What is a recommended stool softener for patients with End-Stage Renal Disease (ESRD)?

Recommended Stool Softener for ESRD Patients

Polyethylene glycol (PEG/Macrogol) is the preferred stool softener for patients with end-stage renal disease, as it causes virtually no net gain or loss of sodium and potassium and can be used safely in renal impairment. 1, 2

Why PEG is Preferred in ESRD

• PEG has a superior safety profile in renal disease because it does not cause electrolyte disturbances, unlike magnesium-based laxatives which can lead to hypermagnesemia in renal impairment 1
• The American College of Oncology strongly endorses PEG as the preferred osmotic laxative based on systematic reviews, with typical dosing of one capful with 8 oz of water twice daily 2
• PEG is more effective than liquid paraffin (mineral oil) and avoids the risks of aspiration pneumonia, anal seepage, and skin excoriation 1, 2

What to Avoid in ESRD

• Magnesium and sulfate salts must be used cautiously or avoided in renal impairment due to risk of hypermagnesemia from excessive doses 1, 2
• Sodium phosphate enemas are contraindicated in ESRD patients with creatinine clearance <60 mL/min/1.73 m² due to risk of serious electrolyte disturbances 3
• Docusate sodium (stool softener) is not recommended as its use in palliative care is based on inadequate experimental evidence, and research shows it is less effective than sennosides alone 1, 4

Treatment Algorithm for Constipation in ESRD

First-line oral therapy:

• Start with PEG (polyethylene glycol) as the primary osmotic laxative 2
• If constipation persists, add a stimulant laxative (senna or bisacodyl) rather than increasing PEG alone 2

For opioid-induced constipation in ESRD:

• Combine PEG with a stimulant laxative (senna or bisacodyl) from the start 2
• Avoid bulk-forming laxatives (psyllium) as they are not recommended for opioid-induced constipation 2

If oral therapy fails after several days:

• Perform digital rectal exam to assess for fecal impaction 1
• If rectum is full, use glycerin suppositories or bisacodyl suppositories as first-line rectal therapy 1, 3
• Avoid sodium phosphate enemas in ESRD; if enema is necessary, use hyperosmotic saline or oil retention enemas 1, 3

Critical Safety Considerations

• Bisacodyl is the preferred rectal option over sodium phosphate in patients with renal impairment 3
• Lactulose can be used as an alternative osmotic agent if PEG is unavailable, though it has a 2-3 day latency period and may cause bloating 1, 2
• Enemas are contraindicated in patients with neutropenia, thrombocytopenia, recent colorectal surgery, or undiagnosed abdominal pain 1, 3, 2

Common Pitfalls to Avoid

• Do not use docusate as monotherapy - research demonstrates it is ineffective compared to stimulant laxatives alone, even when combined with sennosides 4
• Do not prescribe magnesium-containing laxatives without checking renal function - these are commonly used but dangerous in ESRD 1
• Do not use sodium phosphate products (enemas or oral preparations) in any patient with creatinine clearance <60 mL/min 3