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Contributors: A Bansal (U of Pennsylvania) | P Dedhia (U of Cincinnati) | A Elebiary (Lahey Clinic) | X Vela (U of El Salvador) | D Thomson (ECU) | P Jawa (ECU) | S Sridharan

(Lister H ospital, UK)


F Iannuzsella (U of Parma, Italy) | D M itema (Johns H opkins U)

Courtesy: D. Divakaran | mostphotos.com/ 1987407/ human- kidney

Kidney
Konnection
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ISSN 2372- 0824 (Print) | 2372- 0832 (Electronic)

Kidney Konnection is a monthly independent publication from N ephrology On- Demand

KIDNEY FAILURE, BLEEDING, & THE GI TRACT


(by Ahmed Elebiary)

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.

I THINK THEREFORE I KNOW (ANSWERS)


In the April issue we asked you about a 70- year- old patient with non- specific complaints. You spun his/ her urine (Image A) and found
an interesting finding that prompted you to biopsy his/ her kidney. The biopsy findings were shown in Image B and you were asked to
comment on the images, diagnosis, and/ or treatment.
Image A

<- - Image A shows one of many erythrocyte casts


(aka red blood cell casts).

Image B shows one of many glomeruli with - - >


crescents (a bit hard to tell if the crescents are
cellular, fibrocellular, or fibrous)
(continued on page 2)

Image B

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Issue 12 | Volume 1 | 2015
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FIND M E...I'M LOST (ANSWERS)


In the M ay issue we introduced our first Word Find (Topic: renal failure in stem cell transplantation). Admittedly, this
was a hard word find to complete. N evertheless, we want to congratulate our winners and everyone who made an
attempt. Below are the answers.
Clues
1.

The acronym for the condition that


occurs in up to 50% of stem cell
transplant recipients
This entity is indistinguishable from
hepatorenal syndrome and is a major
cause of renal failure in patients
undergoing myeloablative stem cell
transplantation
An antithrombotic and fibrinolytic
used in the management of
venoocclusive disease
The drug class of choice in the
treatment of thrombotic
microangiopathy
Chronic graft- versus- host disease is
associated with this nephrologic
syndrome
Severe forms of thrombotic
microangiopathy require this form of
therapy
The type of stem cell transplant
whereby the cells are from a donor
The type of stem cell transplant
whereby the cells are from a patient

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

I THINK THEREFORE I KNOW (ANSWERS)

(continued from page 1)

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):
-

Age: younger does better than older


Gender: women of child- bearing age must consider the detrimental effects of treatment on future reproductive ability
Race: African- Americans may do better w/ some regimens versus others
Entry creatinine & / or need for renal replacement therapy: higher the former (esp. > 5.0 mg/ dl) or need for dialysis both forecast a
poorer prognosis
- Degree of interstitial fibrosis/ tubular atrophy on biopsy: the more there is, the worse the renal outcome
- Type of crescents: cellular crescents may respond a bit better than fibrous crescents
- Presence of anti- GBM antibody: believe it or not, this actually forecasts a better prognosis (still unclear why)
In an upcoming issue we'll go over the treatment options for AN CA- associated vasculitides.
2

(Thanks to Dr. Jordan Weinstein


(@UKidney) for the images)