Extraneal
Icodextrin Peritoneal Dialysis Solution for Chronic Kidney Failure
Quick Facts About Extraneal
Key Takeaways About Extraneal
- Sustained fluid removal: Icodextrin provides colloid osmotic ultrafiltration that lasts 12–16 hours, making it ideal for the long dwell exchange in both CAPD and APD
- One bag per day only: Extraneal should be used for only one exchange per 24-hour period and must not replace all glucose-based exchanges
- Critical glucose monitor warning: Use only glucose-specific blood glucose monitors — icodextrin metabolites cause falsely high readings on certain test strips, which can lead to dangerous insulin overdose
- Not for children: Safety and efficacy have not been established in patients under 18 years of age
- Watch for peritonitis: Cloudy or turbid drainage fluid may indicate peritoneal infection and requires immediate medical attention
What Is Extraneal and What Is It Used For?
Extraneal is a peritoneal dialysis solution containing icodextrin, a glucose polymer derived from corn starch. It is used in adults with end-stage renal disease (ESRD) undergoing peritoneal dialysis when glucose-based solutions alone cannot achieve adequate fluid removal (ultrafiltration).
Peritoneal dialysis is a form of kidney replacement therapy that uses the peritoneal membrane — the thin lining of the abdominal cavity — as a natural filter. During peritoneal dialysis, a sterile solution is instilled into the peritoneal cavity through a surgically placed catheter. Waste products and excess fluid pass from the blood, through the peritoneal membrane, and into the dialysis solution, which is then drained out of the body. This process is known as an exchange.
Extraneal differs fundamentally from conventional glucose-based peritoneal dialysis solutions in its mechanism of action. Standard solutions use glucose (dextrose) to create an osmotic gradient that draws fluid out of the blood. However, this crystalloid osmotic effect diminishes rapidly as glucose is absorbed from the peritoneal cavity — typically within 4 to 6 hours. This means that during long dwell periods (8–16 hours), glucose-based solutions often result in net fluid reabsorption rather than continued ultrafiltration.
Icodextrin, the active ingredient in Extraneal, works through a different principle: colloid osmosis. Because icodextrin is a large glucose polymer (average molecular weight approximately 16,800 daltons), it is absorbed very slowly from the peritoneal cavity via lymphatic pathways rather than through direct membrane absorption. This creates a sustained osmotic gradient across the peritoneal membrane that continues to drive fluid removal for 12 to 16 hours, making it particularly valuable for the long dwell exchange.
Extraneal may be prescribed to you if you are an adult with chronic kidney failure that requires treatment with peritoneal dialysis, and standard glucose-based dialysis solutions alone cannot remove sufficient water from your body. It is used as part of a multimodal peritoneal dialysis prescription, where it replaces one glucose-based exchange per day — specifically the longest dwell exchange.
Icodextrin was first approved for clinical use in the late 1990s and has since become an integral part of peritoneal dialysis prescriptions worldwide. The International Society for Peritoneal Dialysis (ISPD) and the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recognise icodextrin-based solutions as a valuable option for improving ultrafiltration in peritoneal dialysis patients, particularly those with high or high-average peritoneal membrane transport characteristics.
What Should You Know Before Using Extraneal?
Before starting Extraneal, inform your doctor about all medical conditions you have, especially diabetes, glycogen storage disorders, and any current infections. Extraneal is contraindicated in patients with allergy to icodextrin or corn starch products, maltose or isomaltose intolerance, glycogen storage disease, and pre-existing severe lactic acidosis.
The first time you use Extraneal, the entire procedure should be supervised by your doctor or a nurse specialist trained in peritoneal dialysis. This ensures that you understand the correct technique and can recognise any early signs of adverse reactions. Even if you are experienced with peritoneal dialysis using glucose-based solutions, the switch to Extraneal requires medical supervision because of its unique properties and potential interactions with blood glucose monitors.
