Incidence of bleeding from gastroduodenal ulcers in patients with end-stage renal disease receiving hemodialysis

Abstract

Background: Few large population-based studies have compared the incidence of bleeding of gastroduodenal ulcers between patients with and without end-stage renal disease. We investigated the association between ulcer bleeding and end-stage renal disease in patients receiving hemodialysis, and we sought to identify risk factors for ulcer bleeding.

Methods: We performed a nationwide seven-year population study using data from the National Health Insurance Research Database in Taiwan. We identified 36 474 patients with end-stage renal disease who were receiving hemodialysis, 6320 patients with chronic kidney disease and 36 034 controls matched for age, sex and medication use. We performed log-rank testing to analyze differences in survival time without ulcer bleeding among the three groups. We performed Cox proportional hazard regressions to evaluate the risk factors for ulcer bleeding among the three groups and to identify risk factors in patients receiving hemodialysis.

Results: Patients receiving hemodialysis and those with chronic kidney disease had a significantly higher incidence of ulcer bleeding than controls had (p<0.001). Hemodialysis (hazard ratio [HR] 5.24, 95% confidence interval [CI] 4.67-5.86) and chronic kidney disease (HR 1.95, 95% CI 1.62-2.35) were independently associated with an increased risk of ulcer bleeding. Diabetes mellitus, coronary artery disease, cirrhosis and use of nonsteroidal anti-inflammatory drugs were risk factors for ulcer bleeding in patients with end-stage renal disease who were receiving hemodialysis

Interpretation: Patients with end-stage renal disease who are receiving hemodialysis had a high risk of ulcer bleeding. Diabetes mellitus, coronary artery disease, cirrhosis and the use of nonsteroidal anti-inflammatory drugs were important risk factors for ulcer bleeding in these patients.

Figure 1:

Flow of patients with end-stage renal disease undergoing hemodialysis during the seven-year study period. In total, 26 145 patients were alive at the end of follow-up in 2007. *All patients who were excluded from follow-up had died during the study period (28.3% of patients undergoing hemodialysis).

Figure 2:

Kaplan–Meier estimates of survival time free of peptic ulcer bleeding in patients undergoing hemodialysis, those with chronic kidney disease and controls. *Log rank p < 0.001.

Figure 3:

Adjusted hazard ratios (HRs) for ulcer bleeding in patients receiving hemodialysis. In each stratum, the HRs were compared between patients undergoing hemodialysis and controls. *Each factor was adjusted for all other factors. CI = confidence interval, NSAID = nonsteroidal anti-inflammatory drug.