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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 183-189

Prevalence of constipation among peritoneal dialysis patients in Saudi Arabia: A single-center study


1 Department of Medicine, Nephrology Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
3 Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
4 Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
5 Department of Radiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

Date of Submission23-Sep-2020
Date of Decision10-Dec-2020
Date of Acceptance13-Dec-2020
Date of Web Publication13-Apr-2021

Correspondence Address:
Ahmad Raed Tarakji
Department of Medicine, Nephrology Unit, College of Medicine, King Saud University, P.O. Box 300158, Riyadh 11372
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsm.jnsm_120_20

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  Abstract 


Objectives: Constipation among peritoneal dialysis (PD) patients can lead to serious complications and impair the quality of life. The aim of this study was to determine the prevalence of constipation and its associated factors among PD patients in our center. Methods: A quantitative, cross-sectional study was conducted on PD patients at King Khaled University Hospital in Riyadh, Saudi Arabia, from November 2016 to January 2017. Results: A total of 36 PD patients were included; the male to female ratio was 1. Based on a self-reporting questionnaire, 15 PD patients (41.7%) reported suffering from constipation. However, the prevalence was the same using at least one of Rome III criteria (41.7%) and much lower using Bristol stool form Scale (11%). No significant difference was detected between PD patients with and without constipation in terms of dietary fiber intake, use of calcium and iron supplements, water intake, presence of diabetes and hypertension, or demographic profiles. Conclusion: The high prevalence of constipation among PD patients seen in our population is comparable to those seen in other studies.

Keywords: Constipation, peritoneal dialysis, prevalence, Saudi Arabia


How to cite this article:
Tarakji AR, Alorabi HZ, Alhusainy YA, Alhowaish NY, Alsebti AA, Aljutaili HS. Prevalence of constipation among peritoneal dialysis patients in Saudi Arabia: A single-center study. J Nat Sci Med 2021;4:183-9

How to cite this URL:
Tarakji AR, Alorabi HZ, Alhusainy YA, Alhowaish NY, Alsebti AA, Aljutaili HS. Prevalence of constipation among peritoneal dialysis patients in Saudi Arabia: A single-center study. J Nat Sci Med [serial online] 2021 [cited 2021 Jun 13];4:183-9. Available from: https://www.jnsmonline.org/text.asp?2021/4/2/183/313639




  Introduction Top


Chronic constipation has an impact on patient quality of life, since straining during defecation to pass hard stool or having infrequent/incomplete evacuation can impair a person's general health, social life, and mental health.[1] The medications used to treat chronic constipation are also more expensive than the cost of managing irritable bowel syndrome.[1],[2] Several methods are available to assess and diagnose constipation. One is the Bristol stool form scale (BSFS), which is a validated, reliable, and convenient tool for assessing chronic constipation.[3],[4],[5],[6] The Rome III criteria is another well-known tool, although some concerns regarding its limitations have been raised in the literature.[7],[8] Nevertheless, the Rome III is still considered a suitable reference tool in most recent studies for defining functional gastroenterological disorders, such as functional constipation.[7],[8]

The pooled prevalence of chronic idiopathic constipation in the general population determined in different studies ranges between 7% and 14%.[9],[10] For Saudi Arabia, we were able to find only one study that reported a perceived bowel irregularity in 18.1% of the respondents but without specifying the percentage of constipation.[11] Therefore, we conducted an internet-based pilot study and found a prevalence of 42%, 60%, and 25% by self-reporting, Bristol, and Rome II criteria, respectively, in the general population in Saudi Arabia.[12] A subsequent study conducted in the central region of Saudi Arabia found a presence of constipation in only about 4% of the population.[13]