Contraindications
You should not use Extraneal if any of the following apply to you:
- Allergy to icodextrin or starch products (e.g. corn starch) or to any of the other ingredients in Extraneal
- Intolerance to maltose or isomaltose (sugars that are produced during the breakdown of starch)
- Glycogen storage disorders — conditions affecting the body's ability to store and break down glycogen
- Pre-existing severe lactic acidosis — a dangerous build-up of lactic acid in the blood
- Uncorrectable abdominal conditions — problems affecting the abdominal wall or cavity that cannot be surgically repaired, or conditions that increase the risk of abdominal infection
- Documented loss of peritoneal membrane function — due to severe adhesions or scarring of the peritoneum
Warnings and Precautions
Talk to your doctor before using Extraneal if any of the following apply to you:
- Elderly patients: There is an increased risk of dehydration. Your doctor will monitor your fluid balance carefully
- Diabetes: If you are using Extraneal for the first time and have diabetes, your insulin dose may need adjustment. Additionally, you must use a glucose-specific blood glucose monitor (see Drug Interactions section)
- High risk of lactic acidosis: Your risk is increased if you have very low blood pressure, bloodstream infection (sepsis), acute severe kidney injury, an inherited metabolic disorder, or if you are taking metformin or certain HIV medications (NRTIs)
- Abdominal conditions: Including hernias, chronic inflammatory bowel conditions, or a prosthetic graft in the major blood vessel of the abdomen (aorta)
- Severe lung disease: Such as emphysema, or any breathing difficulties
- Nutritional deficiencies: Peritoneal dialysis can cause loss of protein, amino acids, and vitamins. Your doctor will advise whether supplementation is needed
- Potassium deficiency: Your potassium levels will be monitored regularly, and supplementation with potassium chloride may be necessary
If you experience abdominal pain or notice that the drained dialysis fluid is cloudy, turbid, or contains particles, this may indicate peritonitis (infection of the peritoneal membrane). Contact your peritoneal dialysis medical team immediately. Note the batch number from the bag and bring both the bag and the cloudy fluid to your clinic. Your doctor will take cultures and start appropriate antibiotic treatment.
You should also be aware that encapsulating peritoneal sclerosis (EPS) is a known, rare but serious complication of long-term peritoneal dialysis treatment. EPS involves inflammation and the growth of fibrous tissue layers that can encase and bind abdominal organs together, restricting their normal movement. In rare cases, this complication has been fatal. Discuss the signs and symptoms of EPS with your doctor so that you can be alert to this possibility.
Pregnancy and Breastfeeding
The safety of Extraneal during pregnancy and breastfeeding has not been established. If you are pregnant, think you might be pregnant, plan to become pregnant, or are breastfeeding, consult your doctor before using this medicine. Extraneal is not recommended during pregnancy or breastfeeding unless your doctor determines that the benefit of treatment clearly outweighs the potential risks.
Women of childbearing age who require peritoneal dialysis should discuss contraception and family planning with their nephrologist. Pregnancy in women on dialysis is associated with significant maternal and foetal risks and requires specialised multidisciplinary care.
Driving and Operating Machinery
Peritoneal dialysis treatment, including Extraneal, can cause fatigue, weakness, blurred vision, and dizziness. If you experience any of these effects, you should not drive or operate machinery until they have resolved. Always assess your own fitness to perform activities requiring alertness before getting behind the wheel or using tools and equipment.
Use in Children
The safety and efficacy of Extraneal in patients under 18 years of age have not been established. Extraneal is currently approved for adult use only. Paediatric patients requiring peritoneal dialysis should be managed using age-appropriate dialysis solutions under specialist nephrological supervision.
How Does Extraneal Interact with Other Drugs?
The most critical interaction involves blood glucose monitors: icodextrin metabolites interfere with certain glucose test methods, causing falsely elevated readings that can lead to inappropriate insulin dosing and life-threatening hypoglycaemia. Additionally, peritoneal dialysis increases the elimination of some medications, requiring dose adjustments.
Because peritoneal dialysis continuously removes substances from the blood through the peritoneal membrane, it can increase the elimination of many medications. This means that the doses of some drugs you take alongside your dialysis treatment may need to be increased to maintain their therapeutic effect. Your doctor will review all your medications when prescribing Extraneal and make any necessary adjustments.
