Icodextrin is currently licensed for one bag a day, and we currently lack data about potential toxicity of using 2 bags a day (i.e. effects of icodextrin metabolites, pseudo-hyponatremia).
However, many centers, including ours, frequently use 2 bags of icodextrin per day in selected patients (typically elderly patients with fluid overload, and with significant residual kidney function) – in whom the benefits are expected to be greater than potential harms. We usually use 2 ico dwells + 1 1.5% glucose dwell, and it works very well.
The DIDo study is currently under way to test the efficacy and safety of such approach (https://clinicaltrials.gov/ct2/show/NCT01944852).