Constipation is not normally considered life-threatening in healthy persons, but it is a risk factor of peritonitis in patients undergoing peritoneal dialysis (PD),[14] one of the effective treatments for patients with end stage renal disease.[3] PD involves filling and draining the peritoneal cavity with special fluid through a transcutaneous PD catheter, and one of the challenges of PD is to have a good functioning catheter, which requires regular bowel movements. In contrast to hemodialysis patients, PD patients with constipation have impaired health-related quality of life; therefore; more attention should be paid to PD patients.[15] PD patients have higher scores for constipation than the general population using the gastrointestinal symptom rating scale,[14] although some studies have refuted that claim.[16] PD patients also suffer more reflux symptoms and eating dysfunctions (such as early satiety, difficulties in eating normal portion and post prandial pain), and yet constipation is still one of the main gastrointestinal symptoms.[14],[17],[18] Studies have shown that the prevalence of constipation in PD patients ranges from 6.2% to 28.9%, depending on the assessment tools used in the study.[16],[17],[18],[19],[20] For example, an Australian study showed a prevalence of constipation among PD patients of 12.3% using the Rome III criteria, 25.7% using the BSFS, and 46.3% by the patient's perception.[4]

Multiple studies have revealed diabetes as one established factor for constipation.[4],[21],[22] However, in PD patients, the results were contradictory.[14],[15],[16],[18] The diet of PD patients might have a role in the development of constipation due to low fiber and fluid intakes.[3] In general, high fiber diets or fiber supplements are used to manage constipation, though many fiber-rich foods are also rich in potassium and should be limited in PD patient diets.[23] Another study also found that PD patients have difficulty committing to high fiber diets and that fiber is better administered as supplements.[24] The use of medications such as calcium-based phosphate binders, oral iron supplements, and calcium channel blockers can also contribute to constipation.[3],[25] An increased number of daily pill intakes are associated with higher GI symptoms, including constipation, in PD patients.[18]

At the end of 2011, 13,356 patients were on dialysis in Saudi Arabia and more than 1200 patients (9.28%) were on PD.[26] These numbers, as well as the lack of previous study regarding constipation among PD patients in Saudi Arabia, prompted us to conduct the present study to identify the prevalence of constipation and its associated factors among our PD patients.


  Methods Top


A quantitative, cross-sectional study was conducted in the PD unit between November 2016 and January 2017 at King Khalid University Hospital in Riyadh, Saudi Arabia. All adult (>18 years of age) patients who had been on PD for more than 3 months were included in the study. Patients were excluded if they had a history of dementia, colitis, diabetic gastroparesis, liver or gallbladder disease, or peritonitis in the last 3 months prior to recruitment for the study.

Convenience sampling was used to recruit 36 out of total 53 patients in our PD center based on the inclusion and exclusion criteria. Information about demographics (gender, nationality, residency, age, daily activity, educational level, medical conditions, medications, liquid intake and diet) were collected from all patients.

Data about constipation were collected using a self-administered bilingual Arabic-English questionnaire to assess constipation using three tools: self-perception of constipation, Rome III criteria, and BSFS scores. The questions on the Rome III criteria for functional constipation include straining during at least 25% of defecations, lumpy or hard stools in at least 25% of defecations, sensation of incomplete evacuation for at least 25% of defecations, sensation of anorectal obstruction/blockage for at least 25% of defecations, manual maneuvers to facilitate at least 25% of defecations, and fewer than three defecations per week. Patients were asked to compare the character of their stools with the Bristol Stool Chart.[7],[8] This validated questionnaire was adopted with permission from a previous similar study.[11] Then we added Rome III criteria and BSFS from standardized published questionnaires.[12] The Arabic translation was done by the authors who are fluent in both languages and further confirmed by two other consultants. An initial pilot study was conducted among 20 normal subjects using the questionnaire to ensure language clarity.

Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 22.0 (SPSS Inc., Armonk, New York, USA). Results are expressed as numbers and percentages for categorical data. A P < 0.05 was considered statistically significant.

Ethical approval was granted by the Institutional Review Board (IRB) of the College of Medicine, King Saud University, Riyadh, Saudi Arabia (16/0552/IRB, Research Project Number E-10-2118). All participants signed a consent form. No incentives or rewards were given to participants, and their anonymity and confidentiality were guaranteed.