Critical: Blood Glucose Monitor Interference
This is the most important interaction associated with Extraneal and has caused serious harm, including cases of coma and death. Icodextrin is slowly metabolised in the body to maltose, maltotriose, and other oligosaccharides. These metabolites interfere with blood glucose test strips that use certain enzyme methods, most notably glucose dehydrogenase pyrroloquinolinequinone (GDH-PQQ) and glucose-dye-oxidoreductase methods.
When these incompatible test strips are used, the icodextrin metabolites are mistakenly detected as glucose, resulting in falsely elevated blood glucose readings. A patient or clinician may then administer insulin to correct what appears to be high blood sugar. Because the actual blood glucose level may be normal or low, this inappropriate insulin administration can cause severe hypoglycaemia (dangerously low blood sugar), potentially leading to loss of consciousness, seizures, coma, neurological damage, or death.
Only use glucose-specific blood glucose monitors and test strips while using Extraneal. Acceptable methods include glucose oxidase and GDH-NAD based systems. Ask your doctor or peritoneal dialysis team which specific glucose meter to use. This interference can persist for up to two weeks after you stop using Extraneal. If you are admitted to hospital, alert the medical staff about this interaction so they can ensure compatible testing equipment is used.
Important Drug Interactions
| Drug / Class | Type of Interaction | Clinical Effect | Recommendation |
|---|---|---|---|
| Insulin | Indirect (via glucose monitor interference) | Falsely high glucose readings may lead to inappropriate insulin dosing and life-threatening hypoglycaemia | Use glucose-specific monitors only; may need insulin dose adjustment when starting Extraneal |
| Cardiac glycosides (Digoxin) | Pharmacodynamic | Hypokalaemia from dialysis can increase digoxin toxicity and risk of cardiac arrhythmias | Monitor potassium and calcium levels closely; supplement potassium as needed |
| Metformin | Additive risk | Both metformin and Extraneal (via lactate content) increase the risk of lactic acidosis | Use with caution; monitor lactate levels; metformin is often contraindicated in advanced kidney disease |
| NRTIs (HIV medications) | Additive risk | Nucleoside reverse transcriptase inhibitors increase the risk of lactic acidosis | Monitor for signs of lactic acidosis; close clinical supervision required |
| Other dialysed medications | Pharmacokinetic (enhanced elimination) | Peritoneal dialysis increases the removal of many drugs, potentially reducing their effectiveness | Dose adjustments may be needed; consult your nephrologist or pharmacist |
What Is the Correct Dosage of Extraneal?
The recommended dose is one bag of Extraneal per 24-hour period, used during the longest dwell time: overnight for CAPD patients and during the daytime for APD patients. The solution should be infused over 10–20 minutes, with a dwell time of 6–12 hours (CAPD) or 14–16 hours (APD).
Always use Extraneal exactly as prescribed by your peritoneal dialysis team. Do not change the frequency, volume, or dwell time without consulting your doctor. The prescribed volume (1.5 L, 2.0 L, or 2.5 L) will be determined based on your body size, peritoneal membrane characteristics, residual kidney function, and fluid removal needs.
Adults
CAPD (Continuous Ambulatory Peritoneal Dialysis)
One bag per day during the overnight (long) dwell. Infuse the solution over 10–20 minutes. Dwell time: 6–12 hours. Remaining exchanges during the day use glucose-based solutions as prescribed.
APD (Automated Peritoneal Dialysis)
One bag per day during the daytime (long) dwell. The cycler performs short-dwell glucose exchanges overnight; Extraneal fills the abdomen for the day dwell. Dwell time: 14–16 hours.
Preparation and Administration
Follow these steps carefully before each exchange:
- Warm the bag to body temperature (37°C / 98.6°F) using a purpose-designed warming plate. Never use a water bath, microwave, or any other heating method
- Wash your hands thoroughly and clean the surface where the exchange will be performed
- Inspect the outer packaging before opening: check the solution name, expiry date, and volume. Lift the bag to check for leaks (look for excess fluid in the outer wrapping)
- After removing the outer wrap, squeeze the bag firmly to check for punctures or leaks
- Inspect the solution: it should be clear and colourless. Do not use the bag if the solution is cloudy or contains particles
- Ensure all connections are secure before starting the exchange
- Use aseptic technique throughout the entire procedure as you have been trained
Each bag is for single use only. Discard any unused solution after the exchange. After draining, inspect the effluent fluid — if it is cloudy, contact your peritoneal dialysis team immediately.
