Do you ever feel like your dialysis patients ALWAYS have complaints about gastrointestinal (GI) issues? In my many years of caring for people on dialysis,
I found these concerns to be common and frequently voiced by my patients. Given the number of things that can cause GI issues, it can be easy to focus
on managing symptoms or even watching and waiting to see if they improve. Unfortunately, for people on dialysis, sometimes the symptoms are related
to gastroparesis, a serious condition which can have a significant impact on patient outcomes. As clinicians, it’s important to understand the bigger picture of our patients’ symptoms and to consider the impact that gastroparesis has on nutrition status and quality of life for people with ESKD.

Gastroparesis in Dialysis
Gastrointestinal (GI) symptoms are common in people on dialysis, with an estimated 32% to 85% of patients affected. Dyspepsia is the most common complaint, characterized by nausea, vomiting, abdominal distension, abdominal pain, bloating, belching early satiety, and anorexia. These symptoms
may be related to delayed gastric emptying, the hallmark of gastroparesis. While gastroparesis is a common complication of diabetes, other conditions,
such as uremia, scleroderma, amyloidosis, ulcers, GI surgery, and medications like anticholinergics, opioids, and GLP-1 receptor agonists can also negatively impact gastric emptying.
Van et al. showed that gastric emptying is impaired in people on peritoneal dialysis as compared to healthy controls, even when the peritoneal cavity
is empty. Additionally, they demonstrated that the dextrose content of peritoneal dialysate influenced the severity of delayed gastric emptying.
Several studies have demonstrated that gastroparesis is more common in people with end-stage kidney disease (ESKD) as compared to healthy populations. Approximately one-third of people on dialysis experience delayed gastric emptying and its negative impact on nutrition status and quality of life.
In a small study, Van Vlem et al. demonstrated an inverse correlation between delayed gastric emptying and serum albumin in people on hemodialysis.

Normal Stomach Function vs. Gastroparesis
A healthy stomach effectively digests food through enzymatic action and empties the resulting chyme into the small intestine. Coordinated muscle contractions, hormones, and the vagus nerve influence normal gastric functioning. In gastroparesis, motility is impaired, delaying gastric emptying. Dysfunction of the vagus nerve plays a key role, leading to uncoordinated muscle contractions in the gut. As a result, food remains in the stomach longer, causing the symptoms of dyspepsia previously described.

Diagnosis
Gastroparesis is traditionally diagnosed using a radiolabeled meal and the imaging technique scintigraphy, measuring the amount of the meal remaining
in the stomach at specific points in time. Gastroparesis has also been evaluated and diagnosed using abdominal ultrasound, breath tests, endoscopy, x-rays, and wireless motility capsules.

Consequences of Gastroparesis
Gastroparesis is a form of impaired gut function. In addition to the negative impacts on quality of life, gastroparesis increases nutrition- and health-related risks for those affected. Malnutrition and weight loss may occur as the result of decreased food intake and/or vomiting. Glycemic control may become increasingly difficult in people with diabetes. For people experiencing vomiting, there is an increased risk of aspiration pneumonia, which in turn increases the risk of hospitalization and poor outcomes.

Management Approaches for Gastroparesis
Management of gastroparesis may require a variety of interventions, depending on symptoms and severity. Eating small, frequent meals is a relatively easy strategy that may be effective. Decreasing fat and fiber intake may help to reduce gastric emptying time. Including liquid foods or nutritional supplements may be necessary if the intake of solid food is inadequate.
In addition to dietary modifications, pharmaceutical interventions may also be beneficial. Prokinetic agents, such as metoclopramide or erythromycin
may be used to improve gut motility. Anti-nausea medications may also be helpful. Adjusting medications that may worsen gastroparesis is also beneficial. In severe cases, surgical interventions may be necessary.
Some patients may require more advanced nutrition support in the context of gastroparesis. For dialysis patients who are able to tolerate some degree
of oral diet and/or supplements but are not able to achieve adequate nutrient intake, intradialytic parenteral nutrition (IDPN) or intraperitoneal nutrition (IPN) may be a beneficial supportive therapy to prevent or reverse malnutrition or protein-energy wasting. For patients unable to tolerate oral diet, tube feeding via jejunostomy may be required.

Interdisciplinary Care to Improve Outcomes with Gastroparesis
The next time you’re rounding on your dialysis patients and hear concerns of dyspepsia, pull up a stool and take some time to assess the bigger picture
of your patients’ symptoms. A thorough assessment in collaboration with the interdisciplinary team may reveal suspected gastroparesis. Understanding
the impaired nutrient utilization associated with this GI dysfunction will guide your plan of care to help your patients feel their best.

References

  • Gupta R, Pokhriyal AS, Jindal P, et al. Evaluation of gastric emptying by ultrasonography after recommended fasting period and administration of prokinetic in end-stage renal disease patients. Anesth Essays Res. 2020;14(1):42–48.
  • Ives D, Brown S, Phillips S. Gastroparesis in the Chronic Kidney Disease Patient: Clinical Management and Implications for Practice. J Ren Nutr. 2023 Jul;33(4):e1-e3. doi: 10.1053/j.jrn.2021.12.002. Epub 2022 Mar 12. PMID: 35292400.
  • Van V, Schoonjans RS, Struijk DG, Verbanck JJ, Vanholder RC, Van B, Lefebvre RA, De V, Lameire NH. Influence of dialysate on gastric emptying time in peritoneal dialysis patients. Perit Dial Int. 2002 Jan-Feb;22(1):32-8. PMID: 11929141.
  • Van Vlem B, Schoonjans R, Vanholder R, De Vos M, Vandamme W, Van Laecke S, Lameire N. Delayed gastric emptying in dyspeptic chronic hemodialysis patients. Am J Kidney Dis. 2000 Nov;36(5):962-8. doi: 10.1053/ajkd.2000.19094. PMID: 11054352.
  • Wang C, Chen C, Wang J, Guo X, Deng YC, Liu L, Zhao C. Delayed gastric emptying in nondiabetic patients with end-stage kidney disease. Ren Fail. 2022 Dec;44(1):329-335. doi: 10.1080/0886022X.2022.2030754. PMID: 35188060; PMCID: PMC8865106.

We thank our guest blogger, Rory C. Pace, MPH, RD, CSR, FAND, FNKF Nutrition Therapy Consultant, for sharing his knowledge and insights
in this important blog post!