Exploring thE AssociAtion BEtwEEn icodExtrin And EncApsulAting

pEritonEAl sclErosis In 2001, we published a case series of 6 peritoneal dialysis (PD) patients from Sheffield who had been diagnosed with encapsulating peritoneal sclerosis (EPS). All had experienced ultrafiltration inadequacy, and 5 had been treated with glucose polymer [icodextrin (dura-tion of treatment: 1 month – 2.5 years)] (1). The role that icodextrin might have played in those cases of EPS was not clear, but icodextrin use is linked by associa-tion, because it extends technique survival (2) and is indicated for ultrafiltration difficulties and for patients with high transport status (3), all of which have been described as risk factors for EPS (4,5). Patients who develop EPS have, in general, been on PD for extended periods and in the modern era are likely to have been treated with icodextrin. Is there laboratory evidence that can help? Because we do not understand the pathogenesis of EPS, we rely on suggestions from basic science of in vitro cell damage to give an indication of the biocompatibility of icodextrin. Indeed Gotloib and colleagues drew at-tention to mesothelial cell damage attributable to ico-dextrin in a rat model (6). In the clinic, Martikainen and colleagues found that serum levels of C-reactive protein and interleukin 6 increased during treatment with ico-dextrin (7); increases in effluent fibrinogen degradation products and interleukin 6 have also been reported (8). Batch contamination with peptidoglycan in the early years of icodextrin was clearly a complicating factor, although this problem has subsequently been resolved (9). Of course, there is considerable evidence of adverse effects to the peritoneal membrane from prolonged glucose exposure, and because icodextrin offers the potential to reduce glucose in the dialysis prescription, the clinical benefit needs to be balanced against studies that have identified a possible inflammatory signal (10). Reassurance came from the suggestion of stability of peritoneal membrane function based on serial measure-ments of 4-hour dialysate-to-plasma creatinine from th