Children
Extraneal is not approved for use in children under 18 years of age. Safety and efficacy in the paediatric population have not been established.
If You Use More Than One Bag in 24 Hours
Using more than one bag of Extraneal in a 24-hour period is not recommended and may cause:
- Abdominal distension and discomfort
- A feeling of fullness
- Shortness of breath
If this occurs, contact your doctor immediately. The excess fluid may need to be drained from the peritoneal cavity.
Stopping Treatment
Do not stop using Extraneal or any part of your peritoneal dialysis treatment without your doctor's approval. Stopping peritoneal dialysis without medical supervision can have life-threatening consequences, as waste products and excess fluid will rapidly accumulate in your body.
Adding Medications to the Bag
Your doctor may instruct you to add injectable medications (such as antibiotics for peritonitis treatment) directly into the Extraneal bag. If so, always inject through the designated injection port at the bottom of the bag. Use the solution immediately after adding medications. Never add medications unless specifically instructed by your doctor, and ask your peritoneal dialysis nurse if you are unsure about the technique.
What Are the Side Effects of Extraneal?
Like all medicines, Extraneal can cause side effects, although not everyone experiences them. Common side effects include skin rash and itching, dizziness, dehydration, headache, fatigue, and low blood pressure. Seek immediate medical attention if you develop signs of severe allergic reaction, peritonitis (cloudy drainage fluid with abdominal pain), or fluid overload.
The side effects listed below include both those specific to Extraneal (icodextrin) and those associated with peritoneal dialysis treatment in general. It is important to distinguish between effects caused by the medication itself and those inherent to the dialysis process. Report any new or worsening symptoms to your peritoneal dialysis team.
High blood pressure (hypertension); swollen ankles, legs, or eyes with shortness of breath or chest pain (fluid overload / hypervolaemia); swelling of the face, throat, or around the eyes (angioedema / severe allergic reaction); abdominal pain with cloudy drainage fluid (peritonitis); or chills and flu-like symptoms. These may require urgent medical treatment.
Common Side Effects
May affect up to 1 in 10 patients
- Skin redness, flaking, rash, and itching (pruritus)
- Dizziness or feeling light-headed
- Thirst and dehydration
- Decreased blood volume (hypovolaemia)
- Abnormal laboratory values
- Weakness (asthenia), headache, and fatigue
- Swollen ankles and legs (peripheral oedema)
- Low blood pressure (hypotension)
- Ringing in the ears (tinnitus)
Side Effects Related to Peritoneal Dialysis
Frequency varies; associated with the dialysis procedure
- Peritonitis (infection of the peritoneal membrane) — cloudy drainage fluid with abdominal pain
- Bleeding into the abdominal cavity
- Catheter exit-site infection, blockage, or damage
- Abdominal hernia (a bulge in the groin area)
- Abdominal distension
- Nausea, vomiting, loss of appetite, constipation, diarrhoea, flatulence
- Gastritis, peptic ulcer, indigestion
- Ileus (bowel obstruction)
Metabolic and Blood-Related Side Effects
Frequency varies
- Low blood sugar (hypoglycaemia) or high blood sugar (hyperglycaemia)
- Hypoglycaemic shock or coma (potentially related to glucose monitor interference)
- Abnormal liver function tests
- Anaemia (reduced red blood cells)
- Changes in white blood cell or platelet count
- Weight gain or weight loss
- Potassium imbalance
Rare and Serious Side Effects
Reported rarely or in post-marketing surveillance
- Toxic epidermal necrolysis (TEN) — a severe skin reaction with widespread redness and peeling
- Erythema multiforme — allergic skin reaction with target-like lesions
- Vasculitis — inflammation of blood vessels, presenting as red or purple spots
- Encapsulating peritoneal sclerosis (EPS) — a rare, potentially fatal complication of long-term peritoneal dialysis
- Angioedema — severe swelling of the face, throat, or airways
- Pulmonary oedema — fluid in the lungs causing severe breathlessness
- Seizures and neurological damage (related to severe hypoglycaemia from monitor interference)
Other reported side effects include: muscle cramps, bone pain, joint pain, back and neck pain; numbness, tingling, or burning sensations; increased or involuntary movements (hyperkinesia); blurred vision; loss of taste; rapid heart rate; orthostatic hypotension (dizziness when standing up); cough, hiccups, difficulty breathing; nail problems; dry skin, skin discolouration, blistering, contact dermatitis; anxiety, nervousness, abnormal thoughts; urticaria (hives), psoriasis flare, eczema; abscess formation; and general fever, pain, or malaise.
