The gastrointestinal (GI) tract can be the source of a lot of frustration and turmoil for people experiencing motility dysfunction, nausea, vomiting, and more. Unfortunately, solving the issues are not always straight forward and often require trial and error. It’s important to work with patients closely and help them maintain motivation as they go through the process of identifying aggravating foods, playing around with meal timing and composition, and exploring unique approaches. That’s because patients with chronic GI issues may begin to avoid or significantly reduce their oral intake in order to avoid symptoms which can lead to nutrient imbalances and protein-energy wasting.

Consider this scenario:
A middle-aged man with history of irritable bowel syndrome and working on losing weight adopts a lunchtime salad approach to reduce calories
and increase vegetable consumption. However, about an hour after lunch he would experience bathroom urgency and loose stools. The result
was increased stress, embarrassment, and ultimately became a barrier to his health goals. He became discouraged and avoided vegetables all together.
As we began working together, we explored the specifics around his lunch salad. While vegetable-heavy, it was not a very balanced meal. He experimented with adding a carbohydrate in the form of a grain or whole grain bread with his lunch, something he had been hesitant to do because he believed carbohydrates would prevent weight loss. The change immediately resolved his bathroom urgency after lunch. Embarrassment and discomfort significantly reduced. Once we had crossed that hurdle, we went on to explore ways to resolve lingering gut dysbiosis, introducing and removing foods as uniquely tolerated and adding a probiotic to his regimen.

This is just one example. Within the end stage renal disease (ESRD) population, there are likely many more. That’s because the evidence suggests
the prevalence of GI issues in dialysis is 77%-79%. Helping patients resolve their unique GI challenges will require collaboration and experimentation.
Read on for some adaptable strategies.

Explore Possible Aggravators
Identifying GI issue triggers requires looking into food, medication, stress levels, and more. Often, high fat and spicy foods are at the top of the list
for aggravating foods, but not always. It can be helpful to have patients track their symptoms which is of course easier said than done.

To make tracking easier, you could explore the use of phone-based apps. For example, the TransplantLyfe365 app, a kidney-friendly app available for free,
can help patients track medication, symptoms, intake of specific foods and supplements, and add notes on nutrition.

Patients may be further motivated to keep records if they are time limited, expectation are set early in the process, and you remain committed to rooting out the cause of their issues with contingency plans in place to refer out as needed.

Think Outside the Box
Nausea and vomiting are some of the most common concerns in ESRD. While often ascribed to GI issues, nausea can have many causes.
To help manage nausea, patients can turn to medication like ondansetron or explore alternatives including:

  • Ginger chews or ginger tea, if fluid allowance permits
  • Sugar-free mints or peppermint aromatherapy
  • Deep breathing exercises
  • Avoiding starting dialysis with a completely empty stomach

Vomiting may be a less frequent but potentially greater concern, especially if it is frequent and/or chronic. If your patient is experiencing other symptoms along with vomiting such as early satiety, epigastric pain, and bloating, they should be considered for a gastroparesis work-up.

Consider Dysbiosis
Bowel movements moving too fast and too slow are both problems. Too fast means malabsorption, bathroom urgency, and emotional distress.
Too slow can contribute to hyperkalemia and hyperphosphatemia in the ESRD population along with physical discomfort and changes in appetite.

Introducing a probiotic supplement can improve motility issues on both sides of the issue. Evidence supports that they can help slow down motility
in the setting of diarrhea as well as resolve functional constipation. Further research identifies probiotics with multiple species and strains,
given for a longer duration, and at higher doses are most effective. To learn more about probiotics and gut dysbiosis, you can join our monthly webinar
this November.

For additional resources on GI issues, visit our Clinician Portal.

References

  • Khan, A., Mushtaq, M., Movva, G., Sohal, A., & Yang, J. (2025). Gastrointestinal disease in end-stage renal disease. World Journal of Nephrology, 14(1), 101917.
  • Snelson, M., Biruete, A., McFarlane, C., & Campbell, K. (2020). A Renal Clinician’s Guide to the Gut Microbiota. Journal of Renal Nutrition.
  • Zhang, C., Jiang, J., Tian, F., Zhao, J., Zhang, H., Zhai, Q., & Chen, W. (2020). Meta-analysis of randomized controlled trials of the effects of probiotics on functional constipation in adults. Clinical Nutrition, 39(10), 2960-2969.
  • Mafra, D., Borges, N., Alvarenga, L., Esgalhado, M., Cardozo, L., Lindholm, B., & Stenvinkel, P. (2019). Dietary components that may influence the disturbed gut microbiota in chronic kidney disease. Nutrients, 11(3), 496.

We thank our guest blogger Maiya Slusser, MS, RDN, CD, CNSC, Director, Research and Education for sharing her knowledge and writing this blog post!