 185 35.31 152 29.01 0.034 PAOD 170 32.44 152 29.01 0.255 COPD 117 22.33 117 22.33 1.000 Peritonitis 6 1.15 6 1.15 1.000 Other CI 95 18.13 84 16.03 0.412
CAD: Coronary artery disease CHF: Congestive heart failure DM: Diabetes melliuts AMI: Acute myocardial infarction
CVA: Cerebral vascular accident COPD: Chronic obstructive pulmonary disease PAOD: Peripheral arterial occlusive disease CI: Catastrophic illness
Table 2. Multivariate regression analysis for mortality risk (Cox model )
Unadjusted Adjusted HR 95% CI P HR 95% CI P LB UB LB UB Icodextrin use No 1.00 Yes 0.60 0.36 0.96 0.040* 0.60 0.37 0.99 0.045* Gender Female 1.00 Male 0.76 0.46 1.23 0.263 0.88 0.53 1.47 0.631 Age (years) ≦54 1.00 1.00 55～64 3.67 1.57 8.60 0.003* 2.69 1.11 6.53 0.029 * ≧65 11.93 5.79 24.57 <0.0001* 7.37 3.25 16.71 <0.0001* Monthly income (USD)
<600 1.00 1.00 600-1000 1.59 0.57 4.44 0.372 1.54 0.55 4.34 0.411 1000-1500 1.44 0.46 4.53 0.531 2.18 0.67 7.11 0.197 ＞1500 1.01 0.29 3.58 0.989 0.98 0.27 3.54 0.975 Comorbidity None 1.00 CAD 2.39 1.47 3.88 0.000 * 0.98 0.56 1.70 0.935 CHF 2.83 1.74 4.61 <0.0001* 1.28 0.74 2.21 0.374 DM 3.56 2.06 6.13 <0.0001* 1.56 0.86 2.83 0.143 Hypertension 3.52 0.86 14.37 0.080 2.23 0.53 9.37 0.273 Malignancy 1.14 0.69 1.90 0.607 1.04 0.58 1.86 0.909 AMI 2.24 0.90 5.59 0.085 1.14 0.42 3.07 0.794 Chronic hepatitis 1.18 0.72 1.92 0.512 0.89 0.52 1.51 0.657 CVA 3.65 2.19 6.09 <0.0001* 2.09 1.20 3.64 0.009 * PAOD 1.65 1.02 2.68 0.042 * 1.00 0.58 1.70 0.986 COPD 1.74 1.06 2.86 0.029* 1.09 0.64 1.85 0.752 Peritonitis 0.67 0.39 1.17 0.16 0.58 0.33 1.03 0.064 Other CI 1.41 0.78 2.54 0.259 1.47 0.76 2.85 0.251
CAD: Coronary artery disease CHF: Congestive heart failure DM: Diabetes melliuts AMI: Acute myocardial infarction
CVA: Cerebral vascular accident COPD: Chronic obstructive pulmonary disease PAOD: Peripheral arterial occlusive disease CI: Catastrophic illness
Reference
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(2) Han SH, Ahn SV, Yun JY et al. Effects of icodextrin on patient survival and technique success in patients undergoing peritoneal dialysis. Nephrol Dial Transplant 2012; 27: 2044-2050
(3) Lin A, Qian J, Li X et al. Randomized controlled trial of icodextrin versus glucose containing peritoneal dialysis fluid. Clin J Am Soc Nephrol 2009; 4: 1799-1804
(4) Kuriyama R, Tranaeus A, Ikegami T. Icodextrin reduces mortality and the drop-out rate in Japanese peritoneal dialysis patients. Adv Perit Dial 2006; 22: 108-110