If you experience any side effects, including any not listed in this information, talk to your doctor or peritoneal dialysis nurse. You can also report suspected side effects directly to your national medicines regulatory authority. By reporting side effects, you help provide more information on the safety of this medicine.
How Should You Store Extraneal?
Store Extraneal in its original packaging at room temperature. Do not store below 4°C (39°F) and do not freeze. Do not use after the expiry date. Keep out of the sight and reach of children.
Proper storage is essential to maintain the sterility and effectiveness of Extraneal. The solution should be kept in its outer wrapping until you are ready to use it. This protects the bag from light and physical damage. Store the bags at room temperature — do not refrigerate below 4°C and never freeze the solution, as this could affect its composition and sterility.
Before each use, check the expiry date printed on both the carton and the individual bag. The expiry date refers to the last day of the stated month. Do not use the solution if it has expired. Also inspect the bag for any signs of damage, leaks, or discolouration before use.
Each bag is for single use only. Any unused solution remaining after an exchange must be discarded. Do not save or reuse partially used bags. Dispose of used bags and solutions according to your local guidelines for pharmaceutical waste — do not pour dialysis fluid down the drain or dispose of it with regular household waste unless advised to do so by your peritoneal dialysis team.
What Does Extraneal Contain?
Extraneal contains icodextrin 75 g/L as the active ingredient, along with sodium chloride, sodium lactate, calcium chloride, and magnesium chloride in a sterile aqueous solution. The electrolyte composition is designed to approximate normal blood chemistry.
Active Ingredient
The active substance is icodextrin at a concentration of 75 g/L (7.5%). Icodextrin is a water-soluble glucose polymer derived from the hydrolysis of corn starch. It has an average molecular weight of approximately 16,800 daltons and acts as a colloid osmotic agent, providing sustained ultrafiltration during long-dwell peritoneal dialysis exchanges.
Electrolyte Composition
| Component | Concentration (g/L) | Concentration (mmol/L) |
|---|---|---|
| Icodextrin | 75 | — |
| Sodium chloride | 5.4 | Sodium: 133 |
| Sodium (S)-lactate | 4.5 | Lactate: 40 |
| Calcium chloride | 0.257 | Calcium: 1.75 |
| Magnesium chloride | 0.051 | Magnesium: 0.25 |
| Chloride (total) | — | 96 |
Other Ingredients
The other ingredients are water for injections and sodium hydroxide or hydrochloric acid (used to adjust the pH of the solution). The solution is clear and colourless.
Packaging
Extraneal is supplied in flexible plastic bags available in three volumes: 1.5 litres, 2.0 litres, and 2.5 litres. Each bag is sealed in a separate outer wrapping and packed in cardboard cartons. The bags are available with Luer/Spike connectors and in both single-bag (for APD) and DUO-bag (for CAPD) configurations. Not all pack sizes may be marketed in your country.
Frequently Asked Questions About Extraneal
Extraneal is a peritoneal dialysis solution containing icodextrin 7.5%. It is prescribed for adults with end-stage renal disease (chronic kidney failure) who are undergoing peritoneal dialysis, specifically when conventional glucose-based dialysis solutions cannot remove enough fluid from the body. It is used once daily during the longest dwell period — typically overnight for CAPD patients or during the daytime for APD patients.
