What are the management options for patients experiencing nausea after dialysis?

Management of Nausea After Dialysis

For patients experiencing nausea after dialysis, ondansetron (8 mg IV or oral) is more effective than metoclopramide and should be the first-line antiemetic, while simultaneously investigating and addressing the underlying cause—whether uremia, dialysis disequilibrium syndrome, gastroparesis, or inadequate dialysis dose. 1

Immediate Pharmacologic Management

First-Line Antiemetic Therapy

• Administer ondansetron 8 mg intravenously or orally as the preferred initial agent, as it demonstrates approximately twice the efficacy of metoclopramide in controlling uremia-induced nausea and vomiting (objective improvement score 2.80 vs 1.40, p<0.005). 1
• Ondansetron can be repeated every 4-6 hours for breakthrough symptoms, not exceeding 24 mg in 24 hours. 2
• For persistent nausea despite ondansetron, switch to scheduled around-the-clock dosing rather than as-needed administration. 2

Alternative and Adjunctive Agents

• If ondansetron is contraindicated or ineffective, use dopamine receptor antagonists: metoclopramide 20-30 mg orally 3-4 times daily, prochlorperazine 10-20 mg 3-4 times daily, or haloperidol, titrated to maximum benefit and tolerance. 3, 4
• For refractory nausea, add medications with different mechanisms rather than increasing ondansetron frequency: consider 5-HT3 antagonists, anticholinergics, antihistamines, or corticosteroids. 3, 2

Identify and Address Underlying Causes

Assess for Inadequate Dialysis (Uremia)

• Nausea and vomiting are acknowledged symptoms of uremia and indicate potential dialysis inadequacy. 3
• Measure weekly Kt/V and evaluate if the patient meets adequacy targets (Kt/V ≥1.2 for hemodialysis). 3
• Check nutritional markers: serum albumin, normalized protein nitrogen appearance (nPNA), and dietary protein intake (DPI), as uremic patients tend to have decreased protein intake and spontaneous DPI decreases with worsening kidney function. 3
• Approximately 60% of patients suffer from nausea/vomiting at dialysis initiation, indicating high likelihood of malnutrition in this population. 3

Evaluate for Dialysis Disequilibrium Syndrome (DDS)

• DDS presents with nausea, vomiting, restlessness, and headache in mild forms, caused by cerebral edema from rapid urea removal during hemodialysis. 5, 6
• This occurs primarily in grossly azotemic patients, especially those with severe metabolic acidosis, when dialysis removes urea faster from blood than from brain. 5
• Prevention requires decreasing dialysis efficiency in high-risk patients: shorten initial dialysis duration to 25-30% of normal, lower blood flow or dialysate flow rate, use a less efficient dialyzer, or combine these approaches while increasing dialysis frequency. 5

Assess for Gastroparesis (Peritoneal Dialysis Patients)

• Gastric emptying is significantly impaired in PD patients, particularly when glucose-containing dialysate is present in the peritoneal cavity. 7
• The delay results from absorption of substrate substances with caloric/metabolic activity (glucose, glycerol, amino acids), not merely volume or pressure effects. 7
• PD patients may experience decreased appetite, early satiety, and typically lose 5-15 g protein and 2-4 g amino acids per day in dialysate (equivalent to 0.2 g protein/kg/day). 3
• Consider switching from glucose-containing dialysate to icodextrin, which causes less gastric emptying delay. 7

Dialysis-Specific Interventions

For Hemodialysis Patients with Intradialytic Symptoms

• Increase dialysate sodium concentration (148 mEq/L) early in the session with continuous or stepwise decrease later ("sodium ramping") to minimize nausea and other intradialytic symptoms. 3
• Convert from acetate-containing to bicarbonate-containing dialysate, which results in fewer headaches and less nausea and vomiting. 3
• Reduce dialysate temperature from 37°C to 34-35°C to decrease symptomatic hypotension (which can trigger nausea), reducing incidence from 44% to 34%. 3

For Peritoneal Dialysis Patients

• Monitor for peritonitis, as protein losses double even after mild episodes and can exacerbate uremic symptoms. 3
• Evaluate if patient is changing timing of exchanges (shortening some, lengthening others excessively), leading to inadequate dialysis and uremic symptoms. 3
• Assess nonadherence by checking supplies ordered, home supply inventory, and cycler memory system if available. 3

Special Considerations for Diabetic Patients

• Exercise caution to prevent hypoglycemic episodes in diabetic dialysis patients experiencing nausea or gastrointestinal complaints, as hypoglycemia may be worsened by nausea and inability to eat, plus longer drug duration and increased insulin half-life. 3
• Insulin doses and oral hypoglycemic doses may change substantially during transition to dialysis due to decreased insulin catabolism with further kidney function loss. 3

Monitoring and Follow-Up

• Routinely assess symptom burden using standardized tools, as only half of hemodialysis patients with symptoms receive appropriate treatment. 3
• The six most important symptoms in dialysis patients are tiredness, cramps, pruritus, dyspnea, headaches, and joint pain, with nausea/vomiting being a significant but less prevalent concern. 8
• Symptoms are often long-standing, occur frequently, and show little difference in prevalence between hemodialysis and peritoneal dialysis patients. 8
• High discordance exists between symptoms experienced by dialysis patients and those identified by nephrology providers—address this by directly asking patients about nausea and its impact on daily functioning. 3