Is nausea and vomiting common in patients with End-Stage Renal Disease (ESRD) on dialysis?

Prevalence of Nausea and Vomiting in ESRD Patients on Dialysis

Nausea and vomiting are highly prevalent symptoms in patients with ESRD on dialysis, with nausea affecting approximately 46% (range 9-90%) and vomiting affecting approximately 23% (range 11-68%) of dialysis patients. 1

Prevalence Data and Contributing Factors

The prevalence of these symptoms is well-documented in the literature:

• According to KDIGO guidelines, nausea affects 46% of dialysis patients, with reported ranges from 9-90% across different studies 1
• Vomiting occurs in approximately 23% of dialysis patients, with reported ranges from 11-68% 1
• A 2017 study found the incidence of nausea during hemodialysis sessions to be 28.3% and vomiting 11.7% 2

These symptoms are particularly common at the time of dialysis initiation:

• Approximately 60% of American dialysis patients suffer from nausea/vomiting at the time of dialysis initiation 1
• The NKF-K/DOQI guidelines note that this high prevalence contributes to the likelihood of malnutrition in this population 1

Pathophysiology and Contributing Factors

Several factors contribute to the high prevalence of nausea and vomiting in ESRD patients:

• Uremia: Accumulation of uremic toxins affects the gastrointestinal system 3
• Dialysis-related factors: Rapid fluid shifts, electrolyte imbalances during dialysis sessions 4
• Comorbidities: Particularly diabetic gastroparesis in patients with diabetic nephropathy 3
• Medication side effects: Many medications used in ESRD can cause GI symptoms 4

Differences Between Dialysis Modalities

The type of dialysis can impact the prevalence and severity of these symptoms:

• Peritoneal dialysis patients may experience early satiety and protein loss in the dialysate (5-15g/day), which can exacerbate uremic gastropathy symptoms 3
• The severity of pruritus (and potentially other uremic symptoms) is generally lower in ESRD treated with peritoneal dialysis compared to hemodialysis 1

Clinical Significance

These symptoms have important clinical implications:

• Associated with malnutrition, poor health-related quality of life, and depression 1, 5
• May lead to inadequate nutritional intake and protein-calorie malnutrition 6
• Can significantly impact patients' quality of life and treatment adherence 7

Management Considerations

While management has not been studied systematically in CKD 1, several approaches may help:

• Ensuring adequate dialysis (pruritus and potentially other uremic symptoms are more common in underdialysed patients) 1
• Earlier initiation of dialysis may prevent or potentially reverse deterioration in nutritional status 1
• Use of prokinetics in cases of associated gastroparesis, especially in diabetic patients 3
• Consideration of enteral nutrition via nasojejunal tube in patients with severe gastroparesis 3

Monitoring Recommendations

Regular monitoring of these symptoms is important:

• Assessment of nutritional status through serum albumin levels and estimated daily protein intake 3
• Regular evaluation of gastrointestinal symptoms as part of routine care 3
• Use of validated symptom assessment tools to track symptom burden over time 7

In conclusion, nausea and vomiting are extremely common symptoms in ESRD patients on dialysis, affecting a substantial proportion of this population. Recognizing and addressing these symptoms is essential for improving nutritional status, quality of life, and potentially long-term outcomes in these patients.