Constipation Management in ESRD Patients
First-Line Recommendation
For adults with end-stage renal disease and constipation, start with polyethylene glycol (PEG) 17 grams mixed in 8 ounces of water once daily, titrating up to twice daily if needed, as it is the safest and most effective option with no renal accumulation risk. 1
Treatment Algorithm
Step 1: Initiate PEG as First-Line Therapy
- PEG 17 grams once daily mixed in 8 ounces of water is the preferred initial treatment 1
- Can be titrated up to twice daily if no response after 48 hours 1
- PEG is safe for long-term use in ESRD with durable response up to 6 months 1
- Goal: achieve 1 non-forced bowel movement every 1-2 days 1
Step 2: Add Stimulant Laxative if PEG Alone Fails
- If constipation persists after 4 weeks of PEG, add bisacodyl 10-15 mg daily 2, 1
- Alternative: senna 15-30 mg at bedtime 1
- Stimulant laxatives are appropriate for short-term use or rescue therapy 2
Step 3: Consider Advanced Therapies for Refractory Cases
- Prucalopride 2 mg once daily after failure of first-line treatments 1
- Lubiprostone or linaclotide as second-line agents 1, 3
- These agents have limited systemic absorption and appear safe in CKD 3
Critical Medications to AVOID in ESRD
Magnesium-Based Laxatives: CONTRAINDICATED
- Avoid magnesium oxide, magnesium citrate, and all magnesium-containing laxatives in ESRD due to high risk of life-threatening hypermagnesemia 2, 3
- Magnesium accumulation occurs because renal excretion is the primary elimination route 4
- This is a common pitfall—magnesium laxatives are frequently used in general populations but are dangerous in ESRD 3
Bulk-Forming Laxatives: NOT RECOMMENDED
- Avoid psyllium and other bulk laxatives as they may have insufficient efficacy and can worsen symptoms in ESRD patients with restricted fluid intake 2, 3
Lactulose: Use with Extreme Caution
- Lactulose 30-60 mL BID-QID may be considered as a last resort only 2
- However, it has low certainty of evidence and can worsen diarrhea, particularly problematic in dialysis patients 2
- Despite some studies suggesting reno-protective effects, its practical use in ESRD is limited 3
Special Considerations for ESRD Population
Why Constipation is More Prevalent
- Constipation affects up to 37% of ESRD patients, peaking immediately after dialysis transition 5
- Contributing factors include dietary restrictions (low fiber, fluid restriction), phosphate binders, iron supplements, opioid analgesics, and reduced physical activity 5, 3
Medication Review is Essential
- Anticoagulants, oral iron supplements, opioid analgesics, antihistamines, and non-opioid analgesics are independently associated with constipation in ESRD 5
- Review and minimize constipating medications whenever possible 5
Impact on Kidney Function
- Constipation is associated with worsening kidney function and increased risk of CKD progression 3
- Effective management may have protective effects beyond symptom relief 3
Dosing Adjustments and Safety
PEG Requires No Dose Adjustment
- PEG does not accumulate in renal failure and requires no dose modification 1
- This makes it uniquely safe compared to other laxative classes 3
Prucalopride Requires Dose Reduction
- If using prucalopride for refractory constipation, reduce dose to 1 mg once daily in ESRD patients 3
- Standard 2 mg dose should not be used 3
Tenapanor: Dual Benefit Option
- Tenapanor blocks intestinal phosphate absorption in addition to treating constipation 3
- Provides additional benefit for ESRD patients with hyperphosphatemia and constipation 3
- Consider this agent when both conditions coexist 3
Common Pitfalls to Avoid
Do not use magnesium-based laxatives—this is the most dangerous error, as magnesium accumulation can cause cardiac arrhythmias and death 2, 3
Do not assume standard dosing applies—many medications require adjustment in ESRD, though PEG fortunately does not 4
Do not overlook medication-induced constipation—review and minimize opioids, iron supplements, and phosphate binders when possible 5
Do not use bulk laxatives in fluid-restricted patients—they require adequate hydration to work and can worsen symptoms 2, 3
Do not forget that laxative use peaks around dialysis transition—anticipate increased need during this period 5