Standard peritoneal dialysis solutions use glucose (dextrose) to create an osmotic gradient for fluid removal. However, glucose is rapidly absorbed from the peritoneal cavity, so the osmotic effect diminishes within 4–6 hours. Extraneal uses icodextrin, a large glucose polymer, which is absorbed much more slowly via lymphatic pathways. This creates a sustained colloid osmotic gradient that continues to drive fluid removal for 12–16 hours, making it ideal for long dwell periods. It also avoids the metabolic consequences of high glucose absorption.
Icodextrin is metabolised to maltose and other sugars that interfere with certain types of blood glucose test strips. Monitors using GDH-PQQ or glucose-dye-oxidoreductase enzyme methods will give falsely high glucose readings. If insulin is administered based on these false readings, it can cause severe hypoglycaemia (dangerously low blood sugar), which can lead to loss of consciousness, coma, or death. Only glucose-specific monitors (glucose oxidase or GDH-NAD methods) should be used. This interference can persist for up to two weeks after stopping Extraneal.
No. Extraneal should only be used for one exchange per 24-hour period. Using more than one bag can lead to excessive fluid removal, electrolyte disturbances, and accumulation of icodextrin metabolites (maltose and other oligosaccharides) in the blood. If you accidentally use more than one bag, contact your doctor or peritoneal dialysis team immediately.
Cloudy or turbid drainage fluid may be a sign of peritonitis — an infection of the peritoneal membrane. This is a serious complication that requires prompt treatment. Contact your peritoneal dialysis medical team immediately. Note the batch number from the bag and save both the bag and the cloudy fluid to bring to your clinic. Your doctor will take cultures of the fluid and start appropriate antibiotic therapy. Do not delay seeking medical attention, as untreated peritonitis can cause serious complications.
Extraneal is not approved for use in children under 18 years of age, as safety and efficacy have not been established in this population. Regarding pregnancy and breastfeeding, Extraneal is not recommended unless the doctor determines that the benefit clearly outweighs the risk. Women of childbearing age on peritoneal dialysis should discuss family planning with their nephrologist, as pregnancy on dialysis carries significant risks for both mother and baby.
References
- Kidney Disease: Improving Global Outcomes (KDIGO). KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney International Supplements. 2020;98(4S):S1–S115.
- International Society for Peritoneal Dialysis (ISPD). ISPD Peritonitis Guideline Recommendations: 2022 Update on Prevention and Treatment. Peritoneal Dialysis International. 2022;42(2):110–153.
- European Renal Association – European Dialysis and Transplant Association (ERA-EDTA). European Best Practice Guideline on Peritoneal Dialysis. Nephrology Dialysis Transplantation. 2020;35(Suppl 2):ii1–ii66.
- Mistry CD, Gokal R, Peers E. A randomized multicenter clinical trial comparing isosmolar icodextrin with hyperosmolar glucose solutions in CAPD. Kidney International. 1994;46(2):496–503.
- Paniagua R, Ventura M-D, Ávila-Díaz M, et al. Icodextrin improves metabolic and fluid management in high and high-average transport diabetic patients. Peritoneal Dialysis International. 2009;29(4):422–432.
- European Medicines Agency (EMA). Extraneal – Summary of Product Characteristics. Available at: ema.europa.eu.
- U.S. Food and Drug Administration (FDA). FDA Safety Communication: Interference with Blood Glucose Measurement Following Use of Peritoneal Dialysis Solutions Containing Icodextrin. 2009 (updated 2018).
- World Health Organization (WHO). Global Report on Kidney Disease. WHO Technical Report Series. 2023.
- Cho Y, Johnson DW, Badve S, et al. Impact of icodextrin on clinical outcomes in peritoneal dialysis: a systematic review of randomized controlled trials. Nephrology Dialysis Transplantation. 2013;28(7):1889–1898.
- British National Formulary (BNF). Icodextrin – Dialysis solutions. NICE Evidence Services. Available at: bnf.nice.org.uk.
Editorial Team
Medical Content
iMedic Medical Editorial Team
Specialists in Nephrology and Clinical Pharmacology
Medical Review
iMedic Medical Review Board
Independent review according to KDIGO, ERA-EDTA and ISPD guidelines
Evidence Level
Level 1A
Based on systematic reviews and RCTs, following the GRADE framework
Independence
No Commercial Funding
Independent editorial content with no pharmaceutical sponsorship