Dig Dis Sci (2014) 59:3131–3132 DOI 10.1007/s10620-014-3401-2
CORRESPONDENCE
Risk of Peptic Ulcer Bleeding in Patients with Chronic Kidney Disease and End-Stage Renal Disease Receiving Peritoneal or Hemodialysis Tomoyuki Kawada
Received: 18 September 2014 / Accepted: 11 October 2014 / Published online: 25 October 2014 Ó Springer Science+Business Media New York 2014
To the Editor, Huang et al. [1] conducted a seven-year cohort study to examine the risk of peptic ulcer bleeding (PUB) by chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients receiving hemodialysis (HD) or peritoneal dialysis (PD). The target subjects were composed of 11,408 patients, including 2,239 PD, 2,328 HD, 2,267 CKD and 4,574 control patients without kidney diseases. Hazard ratios (HRs) (95 % confidence intervals) of CKD, PD and HD for PUB were 3.99 (2.24–7.13), 3.71 (2.00–6.87) and 11.96 (7.04–20.31), respectively. In addition, elderly, male, having hypertension, diabetes, cirrhosis, nonsteroidal anti-inflammatory drugs (NSAIDs) and steroid use were also risk factors of PUB. I have some comments on their study. Dong et al. [2] reported that HD and PD patients differ in prevalence, severity and diversity of gastrointestinal (GI) symptoms. They used 15-item questionnaire, having five dimensions on abdominal pain, reflux, indigestion, diarrhea and constipation. Eating dysfunction was also added as the sixth dimension in their study. Mean values of intestinal symptoms such as abdominal pain, diarrhea and constipation were higher in patients with HD, and those of gastric symptoms such as reflux and eating dysfunction were higher in patients with PD. But the prevalence of PUB in patients with HD was fourfold higher than that in patients with PD, which was reported by Huang et al. On this point,
bleeding and some other GI complaints should be considered separately in patients with ESRD receiving dialysis. In general, HD patients frequently receive anticoagulant therapy and higher risk of hemorrhagic stroke exists in patients with HD [3]. Huang et al. report in Table 3 that adjusted HR of patients perceiving HD for PUB was threefold higher than that in patients receiving PD. But medication of NSAIDs and steroid independently related to PUB, and anti-coagulant medications did not become significant predictor for PUB. Taking together, cause of PUB should be separately considered from other bleeding such as hemorrhagic stroke. Finally, the authors presented Kaplan–Meier estimates of PUB event-free survival in Figure 1. As there was a crossing of two curves between patients with CKD and patients with PD, log-rank test between these two groups seems not appropriate. There is also a difficulty for keeping proportionality, and Cox regression model including patients with CKD and patients with PD should be handled with caution. Lau et al. [4] conducted a systematic review on the risk factors for complicated peptic ulcer disease and described that Helicobacter pylori infection, ulcer size and protonpump inhibitor use also related to the risk of peptic ulcer hemorrhage. I recommend their continuous survey to verify the risk of PUB in patients with CKD and with ESRD receiving PD or HD by considering other risk factors.
T. Kawada (&) Department of Hygiene and Public Health, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo 113-8602, Japan e-mail: [email protected]
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3132 Conflict of interest
Dig Dis Sci (2014) 59:3131–3132 The author declares no conflict of interest.
References 1. Huang KW, Leu HB, Luo JC, et al. Different peptic ulcer bleeding risk in chronic kidney disease and end-stage renal disease patients receiving different dialysis. Dig Dis Sci. 2014;59:807–813. 2. Dong R, Guo ZY, Ding JR, Zhou YY, Wu H. Gastrointestinal symptoms: a comparison between patients undergoing peritoneal
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dialysis and hemodialysis. World J Gastroenterol. 2014;20: 11370–11375. 3. Drew DA, Sarnak MJ. Ischemic and hemorrhagic stroke: high incidence in hemodialysis and peritoneal dialysis patients. Am J Kidney Dis. 2014;63:547–548. 4. Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz DC. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion. 2011;84:102–113.
