Getting to the Root of Gastrointestinal Distress

Gastrointestinal (GI) distress is a common problem for many people with end stage kidney disease (1). GI distress symptoms include nausea, vomiting, diarrhea and constipation. While over-the-counter and prescription medications may be able to reduce these symptoms, getting to the root of the issue could offer permanent relief.

There are many reasons why someone would experience GI upset, and a GI assessment and referral to a GI specialist may be important. The following information may be helpful; however, please note there are also many other sources that provide information on GI health.

The 5R Approach

The 5R Approach is often used in functional medicine/nutrition to identify root causes of DI distress (2). The five Rs stand for remove, replace, re-inoculate, repair and replenish.  

1. Remove

The remove stage is an elimination diet, which is a meal plan that avoids or removes certain foods or ingredients to help you find out which foods could be triggering your GI symptoms. Although the dialysis diet is already restrictive, keeping a good food/symptom diary can help determine which specific foods are problematic and should be temporarily removed. Common foods which could be problematic include dairy and gluten; however, FODMAP foods could also be a problem. FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols. These are different short-chain carbohydrates that can cause GI distress. Any food could be problematic. If a food diary indicates that specific foods are a problem, they should be removed temporarily while the gut is being repaired.

2. Replace

The replace step is where you replace, add or encourage the production of the body’s digestive enzymes if they are not being produced as well as they should. This helps support the body to have enough digestive enzyme strength to properly break down and digest food. Proper digestion is key to getting the proper nutrients from foods.

Digestion begins in the mouth. Sufficient chewing is important. Well-chewed food allows the food to mix well with the digestive enzymes in the mouth and enhances breakdown. It’s important to chew food into smaller pieces to allow more surface area for the digestive enzymes to break down. 

Digestive enzymes should also be working to capacity to do their job of breaking down carbohydrates, fats and proteins into smaller pieces. Digestive enzymes can be suppressed due to antacids and medications that reduce acid (3). In addition, low stomach acid can be confused with and mistreated as an over-acid issue (4). 

Some people have found that diluted apple cider vinegar before a meal may help improve digestion (5). You may also try adding herbs and spices such as ginger, fennel and cardamom to meals (6,7). Buying digestive enzymes may be another option, if needed. There are digestive enzymes that can help break down all macronutrients: fat, protein and carbohydrate. The digestive enzymes are lipase, amylase and protease. Some digestive enzyme products include all three. They may be plant- or animal-based.

3. Repair

The third R in the 5R process is repair. The gut has cells that are tightly connected, which prevent harmful substances from leaking through. However, over time, especially when exposed to various assaults that cause inflammation such as foods that cause sensitivities, allergens or toxins, the gut junctions can open and allow harmful substances to leak through into the bloodstream. This is called leaky gut or increased gut permeability (8,9). Gut repair closes the junctions. Foods and nutrients that may help with gut repair include protein such as collagen, zinc and vitamin C. Some people find that bone broth soup (prepared with lower amounts of salt), which is high in collagen, also helps the healing process.

4. Re-inoculate

The re-inoculate step focuses on building a healthy microbiome. The microbiome is made up of living microorganisms, including bacteria, that live in the gut. Often, the gut does not have enough good bacteria and is overgrown with bad bacteria. Various medications and poor eating habits can contribute to this issue.

One way to potentially combat this is by eating foods called probiotics that may help increase the variety and strain of good bacteria. These good bacteria help to produce B vitamins, break down toxins, and can form a barrier in the gut lining that may help stop unwanted particles from entering the bloodstream (10). Probiotics can be found in foods such as yogurt, kimchee, kefir, miso and tempeh.

Eating prebiotics may help feed these bacteria to help them multiply and continue to do their job. Good bacteria may feed on the prebiotics and grow, further protecting the gut lining and potentially crowding out bad bacteria (11). Some examples of prebiotics include asparagus, chicory root, red onion and Jerusalem artichoke. These foods contain a fiber called inulin. Some foods, such as certain brands of yogurt, are supplemented with prebiotics. Prebiotic supplements are also available.

5. Replenish

Finally, the fifth R is replenish. This step focuses on restoring the body’s vital forces by reducing stress and getting quality sleep. In doing so, you can potentially reduce cortisol and other biochemicals and hormones that, when in excess, create a bad environment for the gut microbiota. Good sleep hygiene can help improve sleep. This includes turning off digital devices in your bedroom, reducing light and having a “wind-down” period before going to bed. Avoiding stimulants such as caffeine before bed can also help (12). Natural sleep-enhancing supplements such as chamomile tea or melatonin can potentially help (13, 14). You might also try to reduce stress by doing some deep breathing, listening to music or taking a walk.

Getting Your Gut Back to a Healthy Place

There are many steps you can take to help improve your gut environment and potentially reduce GI distress. These five steps don’t necessarily have to be implemented in this order, and they can also be followed simultaneously. You may find that your GI health improves after implementing just one step. Remember to always talk with your care team before starting any herbal or natural supplements. Speak with a dietitian or your doctor about what your blood results show and what foods you may want to incorporate. Using the 5R approach to addressing root causes of your GI distress can help you find permanent relief and an improved quality of life.


This article is for informational purposes only and is not intended to be a substitute for medical advice. Consult your dietitian or physician for the specific diet that is right for you as diet guidelines vary for each individual based on health condition, diagnosis and many other factors.



1. Mortazavi, M., Adibi, P., Hassanzadeh Keshteli, A., Feizi, A., JameShorani, M., Soodavi, M., & Jafari, M. (2022). Comparison of Gastrointestinal Symptoms between Patients Undergoing Hemodialysis and Healthy Population. Middle East journal of digestive diseases, 14(3), 310–316.


3. Kines, K., & Krupczak, T. (2016). Nutritional Interventions for Gastroesophageal Reflux, Irritable Bowel Syndrome, and Hypochlorhydria: A Case Report. Integrative medicine (Encinitas, Calif.), 15(4), 49–53.



6. Peterson, C. T., Rodionov, D. A., Iablokov, S. N., Pung, M. A., Chopra, D., Mills, P. J., & Peterson, S. N. (2019). Prebiotic Potential of Culinary Spices Used to Support Digestion and Bioabsorption. Evidence-based complementary and alternative medicine : eCAM, 2019, 8973704


8. Ahmad, R., Sorrell, M. F., Batra, S. K., Dhawan, P., & Singh, A. B. (2017). Gut permeability and mucosal inflammation: bad, good or context dependent. Mucosal immunology, 10(2), 307–317.

9. Camilleri M. (2019). Leaky gut: mechanisms, measurement and clinical implications in humans. Gut, 68(8), 1516–1526.




13. Rahman, A., Hasan, A.U. & Kobori, H. (2019). Melatonin in chronic kidney disease: a promising chronotherapy targeting the intrarenal renin–angiotensin system. Hypertens Res 42, 920–923.

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