Managing Symptoms of Nausea and Fatigue in Peritoneal Dialysis Patients

Peritoneal dialysis, but my physical condition has been very poor recently?

Dear Dr.
Wu,
My mother has a history of hypertension for over 30 years.
In January of this year, she was hospitalized for treatment due to renal failure and is currently undergoing peritoneal dialysis.
Prior to starting treatment, there was a delay, during which she experienced persistent vomiting regardless of what she ate, and her energy levels were very low.
After hospitalization, her condition improved.
However, two weeks ago, she suddenly exhibited the same symptoms again.
The hospital arranged for her to be admitted for treatment, where it was discovered that she has gastroesophageal reflux disease (GERD) and a gastric ulcer.
The doctor indicated that there was no major concern.
An ultrasound of the spleen was performed, and it appeared to be normal.
She was prescribed medication and discharged home.
Since her discharge, her condition has not improved.
Even after taking gastric medication, she begins to vomit before eating.
When we returned to the hospital, the doctor only prescribed antiemetic medication.
She has been consistently undergoing peritoneal dialysis treatment, and I am puzzled as to why she is experiencing symptoms similar to those before treatment.
Although they are not identical, they are quite similar.
If the issue is solely related to the gastric ulcer, could it lead to such results? She often expresses that she is very hungry, yet she vomits after eating.
She feels fatigued and lacks energy throughout the day.
I would like to ask the doctor if you could provide guidance on further examinations or offer some medical advice.
Thank you.

Joi, 20~29 year old female. Ask Date: 2012/11/23

Dr. Wu Jiyu reply Internal Medicine

1.
Based on your description, I infer that your mother has been undergoing peritoneal dialysis for about 10 months.
Theoretically, you should have a certain level of familiarity with the peritoneal dialysis nurse.
You can discuss or clarify the symptoms you described with your mother's peritoneal dialysis nurse (or even the nephrologist) regarding the details of the peritoneal dialysis treatment (I won't elaborate further here).

2.
Regarding the gastrointestinal aspect, you mentioned that your mother started experiencing symptoms about two weeks ago, and during her hospitalization, it was discovered (I assume through an endoscopy) that she has gastroesophageal reflux disease (GERD) and a gastric ulcer.
She is currently on medication.
"If it is just related to the gastric ulcer, could it lead to such results?" In fact, gastroesophageal reflux can also cause recurrent nausea and vomiting.
This condition (along with gastric ulcers) typically requires treatment for about 3-6 months, and sometimes symptoms may resolve more slowly (we have encountered cases where patients with only superficial gastritis, a milder condition than GERD or gastric ulcers, experienced vomiting and upper abdominal pain for nearly a month, and they were otherwise healthy middle-aged professionals).
I suggest you discuss this with a gastroenterologist as well.
Additionally, it may be worth considering whether to increase the dosage of that effective gastric medication (I assume your mother is on a proton pump inhibitor, which is a good but expensive medication) to twice daily (of course, the additional dose would need to be purchased out-of-pocket) to see if it helps.

Based on your description above, I infer that your peritoneal dialysis physician has likely reviewed the details of the peritoneal dialysis treatment carefully, which led to the arrangement of the endoscopy, revealing GERD and a gastric ulcer.
After about a week of treatment with a good gastric medication (PPI), you feel that your mother's symptoms have not significantly improved...
Some simple conditions still need to be ruled out, such as constipation or whether there are factors affecting her condition, such as congestive heart failure +/- pulmonary edema.

Reply Date: 2012/11/23

More Info

Managing symptoms of nausea and fatigue in patients undergoing peritoneal dialysis can be quite challenging, especially in the context of underlying conditions such as hypertension, gastroesophageal reflux disease (GERD), and peptic ulcers. Your mother's situation is complex, and it is understandable that you are seeking clarity and guidance on how to manage her symptoms effectively.

Firstly, it is important to recognize that nausea and vomiting can be common symptoms in patients undergoing dialysis, particularly peritoneal dialysis. This can be due to a variety of factors, including the accumulation of toxins in the body due to kidney failure, dietary changes, and the effects of medications. In your mother's case, the recent diagnosis of GERD and peptic ulcers adds another layer of complexity, as these conditions can also contribute to nausea and vomiting.

The fact that your mother has a long history of hypertension and is now experiencing renal failure suggests that her kidneys have been under significant stress for an extended period. This can lead to a buildup of waste products in the bloodstream, which can cause symptoms such as fatigue and malaise. Additionally, the process of peritoneal dialysis itself can sometimes lead to gastrointestinal symptoms, including nausea, particularly if the dialysate solution is not well tolerated.

Given that your mother has been experiencing recurrent vomiting and fatigue, it is crucial to address the underlying causes. Here are some recommendations that may help manage her symptoms:
1. Dietary Modifications: It may be beneficial to work with a dietitian who specializes in renal nutrition. They can help create a meal plan that minimizes nausea while ensuring she receives adequate nutrition. Small, frequent meals that are low in fat and easy to digest may be more tolerable. Avoiding spicy, acidic, or highly seasoned foods can also help reduce gastric irritation.

2. Medication Review: Since your mother is on medications for her conditions, it is important to review these with her healthcare provider. Some medications can exacerbate nausea or interact with each other, leading to increased side effects. The use of antiemetics (medications to prevent nausea and vomiting) should be considered, especially if her symptoms are severe.

3. Monitoring Dialysis Treatment: Ensure that her peritoneal dialysis is being conducted properly. Sometimes, adjustments in the dialysis regimen or the type of dialysate used can alleviate gastrointestinal symptoms. Discuss with her nephrologist whether any changes are necessary.

4. Further Investigations: If her symptoms persist despite these interventions, further investigations may be warranted. This could include imaging studies such as an abdominal ultrasound or CT scan to rule out any complications related to her dialysis or gastrointestinal issues. Additionally, an upper endoscopy may be considered to directly visualize the esophagus and stomach, especially if peptic ulcer disease is suspected to be contributing to her symptoms.

5. Hydration and Electrolyte Balance: Maintaining proper hydration and electrolyte balance is crucial in dialysis patients. Dehydration can worsen fatigue and nausea. Ensure that she is receiving adequate fluids, either orally or through her dialysis treatment.

6. Psychosocial Support: Chronic illness can take a toll on mental health. Providing emotional support and considering counseling or support groups may help improve her overall well-being.

In conclusion, managing nausea and fatigue in peritoneal dialysis patients requires a multifaceted approach that addresses dietary needs, medication management, and potential underlying conditions. It is essential to maintain open communication with her healthcare team to ensure that her symptoms are adequately addressed and that she receives comprehensive care. If her symptoms do not improve, do not hesitate to seek a second opinion or further evaluation from specialists in nephrology or gastroenterology.

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