From the Guidelines
For dialysis patients with constipation, I recommend a stepwise approach starting with lifestyle modifications before medications, as constipation is a common issue in these patients due to various factors such as fluid restrictions, dietary limitations, and medication side effects 1.
Management Options
The management of constipation in dialysis patients should prioritize a stepwise approach to minimize risks and maximize benefits.
- Increase fluid intake to 1-1.5 liters daily (within fluid restrictions) to help soften stool and make it easier to pass.
- Gradually increase dietary fiber to 20-25g daily to promote regular bowel movements, while being mindful of dietary phosphate restrictions.
- Encourage regular physical activity as tolerated to stimulate bowel movements and overall health.
Medication Options
If lifestyle modifications are insufficient, medication options can be considered:
- Start with stool softeners like docusate sodium 100mg twice daily to facilitate easier passage of stool.
- If ineffective, add osmotic laxatives such as polyethylene glycol (PEG) 17g daily or lactulose 15-30ml daily, as seen in a patient treated with lactulose for constipation 1.
- Avoid magnesium-based laxatives like magnesium hydroxide or magnesium citrate in dialysis patients due to the risk of magnesium accumulation, which can be harmful in patients with impaired renal function.
- Stimulant laxatives like bisacodyl 5-10mg or senna 8.6-17.2mg should be used short-term only if other methods fail, due to the potential for dependence and decreased efficacy over time.
Importance of Regular Bowel Assessment
Regular bowel assessment is crucial in dialysis patients to identify constipation early and prevent complications. Patients should be educated to report any persistent constipation despite these measures, as it could indicate more serious underlying conditions requiring further evaluation. According to a review of supportive care in chronic kidney disease, constipation affects a significant portion of dialysis patients, with a reported prevalence of 40% 1.
From the Research
Management Options for Constipation in Dialysis Patients
The management of constipation in patients undergoing dialysis with impaired renal function can be challenging. Several studies have investigated the efficacy of different treatment options for constipation in these patients.
- Lifestyle modifications, such as scheduled toileting after meals, increased fluid intake, and increased dietary fiber intake, are often recommended as the initial treatment for constipation 2.
- Additional fiber intake in the form of polycarbophil, methylcellulose, or psyllium may also improve symptoms 2.
- Osmotic laxatives, such as polyethylene glycol, can be effective in managing constipation in hemodialysis patients 3.
- Stimulant laxatives, such as sennosides, can also be used to treat constipation, but may be less effective when combined with stool softeners like docusate 4.
- Newer agents, such as linaclotide and lubiprostone, may be considered for patients who do not respond to first-line therapies 2, 5.
- Increasing dietary fiber intake through supplements or high-fiber foods may also help improve bowel function and reduce laxative requirement in patients on peritoneal dialysis 6.
Treatment Considerations
When managing constipation in dialysis patients, it is essential to consider the potential risks and benefits of different treatment options.
- Long-term use of magnesium-based laxatives should be avoided due to the risk of toxicity 2.
- The use of docusate may not be effective in inducing laxation and may require additional interventions 4.
- Peripherally acting mu-opioid antagonists may be effective for opioid-induced constipation, but are expensive 2.