It is known that prevalence of upper gastrointestinal bleeding is higher in the patients with chronic renal insufficiency, and in these patients, upper gastrointestinal bleeding is deemed responsible for 3-7% of overall deaths 6
In the present study, male/female ratio was 1.1/1 in the CRI group and 2.1/1 in the control group. Male/female ratio in the CRI group was similar to that in the study conducted by Wasse et al. 7. Higher prevalence of GIS bleeding in males has been tried to be explained by higher prevalence of underlying disease and alcohol consumption in males 8. However, the reason for increasing prevalence in females is unclear.
It was observed that the patients in the CRI group were older than the patients in the control group. Higher prevalence of gastrointestinal system bleeding in elderly can be explained by increased prevalence of concomitant disease and drug use, increase in the prevalence of H.pylori with age, and increased prevalence of ischemic mucosal injury 9. Wasse et al. determined that the risk of upper GIS bleeding in CRI patients increases by 11% with each decade 7.
In the present study, prevalence of chronic disease was higher in the CRI group with hypertension, coronary artery disease and heart failure being the most prevalent. In the literature, Theoscharis et al. 9 found cardiovascular disease to be the leading followed by hypertension and diabetes mellitus. Wasse 7 determined that presence of cardiovascular disease and diabetes enhance the risk of upper GIS bleeding by 1.6 and 1.13, respectively.
Prevalence of drug usage was significantly higher in the CRI patients with aspirin used most frequently. Oliveira et al. 10 determined peptic ulcer and erosive gastritis/duodenitis to be the leading causes of upper GIS bleeding in 301 patients with CRI, and bleeding was attributed to NSAID in the majority of these patients. In another study conducted in 190 hemodialysis patients, it was found that the use of antiaggregant agent in hemodialysis patients 3 times enhanced the risk of bleeding.
Hemoglobin and hematocrit values at the time of admission is important for monitoring, prognosis, and manipulating treatment in the patients present with upper GIS bleeding. In the present study, low hemoglobin values in the CRI group was considered to be associated with chronic disease anemia. Mean amount of erythrocyte transfusion over the course of hospital stay was 3.4 units in the CRI group and 2.7 units in the control group. In the literature, Gado et al. 11 found the mean amount of erythrocyte transfusion to be 3 units.
The rate of endoscopy performed in 24 hours was higher in the present study as compared to many studies. More than 70% of the patients in each group underwent endoscopy within 24 hours. Whilst Zaltman et al. 8 found the prevalence of endoscopy performed in 24 hours as 52.8%, Hearnshaw et al. 12 found it to be 50%.
On endoscopic examination, gastric ulcer was the most common lesion (25.6%) in the CRI group, whereas duodenal ulcer was most common (27.9%) in the control group. In the study conducted by Chalasani et al., the most frequent endoscopic lesions were gastric ulcer (37%) and duodenal ulcer (23%) followed by angiodysplasia, and it was stated that angiodysplasia is more prevalent in CRI patients as compared to the patients with normal renal functions 13. Prevalence of variceal bleeding was 10% in the CRI group and 7.7% in the control group. Golánová et al. 14 found the prevalence of variceal bleeding as 10%.
In the CRI group, upper GIS malignancy was seen in 5 patients (5.6%) whereas in 1 patient (1%) in the control group. We had not seen a study about upper GI malignancies at CRI patients in literature. In these patients, the high rate of malignant neoplasm of the stomach to be age-related and also may be associated with gastrin hypersecretion, increase H. pylori colonization. New studies for GIS malignancies are needed in CRI patients with more patients.
With regard to Forrest classification, the majority of patients in the CRI group was Forrest 2a and the majority of patients in the control group was Forrest 3 indicating that severity of ulcer was more common in peptic ulcer-related bleeding in the CRI group. This was considered to be associated with increased drug use with age, which is a risk factor for ischemic mucosa. In the present study, endoscopic intervention was performed in averagely 51% of patients. This was higher than that found by Kapsoritakis et al. 2, which was 32.7%. Also we found that the rate of control endoscopy applied to the patients were higher in the control group. We thought that the reason for this is due to the higher rates of gastric and duodenal ulcer seen in the control group (control: 53%, CRI: 46.7%).
Zuckerman et al. 15 conducted a study in CRI patients with upper GIS bleeding and observed that CRI patients had more frequent rebleeding; they found the prevalence of rebleeding to be 25% in the patients with renal insufficiency and 11% in the patients without renal insufficiency. Also Lee et al. 16 shows that predictive factors for rebleeding in non-variceal upper gastrointestinal bleeding are; CRI, hemodynamic instability, and endoscopic high-risk appearance. In the present study, however, rebleeding occurred in 13.3% of CRI patients and in 11.5% of the control group with no significant difference determined between CRI group and the control group different from the literature. In the recent years, favorable advances both in medical and surgical treatments have caused surgical treatment to take the backseat. Actually, Theocharis 9 found the prevalence of surgical treatment in the patients with upper GIS bleeding to be 5.9% in 1995 and 3.1% in 2005. In the present study, prevalence of surgical treatment was higher than the literature with 5.6% found in the CRI group and 6.7% in the control group.
Parasa et al. 17 conducted a study in 2013 and determined mortality rate to be significantly higher in CRI patients with peptic ulcer bleeding as compared to the control group (4.8%-1.9%). Again, it was determined that these patients lead to higher tendency to surgery, longer duration of hospital stay and higher hospital cost. In the present study, hospital mortality rate was higher in the CRI group, but no statistical difference was determined between the groups. Duration of hospital stay was similar in both groups; however, need for transfusion and the rate of hospital-acquired complications were higher in the CRI group with higher hospital cost determined in this group. Weng et al. 18 evaluated cases with renal insufficiency and upper GIS bleeding and found mortality rate to be 13.7% in the first month and 27% in the first year; they determined that mortality is associated with advance age, female gender, hospital-acquired infections, and low albumin and white blood cell concentrations. Lower hospital mortality rate in the present study as compared to that study was considered to be associated with exclusion of long-term mortality from the study. Similar with the literature, the present study found that hospital mortality rate is correlated with low albumin (exitus patients: 2.68 g/dL, non-exitus: 3.27 g/dL; p=0.028) and calcium (exitus patients: 8.24 mg/dL, non-exitus: 8.92 mg/dL; (p=0.04) concentrations and rebleeding (exitus patients: 25%, non-exitus: %2.5; p=0.016), but not with gender (p=0.367) and duration of hospital stay (p=0.143).