Tenapanor‐Associated Bowel Effects in Hemodialysis: Persistence Barriers and Practical Continuation Strategies

BACKGROUND: Tenapanor is a mechanistically distinct treatment for hyperphosphatemia in hemodialysis and can reduce phosphate-binder pill burden in selected patients. However, its real-world value is constrained by bowel effects, particularly diarrhea, which commonly emerges early after initiation and may lead to treatment aversion or discontinuation. SUMMARY: In this review, treatment persistence refers to the ability to continue tenapanor through the early bowel-symptom period without permanent discontinuation due to gastrointestinal symptoms or treatment aversion, while maintaining clinically meaningful phosphate control. Current evidence indicates that tenapanor-associated bowel effects are clinically bidirectional. They may improve stool consistency and reduce laxative dependence in constipation-prone patients, whereas the same bowel shift may cause loose stools, urgency, discomfort, dialysis-session anxiety, and discontinuation in others. Longer-term studies suggest that patients who remain on therapy may maintain phosphate control with fewer concomitant phosphate-binder tablets, although early discontinuation and completer effects require cautious interpretation. A persistence-oriented approach includes baseline bowel-habit assessment, region-specific and label-consistent initiation and dose adjustment, individualized timing around dialysis sessions, review of concomitant bowel-active medications, anticipatory patient education, and monitoring for fluid and electrolyte consequences. CONCLUSIONS: Tenapanor-associated bowel effects are a central implementation barrier rather than a secondary tolerability issue. Persistence may be improved by matching treatment to baseline bowel phenotype and using a tolerability-first, safety-conscious continuation framework. Prospective studies should define predictors of persistence and validate supportive strategies.