Gastrointestinal Hemorrhage in Patients with End-Stage Renal Disease (ESRD): Insights From the Healthcare Utilization Project

Abstract

Introduction: Gastrointestinal hemorrhage (GIH) is a common complication in patients with end stage renal disease (ESRD), likely resulting from uremic platelet dysfunction, alterations in acid secretion and mucosal integrity. Some of the more common causes of GIH in ESRD include peptic ulcer disease, vascular ectasia and angiodysplasia. Its management often requires multiple transfusions and endoscopic interventions, leading to significant morbidity, mortality and economic burden. Methods: All hospitalizations in the National Inpatient Sample (NIS) database with a primary or secondary discharge diagnosis of ESRD (ICD-9 code 585.6) during years 2005-2011 were identified. Hospitalizations complicated by GIH (ICD-9 code 578.0, 578.1, 578.9) in this cohort were then analyzed. Prevalence of comorbidities was determined using Agency for Healthcare Research and Quality (AHRQ) comorbidity measures. Statistical significance of variation in the number of hospital discharges, demographics, cost of care, comorbidity measures and outcomes during the study period were determined using Cochran-Armitage trend test. Results: In 2005, there were 165,344 hospitalizations with discharge diagnoses of ESRD compared to 1,029,371 in 2011 (p-trend< 0.0001, Figure 1A). The percentage of hospitalizations with GIH increased from 1.75% in 2005 to 2.07% in 2011 (p-trend< 0.0001, figure 1B). Most of the hospitalizations were among men. We also found a modest but statistically significant increase in in-hospital mortality (15.5% in 2005 to 16.9% in 2011) (p= 0.015, figure 1C). Cost of care increased from $17,628 in 2005 to $25,594 in 2011 (adjusted for inflation, p-trend< 0.0001, figure 1D). The most commonly associated comorbidities in this population were hypertension (HTN), diabetes mellitus (DM) and congestive heart failure (CHF). HTN, DM, CHF and several other comorbidities including chronic pulmonary disease, peripheral vascular disease and rheumatic disease showed increasing trends (Figure 2).541_A Figure 1 No Caption available.541_B Figure 2 No Caption available.Conclusion: During the study period, there was a significant increase in the total number of hospitalizations with ESRD complicated by GIH. Although in-hospital mortality only increased slightly, there was a significant rise in the cost of care, perhaps due to increasing use of advanced diagnostic and therapeutic modalities and increasing numbers of comorbid conditions. Further studies are required to identify and more fully understand any additional risk factors that may have contributed to these findings.