The authors cautiously suggested that, for patients undergoing long-dwell exchange in peritoneal dialysis, icodextrin provided greater fluid removal and small-solute clearance, did not cause damage to residual kidney function and was particularly appropriate for use in patients with high peritoneal transport status. This conclusion reflects the evidence presented and seems reliable.

To evaluate the safety and efficacy of 7.5% icodextrin solution for the long-dwell exchange in patients undergoing peritoneal dialysis, and to establish indications for icodextrin.

MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to June 2010. Search terms were reported. Authors were contacted for unpublished data. Reference lists of included trials and relevant reviews were scanned to identify further studies.

Eligible for inclusion were parallel randomised controlled trials (RCTs) that compared 7.5% icodextrin with glucose solution for the long-dwell exchange in adults who received continuous ambulatory peritoneal dialysis for at least three months, or automated peritoneal dialysis for at least 30 days. Trials had to have at least two intervention groups and contain 10 or more patients. The outcomes of interest were net ultrafiltration during the long dwell, peritoneal clearance of creatinine and urea nitrogen, incidence of negative net ultrafiltration, ultrafiltration efficiency ratio, preservation of residual renal function, mortality, rash, peritoneal dialysis-related peritonitis, and total adverse events.

The mean age of included patients ranged from 45 to 61 years. Some patients received continuing cycling peritoneal dialysis.

Two reviewers independently selected the trials for inclusion. Disagreements were resolved with a third party by consensus.

Trial quality was assessed using Jadad scores (with a maximum of 5 points for high quality) and a checklist developed by the Cochrane Renal Group. Items assessed were allocation concealment, intention-to-treat analysis, completeness of follow-up, and blinding. Trial investigators were contacted for missing information where necessary.

Two reviewers independently carried out the quality assessment.

Data were extracted to calculate relative risks (RR), mean differences (MD) and 95% confidence intervals (CI). Authors were contacted for missing information where necessary.

One reviewer extracted the data; this was checked by a second reviewer.

Relative risks and weighted mean differences were calculated in a random-effects meta-analysis. A fixed-effect model was also applied to assess robustness and identify potential outliers. Inverse variance weighting was used. Statistical heterogeneity was assessed using Χ² and Ι² tests.

Subgroup analyses were conducted to explore the influences of diabetic status, glucose concentration, and peritoneal solute transporter status. Sensitivity analysis was carried out to explore the effects of individual trials.

Publication bias was assessed using a funnel plot and tested with Egger’s and Begg’s tests.

Nine RCTs (1,190 patients, sample size range 38 to 287) were included in the review. For quality, four trials scored 5 points on the Jadad scale, three trials scored 3, and two trials scored 2. Allocation concealment was adequate in seven trials. Blinding was conducted in four trials. Intention-to-treat analysis was conducted in five trials. Follow-up ranged from one month to two years. Loss to follow-up was high in three trials.

Compared with glucose for peritoneal dialysis long-dwell exchange, icodextrin was associated with a significantly higher ultrafiltration efficiency ratio (MD 6.84, 95% CI 4.43 to 9.25; two trials; Ι²=0%), higher peritoneal clearances of creatinine (MD 0.51, 95% CI 0.35 to 0.67; five trials; Ι²=0%) and higher peritoneal clearances of urea nitrogen (MD 0.43, 95% CI 0.26 to 0.61; four trials; Ι²=0%). There was no significant difference between groups for preservation of residual renal function (four trials; Ι²=34%).

Icodextrin was associated with significant increases in net ultrafiltration compared to glucose concentrations of 1.5%, 2.5% and 4.25%; it was also superior to glucose in high-average/high and low-average transporters, but not low transporters (results reported in the paper).

Negative net ultrafiltration was significantly lower in the icodextrin group (RR 0.13, 95% CI 0.07 to 0.25; four trials; Ι²=18.2%).

The only statistically significant safety outcome was the increased occurrence of rash in the icodextrin group (RR 2.41, 95% CI 1.42 to 4.10; four trials; Ι²=0%).

There was insufficient information to explore the influence of diabetic status.

Sensitivity analysis did not alter the main findings.

There was no evidence of publication bias.

Icodextrin provided patients with greater fluid removal and small-solute clearance and did not cause any damage to residual renal function. Icodextrin was particularly appropriate for use in patients with high peritoneal transport status. These findings should be interpreted with caution as definitive conclusions could not be reached.

The review question was clear. The inclusion criteria were sufficiently detailed to allow replication. Three relevant databases were searched; attempts were made to retrieve unpublished data. The review process was conducted with adequate steps to minimise error and bias.

Appropriate quality assessment tools were applied to included trials. The results of this assessment were clearly reported in detail. The authors drew attention to the variable quality and high drop-out rates in the context of implications for future research. Trial details were presented. The method of synthesis appeared to be appropriate.

The authors’ cautious conclusion reflects the evidence presented and seems reliable.

Practice: The authors did not state any implications for practice.

Research: The authors stated that a large well-designed RCT was needed to compare icodextrin with glucose and could also be used to assess patient satisfaction and treatment preferences. This should be conducted alongside an economic evaluation.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.