Abstract
Background
The epidemiology of gastrointestinal bleeding (GIB) in end-stage renal disease (ESRD) has not been adequately characterized. Using United States Renal Data System data we investigated the epidemiology of GIB in hospitalized patients receiving long-term dialysis.
Methods
Medicare ESRD patients who began dialysis between 1996 and 2005 were followed from 90 days after starting dialysis to death, transplant, loss of Medicare, or December 31, 2006. GIB events were identified using claims data. Predictors of GIB incidence were analyzed using over-dispersed Poisson regression and Cox regression was used to evaluate the effect on survival. Repeat episodes were modeled using a partially conditional Cox regression model.
Results
406,836 patients were followed for 832,131 person-years, during which 133,967 events were identified. The incidence of GIB was stable through year 2000 but steadily increased thereafter. Chronic gastric ulcer and colonic diverticulosis were the commonest defined causes of upper and lower GIB respectively. Age >49 years, female gender, hypertension as the cause of ESRD, and initiation on hemodialysis was associated with a greater risk of GIB. An episode of GIB conferred a increased hazard of death (hazard ratio 1.9, 95 % CI 1.86–1.93). A previous episode of GIB was associated with greater hazard of another episode (hazard ratio 3.93, 95 % CI 3.82–4.05).
Conclusions
In ESRD patients incident to long-term dialysis the incidence of hospital-associated GIB is increasing, is associated with a greater hazard of death, and carries a great hazard of repeat episodes.
References
Luo J-C, Leu H-B, Huang K-W, Huang C–C, Hou M-C, Lin H-C, Lee F-Y, Lee S-D (2011) Incidence of bleeding from gastroduodenal ulcers in patients with end-stage renal disease receiving hemodialysis. CMAJ 183:E1345–E1351
Luo J-C, Leu H-B, Hou M-C, Huang K-W, Lin H-C, Lee F-Y, Chan W-L, Lin S-J, Chen J-W (2013) Nonpeptic ulcer, nonvariceal gastrointestinal bleeding in hemodialysis patients. Am J Med 126:264.e25–264.e32
Toke AB (2010) GI bleeding risk in patients undergoing dialysis. Gastrointest Endosc 71:50–51
US Renal Data System (2013) USRDS 2013 annual data report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda
Sood P, Kumar G, Nanchal RA, Ahmad S, Ali M, Kumar N, Ross EA (2012) Chronic kidney disease and end-stage renal disease predict higher risk of mortality in patients with primary upper gastrointestinal bleeding. Am J Nephrol 35:216–224
Cheung J, Yu A, LaBossiere J, Zhu Q, Fedorak RN (2010) Peptic ulcer bleeding outcomes adversely affected by end-stage renal disease. Gastrointest Endosc 71:44–49
Wasse H, Gillen DL, Ball AM, Kestenbaum BR, Seliger SL, Sherrard D, Stehman-Breen CO (2003) Risk factors for upper gastrointestinal bleeding among end-stage renal disease patients. Kidney Int 64:1455–1461
Wu C-Y, Wu M-S, Kuo KN et al (2011) Long-term peptic ulcer rebleeding risk estimation in patients undergoing haemodialysis: a 10-year nationwide cohort study. Gut 60:1038–1042
Kuo CC, Kuo HW, Lee IM, Lee CT, Yang CY (2013) The risk of upper gastrointestinal bleeding in patients treated with hemodialysis: a population-based cohort study. BMC Nephrol 14:15. doi:10.1186/1471-2369-14-15
Parasa S, Navaneethan U, Sridhar AR, Venkatesh PG, Olden K (2013) End-stage renal disease is associated with worse outcomes in hospitalized patients with peptic ulcer bleeding. Gastrointest Endosc 77:609–616
Shih YT (2014) Effect of insurance on prescription drug use by ESRD beneficiaries. https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/99springpg39.pdf. Accessed 23 Jan 2014
Researcher’s guide (2014) http://www.usrds.org/2013/rg/A_intro_sec_1_13.pdf. Accessed 21 Jan 2014
Kaneva K, Bansal V, Hoppensteadt D, Cunanan J, Fareed J (2013) Variations in the circulating heparin levels during maintenance hemodialysis in patients with end-stage renal disease. Clin Appl Thromb Hemost 19:449–452
Fishbane S, Berns JS (2005) Hemoglobin cycling in hemodialysis patients treated with recombinant human erythropoietin. Kidney Int 68:1337–1343
Gilbertson DT, Ebben JP, Foley RN, Weinhandl ED, Bradbury BD, Collins AJ (2008) Hemoglobin level variability: associations with mortality (2008). Clin J Am Soc Nephrol 3:133–138
Selby NM, Fonseca SA, Fluck RJ, Taal MW (2012) Hemoglobin variability with epoetin beta and continuous erythropoietin receptor activator in patients on peritoneal dialysis. Perit Dial Int 32:177–182
Sood MM, Larkina M, Thumma JR et al (2013) Major bleeding events and risk stratification of antithrombotic agents in hemodialysis: results from the DOPPS. Kidney Int 84:600–608
Acknowledgments
We thank Agnes Libot, MD for help in identifying ICD-9-CM codes of gastrointestinal bleeding and Qun Xiang, MS for help in statistical analysis. Support received by grant 8UL1TR000055 from the Clinical and Translational Science Award (CTSA) program of the National Center for Research Resources and the National Center for Advancing Translational Sciences.
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
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The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government.
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Trivedi, H., Yang, J. & Szabo, A. Gastrointestinal bleeding in patients on long-term dialysis. J Nephrol 28, 235–243 (2015). https://doi.org/10.1007/s40620-014-0132-6
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DOI: https://doi.org/10.1007/s40620-014-0132-6