  Results Top


A total of 36 PD patients were included in the study: 18 (50.0%) males and 18 (50.0%) females. [Table 1] shows the detailed demographic profiles of the 36 PD patients. Thirty-one (86.1%) patients were Saudis. Sixteen patients (44.4%) had a sedentary lifestyle, and 29 patients (80.6%) were educated to at least the high school level. Among the 36 patients, 31 (86.1%) had hypertension and 12 (33.3%) had diabetes. Twenty-seven patients (75.0%) took calcium supplements, and 26 patients (72.2%) took laxatives. Fifteen patients (41.7%) claimed to have suffered from constipation. Most patients consumed rice and pasta as their main dish (n = 31, 86.1%), and a similar number consumed fruits and vegetables (n = 30, 83.3%).
Table 1: Demographic profiles of 36 peritoneal dialysis patients at King Khaled University Hospital, Riyadh, Saudi Arabia

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Based on a self-reporting questionnaire, 15 PD patients (41.7%) reported suffering from constipation. However, the prevalence was the same using at least one of Rome III criteria (41.7%) and much lower using BSFS (11%). The reported symptoms of our PD patients based on the Rome III diagnostic criteria for functional constipation is summarized in [Figure 1]. The type of stool reported by our patients based on the BSFS is shown in [Figure 2].
Figure 1: Frequencies of responses according to the Rome III diagnostic criteria for functional constipation

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Figure 2: Patient responses according to the Bristol stool form scale[6]

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Statistical analysis had shown that no significant differences were noted in the character of the stool using the Bristol chart between males and females (P = 0.359), between Saudis and nonSaudis (P = 0.470), across different age groups (P = 0.580), across different daily activities (P = 0.583), and across different educational levels (P = 0.411) [Table 2]. No significant differences in character of stool were noted according to the amount of water intake (P = 0.559), the lumpiness and hardness of stool (P = 0.181), the use of calcium-based phosphorus binders (P = 0.392), the use of laxatives (P = 0.642), the use of thyroid replacement (P = 0.960), or the sensation of having difficulty in defecation (P = 0.142), the sensation of incomplete defecation (P = 0.707), the sensation of anorectal obstruction (P = 0.557), or defecation fewer than 3 times per week (P = 0.612). However, significantly more patients with constipation had to manually facilitate defecation compared with patients who had normal stool character or those having diarrhea (P = 0.010) [Table 3].
Table 2: Demographic variables of patients according to the Bristol stool form scale

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Table 3: Patient responses to questions using the Rome III criteria and perceptions according to the Bristol stool character chart

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Of the 12 patients who had diabetes, six (50.0%) suffered from constipation; however, the difference in the prevalence of constipation among diabetic and nondiabetic PD patients was not statistically significant (P = 0.499). Of the 15 patients with hypertension, 11 patients (73.3%) suffered from constipation; however, no significant difference was detected in the prevalence of constipation among hypertensive and nonhypertensive PD patients (P = 0.134). Ten of 15 patients (66%) who had constipation used laxatives, but again the difference in the use of laxatives among PD patients who were constipated and not constipated was not statistically significant (P = 0.709). No significant differences were also noted in the amount of water and liquid intake per day between patients who were constipated and not constipated (P = 0.441). The prevalence of constipation was also not significantly different among patients who consumed or did not consume dairy products (P = 0.236), pepper and spices (P = 0.192), meat and chicken (P = 0.630), fruits and vegetables (P = 0.677), wheat and bran grains (P = 0.499), and rice and pasta (P = 0.630).


  Discussion Top


This study showed that four patients (11.1%) experienced mild to severe constipation based on the BSFS, similar to the findings from previous prevalence studies.[16],[17],[18],[19],[20] Conversely, based on the Rome III diagnostic criteria, one third to almost one half of the PD patients had one of the following symptoms: straining, lumpy or hard stool, or incomplete evacuation; this level was higher than the 12.3% reported by Lee et al. in 2016.[4] The high prevalence of constipation among PD patients is believed to be an effect of their dietary restrictions,[3] which limit the consumption of high-fiber foods as these are high in potassium and phosphate.[3],[4] Some studies have found that age might be associated with constipation in PD patients; however, our patients were all in the young to middle-aged groups. Old age might not pay a direct role in developing constipation among PD patients, whereas decreased appetite from depression might be a contributor.[27]

Our finding in this study of no significant association between the prevalence of constipation among diabetic and nondiabetic PD patients is worth mentioning. This result is in contrast to previous studies that established diabetes as one factor for constipation among PD patients.[4],[21],[22]

