Published online Oct 16, 2019. doi: 10.4253/wjge.v11.i10.504
Peer-review started: June 19, 2019
First decision: August 2, 2019
Revised: August 21, 2019
Accepted: September 11, 2019
Article in press: September 11, 2019
Published online: October 16, 2019
Gastrointestinal (GI) angiodysplasia are commonly occurring vascular malformations in the GI tract and account for approximately 6% of lower GI bleeding and up to 8% of upper GI bleeds. Chronic kidney disease and subsequent end-stage renal disease (ESRD) have been associated with increased development and risk of hemorrhage from GI Angiodysplasia.
There are few epidemiology studies exploring the association between angiodysplasia-related GI bleeding in renal disease patients. With increasing burden of chronic kidney disease, prevalence of nearly 15% in United States adults, the proportion of GI bleeding attributed to Angiodysplasia in renal disease patients is expected to increase. Studies need to be carried out to determine the burden and epidemiology, clinical presentation, diagnosis, management and outcomes of angiodysplasia-associated GI bleeding in renal disease patients. Such efforts would help guide clinicians to be watchful and prevent major bleeding in susceptible renal disease patients, improve outcomes and reduce hospitalization costs, especially in the elderly and chronic disease patients.
The main objectives of this study were to determine nationwide prevalence, hospitalization trends, and risk factors of hospitalization for angiodysplasia-associated GI hemorrhage in ESRD patients in the United States. Secondary objectives that were realized included length of stay, average total inpatient charges and mortality rate. The nationwide objectives achieved in this study provide baseline estimates for future research, the prevalence and risk factors identified should guide prevention and lead to improved management and outcomes in such patients.
This retrospective study utilized the Nationwide Inpatient Sample, database from 2009 to 2014. International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes, were used to identify all patients nationwide with ESRD hospitalizations during the study period, and a subset of ESRD hospitalizations with angiodysplasia associated-GI bleeding were identified and compared. Independent variables (risk factors) included hospitalization year (2009-2014), gender, age category, race, primary payor, median household income quartile, Charlson Deyo-comorbidity index, hypertension, diabetes mellitus, tobacco use, obesity, hospital location (rural, urban, urban teaching), and hospital region. Multivariable regression modelling was performed to determine the risk factors associated with angiodysplasia associated-GI hemorrhage in ESRD hospitalized patients.
Angiodysplasia-associated GI hemorrhage in ESRD patients had a prevalence of 0.45% (n = 24709) among all ESRD hospitalizations (n = 5505252). Multivariable regression analysis showed that higher odds of angiodysplasia associated-GI hemorrhage in ESRD hospitalized patients occurred with increasing year trend from 2009-2014; increasing age; African American race; increasing Charlson-Deyo Comorbidity Index; hypertension; and tobacco use. And lower odds were associated with rural and urban nonteaching hospitals in comparison to urban teaching hospitals. ESRD hospitalizations with Angiodysplasia associated-GI bleeding had mean length of stay of 8.71 d, total average inpatient charges of $82340, and mortality rate of 3.41%.
To our knowledge this is the first nationwide study that has determined baseline epidemiology estimates, hospitalization trends, risk factors and outcomes of angiodysplasia-associated GI bleeding in renal failure (ESRD) hospitalized patients. During the study period of 2009-2014, the hospitalization rate of angiodysplasia-associated GI bleeding in (ESRD) hospitalized patients increased by 6.7%, which indicates that recurrent hemorrhage in such patients should be expected. Clinical implications include patient communication to ESRD patients to immediately seek medical care if they have any signs of GI bleeding. Elderly ESRD patients had the strongest association for angiodysplasia-associated GI bleeding and such patients should be carefully observed for any signs and symptoms of GI bleeding. Hypertensive ESRD patients also had high risk and since elderly patients are frequently hypertensive, the risk for angiodysplasia-associated GI bleeding gets compounded. African American ESRD patients also had increased odds of angiodysplasia-associated GI bleeding that could be attributed to inadequate control of chronic conditions (e.g. hypertension, diabetes mellitus). Further studies need to be carried out to determine if there is a genetic predisposition in ESRD African American patients for angiodysplasia-associated GI bleeding. This study is the first one to report that Diabetes mellitus in ESRD patients was associated with decreased odds of angiodysplasia-associated GI bleeding. The biological mechanisms of diabetes mellitus and glycemic control being a protective factor for angiodysplasia-associated GI bleeding in renal disease patients needs to be elucidated in future studies.
With increasing burden of renal disease, angiodysplasia-associated GI bleeding in ESRD patients has shown a rising trend. Elderly age group, African American race, overall co-morbidities, hypertension and smoking were significant risk factors for angiodysplasia-associated GI bleeding in ESRD patients. The role of diabetes mellitus in this study showed decreased odds of angiodysplasia-associated GI bleeding in renal disease patients. Future translational studies should look at the underlying biological mechanisms of hyperglycemia being a protective factor for angiodysplasia-associated GI bleeding in renal disease patients.