番茄社区

LONG BEACH, Calif. -- People with advanced chronic kidney disease (CKD) faced higher rates of potentially fatal gastrointestinal bleeding, a retrospective study found.

Those with stage 5 CKD had a 40% higher chance of being hospitalized with gastrointestinal (GI) bleeding than patients without CKD (aOR 1.4, 95% CI 1.3-1.4, P<0.001), reported Mingyue He, MD, of Temple University Hospital in Philadelphia, at the National Kidney Foundation (NKF) Spring Clinical meeting.

In addition to a higher GI bleeding risk requiring hospitalization, those with stage 5 CKD had significantly higher chances of inpatient all-cause mortality compared with patients free of CKD:

• Stage 5 CKD not on dialysis: aOR 2.3 (95% CI 1.4-3.9, P=0.001)
• Stage 5 CKD on dialysis: aOR 1.9 (95% CI 1.6-2.3, P<0.001)

On the other hand, patients who had previously undergone a kidney transplant had a GI bleeding risk comparable to those without CKD.

Stage 5 CKD with or without dialysis are independent risk factors for GI bleeding in hospital mortality, He told 番茄社区.

"Gastrointestinal bleeding is a medical emergency and represents a significant proportion of hospital admissions and healthcare costs," she explained. "In my clinical practice, I noticed that patients with end-stage kidney disease (ESKD) were less likely to undergo early endoscopic evaluations, compelling me to investigate whether this contributed to higher mortality."

She added that she wasn't necessarily surprised to see a higher incidence of mortality in patients with advanced CKD, especially those on dialysis given their multiple comorbidities, as 90% percent had Charlson Comorbidity Index greater than 3.

Although there were comparable endoscopy rates across all patients hospitalized with GI bleeding, patients with stage 5 CKD had significantly fewer early endoscopies (performed within 24 hours) and had more delayed endoscopies (performed over 48 hours later). On top of that, stage 5 CKD patients who had delayed endoscopies had a 60% higher chance of mortality (aOR 1.6, 95% CI, 1.2-2.1, P=0.001).

"To mitigate the potential confounding effect of hemodynamic instability upon admission, which could lead to delayed endoscopy and higher mortality, we excluded patients requiring intubation or pressor support within 24 hours of admission, and further analysis validated our initial findings," He noted.

According to international consensus guidelines, endoscopy should occur within 24 hours of presentation for patients with acute upper GI bleeding. But He pointed out this doesn't always happen in clinical practice since endoscopic evaluations may be delayed or canceled for various reasons.

"Factors such as previous endoscopic procedures, electrolyte disturbances, dialysis schedules, and thrombocytopenia can influence the decision-making process regarding the timing of endoscopy," she listed. "The increased risk of anesthesia complications in patients with advanced CKD and ESKD may also contribute to delays in endoscopy."

While those contributing factors weren't captured in the current study -- a limitation of the analysis -- He recommended future research look into the reasons driving the discrepancies in endoscopy timing. "Understanding the reasons for delayed endoscopic evaluations in ESKD patients is crucial for improving adherence to guidelines and patient outcomes," she said.

Patients with advanced CKD on dialysis also had higher rates of angiograms, ventilation, vasopressor use, blood transfusion, and prolonged, costly hospitalizations compared with patients without CKD. They also had more GI bleeding caused by ulcers or unspecified causes. Stage 5 CKD patients regardless of dialysis status also had a higher GI bleeding risk linked with angiodysplasia.

Meanwhile, kidney transplant recipients had a significantly increased risk for diverticular bleeding.

"Interestingly, we also found that post-kidney transplant, the incidence of angiodysplasia significantly decreases, suggesting a link to uremic-related factors such as platelet dysfunction contributing to angiodysplasia bleeding," He said.

Data for the study was drawn from the 2019 Nationwide Inpatient Sample database on 527,640 adults admitted non-electively with either upper or lower GI bleeding.

He added that her group plans to publish an expanded analysis with a larger sample size from this database on the topic.

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