Professional Documents
Culture Documents
Kidney
Konnection
Stay connected with Kidney Konnection through the N OD Plus App: http: / / goo.gl/ tfSAQT
It's a fact! The incidence of GI bleeding in chronic kidney disease patients including those on dialysis is significantly higher than the
general population. Acute upper gastrointestinal bleeding carries a very high mortality; it accounts for 3- 7% of all deaths in patients with
ESRD. In an analysis of the US Renal Data System (USRDS) Dialysis M orbidity and M ortality Study, Wasse and colleagues reported a
rate of 23 upper GI bleeding events per 1000 person- years. That's more than 10 times higher than the general population. There is a one
study showed that 19% of patients with CKD have +ve FOBTs!
Why do they bleed more? Uremia is very toxic to both the GI mucosa and platelets; that?s all you need to cause an intractable
gastrointestinal hemorrhage. Uremia causes platelet dysfunction. There is also a direct effect of uremia on the GI mucosa due to oxidative
stress. In addition to that, patients receiving hemodialysis (H D) have a higher risk because of heparin used during H D. Risk increases
with other co- morbidities like diabetes mellitus, coronary artery disease, cirrhosis and the use of non- steroidal anti- inflammatory drugs.
Where do they bleed from? Bleeding can happen anywhere from the esophagus to the rectum. Angiodysplasias and gastritis/ peptic ulcer
disease are the most common causes of upper GI bleeding. The most common site is the duodenum. Duodenal lesions were found in 61%
of ERSD patients with +ve fecal occult blood tests. The most common site of lower gastrointestinal tract bleeding is the proximal colon.
Colonic neoplasms, angiodyplasia and diverticulosis are the most common causes of lower tract bleeding. Angiodysplasia has been shown
to cause an increased risk of recurrent bleeding in patients with renal failure and is the most common cause of recurrent lower
gastrointestinal bleeding likely due to use of heparin 3 times a week during hemodialysis.
What should I do? Always keep in mind that GI bleeding is very common in CKD and ESRD patients. Anemia should always be
evaluated with a thorough history, physical exam (and yes, a digital rectal exam with stool guaiac is needed!). Avoid the common
mistake of attributing anemia to erythropoietin deficiency. Screen these high risk patients and refer them to gastroenterology early.
Image B
2.
3.
4.
5.
6.
7.
8.
Answers
1. CVH D
2. Venooclusive Disease
3. Defibrotide
4. ACE inhibitor
5. N ephrotic Syndrome
6. Plasmapheresis
7. Allogeneic
8. Autologous
The serologies finally returned and the patient was anti- neutrophil cytoplasmic antibody (AN CA) positive (titer = 1: 640). Based on this
information, the most appropriate diagnosis at this time is AN CA- associated vasculitis (AAV)
Treatment for this condition will depend on a number of factors (some of which are listed below):
-