For PD patients who have no concern regarding potassium and phosphorus intake, several studies have shown that the consumption of a high dietary fiber diet and the use of laxatives reduce the occurrence of constipation in PD patients.[3],[23],[24] However, in the present study, no relationship was evident between the types of food and constipation among our PD patients. Our previous study done on the general population showed that low dietary intake of fruits and vegetables was significantly associated with constipation, based on Bristol's criteria and self-perception.[12] The prevalence of constipation was not significantly higher among our PD patients who used calcium and iron supplements, in contrast to other studies that reported a significant association between the use of these medications and the increased risk of constipation among PD patients.[3],[25] Various gastrointestinal problems occur among PD patients with a greater intake of pills per day.[18] However, we did not collect data regarding the duration of use and the number of pills of these medications in our study population.

One main limitation of our study is that the data were collected by self-administered questionnaires, which may have affected the accuracy of the responses through subjective bias in answering the questions. Another limitation is the relatively small number of subjects, which may have influenced the power of the statistical tests and the significance of the results. Further study with larger samples is therefore warranted. Dietary studies have limitations. We used a general question to ask about the different types of food without specific details. Knowing that patients on PD have special diet requirements, further study with detailed dietary records is warranted.


  Conclusion Top


The prevalence of constipation among PD patients seen in this population is comparable to those reported in other studies. However, the findings of the present study did not indicate any significant relationship between the prevalence of constipation among PD patients and their dietary fiber intake, use of calcium and iron supplements, water intake, presence of diabetes and hypertension, or demographic profiles, including age and gender.

Acknowledgment

We would like to thank Scribendi (https://www.scribendi.com/) for English language editing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Belsey J, Greenfield S, Candy D, Geraint M. Systematic review: Impact of constipation on quality of life in adults and children. Aliment Pharmacol Ther 2010;31:938-49.  Back to cited text no. 1
    
2.
Nyrop KA, Palsson OS, Levy RL, Von Korff M, Feld AD, Turner MJ, et al. Costs of health care for irritable bowel syndrome, chronic constipation, functional diarrhoea and functional abdominal pain. Aliment Pharmacol Ther 2007;26:237-48.  Back to cited text no. 2
    
3.
Lee A. Constipation in patients on peritoneal dialysis: A literature review. Ren Soc Aust J 2011;7:122-9.  Back to cited text no. 3
    
4.
Lee A, Lambert K, Byrne P, Lonergan M. Prevalence of constipation in patients with advanced kidney disease. J Ren Care 2016;42:144-9.  Back to cited text no. 4
    
5.
Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997;32:920-4.  Back to cited text no. 5
    
6.
Saad RJ, Rao SS, Koch KL, Kuo B, Parkman HP, McCallum RW, et al. Do stool form and frequency correlate with whole-gut and colonic transit? Results from a multicenter study in constipated individuals and healthy controls. Am J Gastroenterol 2010;105:403-11.  Back to cited text no. 6
    
7.
Mostafa R. Rome III: The functional gastrointestinal disorders, third edition, 2006. World J Gastroenterol 2008;14:2124-5.  Back to cited text no. 7
    
8.
Park JM, Choi MG, Cho YK, Lee IS, Kim JI, Kim SW, et al. Functional gastrointestinal disorders diagnosed by Rome III questionnaire in Korea. J Neurogastroenterol Motil 2011;17:279-86.  Back to cited text no. 8
    
9.
Suares NC, Ford AC. Prevalence of, and risk factors for, chronic idiopathic constipation in the community: Systematic review and meta-analysis. Am J Gastroenterol 2011;106:1582-91.  Back to cited text no. 9
    
10.
Markland AD, Palsson O, Goode PS, Burgio KL, Busby-Whitehead J, Whitehead WE. Association of low dietary intake of fiber and liquids with constipation: Evidence from the National Health and Nutrition Examination Survey. Am J Gastroenterol 2013;108:796-803.  Back to cited text no. 10
    
11.
Zubaidi AM, Al-Saud NH, Al-Qahtani XA, Shaik SA, Abdulla MH, Al-Khayal KA, et al. Bowel function and its associated variables in Saudi adults. A population based study. Saudi Med J 2012;33:627-33.  Back to cited text no. 11
    
