Using Polyethylene Glycol 3350 Plus Electrolytes in Constipated Hemodialysis Patients: A Case SeriesⅢ

Despite the high prevalence of chronic constipation in hemodialysis patients, there have been few clinical reports on the use of laxatives. Although PEG is not contraindicated to hemodialysis patients and has been widely used as the preparation for colonoscopy at a higher single dose, the efficacy and safety of PEG in continuous use as a laxative among hemodialysis patients have not been elucidated. This is the first report to assess the efficacy and safety of PEG 3350+E for continuous use in hemodialysis patients. 

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The administration of PEG3350+E resulted in a significant increase in the rate of SBMs and CSBMs in constipated hemodialysis patients. The ratio of BMs with ideal stool consistency also increased significantly. The improvement of the JPAC-QOL score may reflect these efficacies. By adding PEG3350+E, the number of stimulant laxatives dramatically decreased, and four (Case 1, 2, 5, 6) out of seven patients overcame their dependence on the long-term continuous use of stimulant laxatives. Even the three partial responders (Cases 3, 4, 7) were able to reduce their stimulant laxative amount to some degree after adding PEG3350+E. 

This was a meaningful outcome in the patients who were completely or partly relieved from the risk of intractable constipation caused by physical tolerance and psychological dependence on stimulant laxatives. These results indicate the positive impact of PEG3350+E on the treatment of constipated hemodialysis patients. However, there were no significant changes in the ratio of BMs with no straining. Although the reduction in stimulant laxatives increased SBMs and CSBMs, it also led to the attenuation of evacuation strength derived from stimulant laxatives. This may be the reason why no improvement in straining was observed in this study. 

Next, we assessed the safety of PEG3350+E in continuous use among hemodialysis patients, since a certain amount of water is required to take the medicine, and the drug contains sodium, both of which can cause adverse effects on hemodialysis patients. As a result, the continuous administration of PEG3350+E did not change the SBP, body weight gain, serum levels of sodium, potassium,m or album,n or the sodium chloride intake in constipated hemodialysis patients. This indicates that the water needed for reconstitution of PEG3350+E and ingredients of PEG3350+E might not be absorbed into the patients. However, the significant elevation of DBP observed suggests two possibilities. 

First, the small amount of water needed for the reconstitution of PEG3350+E might be partly absorbed via the intestine. Alternatively, the reduction in stimulant laxatives may increase the absorption of water in the intestine via the attenuation of the evacuation strength, which might lead to the retention of water. 

However, neither possibility is clear, as the SBP and body weight did not change statistically. The discrepancy between the SBP and DBP was unclear; however, one possibility is that medications for blood pressure may have masked the change in the SBP. Even though the accurate assessment of the water absorption and blood pressure in hemodialysis patients was difficult, water and sodium loading with PEG3350+E did not induce serious adverse effects on the body fluid retention or blood pressure in this study. Therefore, we believe that PEG3350+E can be safely used in hemodialysis patients. According to the data on the dose of PEG3350+E in Fig. 2B, partial responders (Case 4, 7) took a relatively high dose of PEG3350+E, indicating that the effect of PEG3350+E for these patients was limited. The difference in the response to PEG3350+E between responders and partial responders was unclear. 

However, we speculated that an increase in lanthanum carbonate for hyperphosphatemia may have affected the resistant response for PEG3350+E, as lanthanum carbonate can cause gastrointestinal side effects, including constipation (17, 18). Although there is no evidence of a resistant response for PEG derived from lanthanum carbonate, the increase in lanthanum carbonate for hyperphosphatemia during the intervention period in Case 7 may have affected the resistant response for PEG3350+E.

Through this study, we learned that constipated hemodialysis patients tend to defecate before a hemodialysis session because they want to avoid evacuation during hemodialysis and the assessment of excessive body weight gain. Thus, they tend to expect a predictable and immediate effect of medications on constipation, which may be one reason for their stimulant laxative dependency. As a result, in two patients (Cases 3, and 4), the dose of stimulant laxatives was beyond the recommended dose in this study. In these two cases, PEG3350+E was not able to replace stimulant laxatives completely, although the amounts of stimulant laxatives were reduced slightly. These two patients did not express any wish for an additional increase in PEG3350+E because it carried a risk of inducing excessive body weight gain if their BMs did not improve. 

In such cases, we should not continue to administer PEG3350+E, and instead, other laxatives, such as lubiprostone, linaclotide, or elobixibat, should be considered for the further reduction of stimulant laxatives. Worries about fluid accumulation and excessive body weight gain are characteristic in hemodialysis patients. Indeed, two patients discontinued PEG3350+E for that reason, although their safety parameters did not meet any reduction or discontinuation criteria. 

Therefore, the fluid accumulation and excessive body weight gain should be considered when administering PEG3350+E to hemodialysis patients. Several limitations associated with the present study warrant mention. This was a single-center, open-label, nonrandomized controlled study. 

The number of patients who participated was small, and the observation period was short. The use of stimulant laxatives may have influenced the absorption of water, so it proved to be difficult to accurately assess the safety of PEG3350+E in water absorption. However, this study suggests that the administration of PEG3350+E may decrease the use of stimulant laxatives and increase SBMs and CSBMs without causing serious adverse effects among constipated hemodialysis patients. 

In conclusion, PEG3350+E can be useful and effective for the treatment of constipation in hemodialysis patients under careful observation. Further studies are needed to assess the efficacy and safety of PEG3350+E in constipated hemodialysis patients.

Natural Herbal Medicine For Relieving Constipation-Cistanche 

Cistanche is a genus of parasitic plants that belongs to the family Orobanchaceae. These plants are known for their medicinal properties and have been used in Traditional Chinese Medicine (TCM) for centuries. Cistanche species are predominantly found in the arid and desert regions of China, Mongolia, and Central Asia. Cistanche plants are characterized by their fleshy, yellowish stems and are highly valued for their potential health benefits. In TCM, Cistanche is believed to have tonic properties and is commonly used to nourish the kidney, enhance vitality, and support sexual function. It is also used to address issues related to aging, fatigue, and overall well-being. While Cistanche has a long history of use in traditional medicine, scientific research on its efficacy and safety is ongoing and limited. However, it is known to contain various bioactive compounds such as phenylethanoid glycosides, iridoids, lignans, and polysaccharides, which may contribute to its medicinal effects.

Wecistanche's cistanche powder, cistanche tablets, cistanche capsules, and other products are developed using desert cistanche as raw materials, all of which have a good effect on relieving constipation. The specific mechanism is as follows: Cistanche is believed to have potential benefits for relieving constipation based on its traditional use and certain compounds it contains. While scientific research specifically on Cistanche's effect on constipation is limited, it is thought to have multiple mechanisms that may contribute to its potential to relieve constipation. Laxative Effect: Cistanche has long been used in Traditional Chinese Medicine as a remedy for constipation. It is believed to have a mild laxative effect, which can help promote bowel movements and induce constipation. This effect may be attributed to various compounds found in Cistanche, such as phenylethanoid glycosides and polysaccharides. Moistening the Intestines: Based on traditional use, Cistanche is considered to have moisturizing properties, explicitly targeting the Intestines. Promoting hydration and lubrication of the Intestines may help soften tools and facilitate easier passage, thereby relieving constipation. Anti-inflammatory Effect: Constipation can sometimes be associated with inflammation in the digestive tract. Cistanche contains certain compounds, including phenylethanoid glycosides and lignans, that are believed to have anti-inflammatory properties. By reducing inflammation in the intestines, it may help improve bowel movement regularity and relieve constipation.