CORRESPONDENCE
Risk of Peptic Ulcer Bleeding in Patients with Chronic Kidney Disease and End-Stage Renal Disease Receiving Peritoneal or Hemodialysis Tomoyuki Kawada
Received: 18 September 2014 / Accepted: 11 October 2014 / Published online: 25 October 2014 Ó Springer Science+Business Media New York 2014
To the Editor, Huang et al. [1] conducted a seven-year cohort study to examine the risk of peptic ulcer bleeding (PUB) by chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients receiving hemodialysis (HD) or peritoneal dialysis (PD). The target subjects were composed of 11,408 patients, including 2,239 PD, 2,328 HD, 2,267 CKD and 4,574 control patients without kidney diseases. Hazard ratios (HRs) (95 % confidence intervals) of CKD, PD and HD for PUB were 3.99 (2.24–7.13), 3.71 (2.00–6.87) and 11.96 (7.04–20.31), respectively. In addition, elderly, male, having hypertension, diabetes, cirrhosis, nonsteroidal anti-inflammatory drugs (NSAIDs) and steroid use were also risk factors of PUB. I have some comments on their study. Dong et al. [2] reported that HD and PD patients differ in prevalence, severity and diversity of gastrointestinal (GI) symptoms. They used 15-item questionnaire, having five dimensions on abdominal pain, reflux, indigestion, diarrhea and constipation. Eating dysfunction was also added as the sixth dimension in their study. Mean values of intestinal symptoms such as abdominal pain, diarrhea and constipation were higher in patients with HD, and those of gastric symptoms such as reflux and eating dysfunction were higher in patients with PD. But the prevalence of PUB in patients with HD was fourfold higher than that in patients with PD, which was reported by Huang et al. On this point,
bleeding and some other GI complaints should be considered separately in patients with ESRD receiving dialysis. In general, HD patients frequently receive anticoagulant therapy and higher risk of hemorrhagic stroke exists in patients with HD [3]. Huang et al. report in Table 3 that adjusted HR of patients perceiving HD for PUB was threefold higher than that in patients receiving PD. But medication of NSAIDs and steroid independently related to PUB, and anti-coagulant medications did not become significant predictor for PUB. Taking together, cause of PUB should be separately considered from other bleeding such as hemorrhagic stroke. Finally, the authors presented Kaplan–Meier estimates of PUB event-free survival in Figure 1. As there was a crossing of two curves between patients with CKD and patients with PD, log-rank test between these two groups seems not appropriate. There is also a difficulty for keeping proportionality, and Cox regression model including patients with CKD and patients with PD should be handled with caution. Lau et al. [4] conducted a systematic review on the risk factors for complicated peptic ulcer disease and described that Helicobacter pylori infection, ulcer size and protonpump inhibitor use also related to the risk of peptic ulcer hemorrhage. I recommend their continuous survey to verify the risk of PUB in patients with CKD and with ESRD receiving PD or HD by considering other risk factors.
T. Kawada (&) Department of Hygiene and Public Health, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo 113-8602, Japan e-mail: [email protected]
123
3132 Conflict of interest
Dig Dis Sci (2014) 59:3131–3132 The author declares no conflict of interest.
References 1. Huang KW, Leu HB, Luo JC, et al. Different peptic ulcer bleeding risk in chronic kidney disease and end-stage renal disease patients receiving different dialysis. Dig Dis Sci. 2014;59:807–813. 2. Dong R, Guo ZY, Ding JR, Zhou YY, Wu H. Gastrointestinal symptoms: a comparison between patients undergoing peritoneal
123
dialysis and hemodialysis. World J Gastroenterol. 2014;20: 11370–11375. 3. Drew DA, Sarnak MJ. Ischemic and hemorrhagic stroke: high incidence in hemodialysis and peritoneal dialysis patients. Am J Kidney Dis. 2014;63:547–548. 4. Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz DC. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion. 2011;84:102–113.