12.
Alhusainy YA, Alhowaish NY, Alorabi HZ, Alsebti AA, AlJutaili HS, Tarakji AR, et al. Symptoms and prevalence of constipation among adult population of Riyadh city: An internet based survey. Egypt J Hosp Med 2018;70:1317-22.  Back to cited text no. 12
    
13.
Alhassan M, Alhassan A, Alfarhood A, Alotaibi K, Alrashidy N, Alshalhoub K, et al. Prevalence of constipation among central region population, Riyadh and Qassim provinces, Saudi Arabia, 2018-2019. J Family Med Prim Care 2019;8:673-6.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Strid H, Simrén M, Johansson AC, Svedlund J, Samuelsson O, Björnsson ES. The prevalence of gastrointestinal symptoms in patients with chronic renal failure is increased and associated with impaired psychological general well-being. Nephrol Dial Transplant 2002;17:1434-9.  Back to cited text no. 14
    
15.
Zhang J, Huang C, Li Y, Chen J, Shen F, Yao Q, et al. Health-related quality of life in dialysis patients with constipation: A cross-sectional study. Patient Prefer Adherence 2013;7:589-94.  Back to cited text no. 15
    
16.
Cano AE, Neil AK, Kang JY, Barnabas A, Eastwood JB, Nelson SR, et al. Gastrointestinal symptoms in patients with end-stage renal disease undergoing treatment by hemodialysis or peritoneal dialysis. Am J Gastroenterol 2007;102:1990-7.  Back to cited text no. 16
    
17.
Dong R, Guo ZY, Ding JR, Zhou YY, Wu H. Gastrointestinal symptoms: A comparison between patients undergoing peritoneal dialysis and hemodialysis. World J Gastroenterol 2014;20:11370-5.  Back to cited text no. 17
    
18.
Dong R, Guo ZY. Gastrointestinal symptoms in patients undergoing peritoneal dialysis: Multivariate analysis of correlated factors. World J Gastroenterol 2010;16:2812-7.  Back to cited text no. 18
    
19.
Yasuda G, Takeshita Y, Kimura T, Tochikubo O, Ikeda Y, Tokita Y, et al. Constipation occurs less frequently in CAPD patients than in HD patients. Perit Dial Int 1995;15:283.  Back to cited text no. 19
    
20.
Yasuda G, Shibata K, Takizawa T, Ikeda Y, Tokita Y, Umemura S, et al. Prevalence of constipation in continuous ambulatory peritoneal dialysis patients and comparison with hemodialysis patients. Am J Kidney Dis 2002;39:1292-9.  Back to cited text no. 20
    
21.
Talley NJ, Jones M, Nuyts G, Dubois D. Risk factors for chronic constipation based on a general practice sample. Am J Gastroenterol 2003;98:1107-11.  Back to cited text no. 21
    
22.
Bytzer P, Talley NJ, Leemon M, Young LJ, Jones MP, Horowitz M. Prevalence of gastrointestinal symptoms associated with diabetes mellitus: A population-based survey of 15,000 adults. Arch Intern Med 2001;161:1989-96.  Back to cited text no. 22
    
23.
Sutton D, Dumbleton S, Allaway C. Can increased dietary fibre reduce laxative requirement in peritoneal dialysis patients? J Ren Care 2007;33:174-8.  Back to cited text no. 23
    
24.
Sutton D, Ovington S, Engel B. A multi-centre, randomised trial to assess whether increased dietary fibre intake (using a fibre supplement or high-fibre foods) produces healthy bowel performance and reduces laxative requirement in free living patients on peritoneal dialysis. J Ren Care 2014;40:157-63.  Back to cited text no. 24
    
25.
Elliott WJ, Ram CV. Calcium channel blockers. J Clin Hypertens (Greenwich) 2011;13:687-9.  Back to cited text no. 25
    
26.
Saudi Center for Organ Transplantation (SCOT Data). Dialysis in the Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl 2012;23:881-9.  Back to cited text no. 26
    
27.
Setyapranata S, Holt SG. The gut in older patients on peritoneal dialysis. Perit Dial Int 2015;35:650-4.  Back to cited text no. 27
    


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