Endoscopic findings in end-stage renal disease

Prediction of gastrointestinal bleeding hospitalization risk in hemodialysis using machine learning

BACKGROUND

Gastrointestinal bleeding (GIB) is a clinical challenge in kidney failure. INSPIRE group assessed if machine learning could determine a hemodialysis (HD) patient's 180-day GIB hospitalization risk.

METHODS

An eXtreme Gradient Boosting (XGBoost) and logistic regression model were developed using an HD dataset in United States (2017-2020). Patient data was randomly split (50% training, 30% validation, and 20% testing). HD treatments ≤ 180 days before GIB hospitalization were classified as positive observations; others were negative. Models considered 1,303 exposures/covariates. Performance was measured using unseen testing data.

RESULTS

Incidence of 180-day GIB hospitalization was 1.18% in HD population (n = 451,579), and 1.12% in testing dataset (n = 38,853). XGBoost showed area under the receiver operating curve (AUROC) = 0.74 (95% confidence interval (CI) 0.72, 0.76) versus logistic regression showed AUROC = 0.68 (95% CI 0.66, 0.71). Sensitivity and specificity were 65.3% (60.9, 69.7) and 68.0% (67.6, 68.5) for XGBoost versus 68.9% (64.7, 73.0) and 57.0% (56.5, 57.5) for logistic regression, respectively. Associations in exposures were consistent for many factors. Both models showed GIB hospitalization risk was associated with older age, disturbances in anemia/iron indices, recent all-cause hospitalizations, and bone mineral metabolism markers. XGBoost showed high importance on outcome prediction for serum 25 hydroxy (25OH) vitamin D levels, while logistic regression showed high importance for parathyroid hormone (PTH) levels.

CONCLUSIONS

Machine learning can be considered for early detection of GIB event risk in HD. XGBoost outperforms logistic regression, yet both appear suitable. External and prospective validation of these models is needed. Association between bone mineral metabolism markers and GIB events was unexpected and warrants investigation.

TRIAL REGISTRATION

This retrospective analysis of real-world data was not a prospective clinical trial and registration is not applicable.

Eradication Therapy for Helicobacter pylori Infection in Patients Receiving Hemodialysis: Review

Patients receiving hemodialysis (HD) often develop gastrointestinal diseases. Recently, although in general population, clinical guidelines for Helicobacter pylori have strongly recommended its eradication in patients to prevent gastric cancer, optimal eradication regimen and optimal dosage of drugs for patients receiving HD have not been established, due to possible incidence of adverse events. Some antimicrobial agents used in eradication therapy, particularly amoxicillin, can exacerbate renal dysfunction. Given the delayed pharmacokinetics of drugs in patients receiving HD compared with those in healthy individuals, drug regimen and dosage should be considered to minimize adverse effects. Although previous studies have investigated the benefits of eradication therapy for patients receiving HD, because most studies were small in terms of the number of enrolled patients, it is hard to show evidence. The numbers of eradication in HD patients have recently increased, and it is important to provide an optimal regimen. The consideration of eradication in patients undergoing HD with a reduction in the drug dose by 1/2-1/3 may prevent adverse events. Additionally, another important consideration is whether adverse events can be prevented while maintaining a similar eradication rate with reduced drug dosages. Recent meta-analysis findings indicate comparable eradication rates in patients receiving HD and healthy individuals, both with the same dosage regimen and at a reduced dosage regimen, with no significant differences (relative risk [RR] for successful eradication: 0.85 [95% confidence interval (CI): 0.48-1.50]). Unlike with the same dosage regimen (RR for adverse events: 3.15 [95% CI: 1.93-5.13]), the adverse events in the dosage reduction regimen were similar to those in healthy individuals (RR: 1.26 [95% CI: 0.23-6.99]). From a pharmacological perspective, the eradication regimen in patients receiving HD should consider the dosage (1/2-1/3 dosage), dosing number (bid), dosing timing of drugs (after HD), and susceptibility to antimicrobial agents.

Gastric pH and serum gastrin concentration in age-matched healthy dogs and dogs with chronic kidney disease

BACKGROUND

Gastric hyperacidity and hypergastrinemia are purported to cause gastric ulceration in dogs with chronic kidney disease (CKD); however, no published studies have evaluated gastric pH with serum gastrin concentrations in dogs with CKD.

HYPOTHESIS

To compare mean intragastric pH, mean percent pH distribution, and serum gastrin concentrations in dogs with CKD to age-matched, healthy dogs. We hypothesized there would be no difference in mean gastric pH or serum gastrin between groups.

ANIMALS

Thirteen dogs with CKD; 10 aged-matched healthy dogs.

METHODS

Prospective, case-control study. Serum chemistry, complete blood count, urinalysis, and serum gastrin concentrations were evaluated in all dogs before radiographic-assisted gastric placement of a pH capsule. Forty-eight-hour continuous gastric pH monitoring was performed in all dogs. Serum gastrin concentration, mean pH, and mean percentage time that gastric pH was strongly acidic (pH <1 and pH <2) were compared between groups using a repeated measures mixed-model ANOVA.

RESULTS

No significant differences were observed between groups for any pH measurements, including mean ± SD gastric pH (CKD, 2.37 ± 0.87; healthy, 2.39 ± 0.99; P > .05). Serum gastrin concentrations were not significantly different between groups (median [range]: CKD, 10.5 ng/dL [<10-17.1]; healthy, 10.9 ng/dL [<10-15]; P > .05).

CONCLUSIONS AND CLINICAL IMPORTANCE

Our client-owned dogs with CKD did not have lower gastric pH or higher serum gastrin concentrations compared to healthy dogs. Our results suggest that prophylactic gastric acid suppression in dogs with CKD is not warranted unless other clinical indications for use are present.

The Role of Gastroenterologists in Preoperative Assessment and Management of Prospective Renal Transplantation Candidates

Renal transplant is the most common organ transplant worldwide, accounting for 65% of the total number of transplants. End-stage renal disease (ESRD) often has multiple significant comorbidities. Among the gastrointestinal (GI) disorders, peptic ulcer disease (PUD), cholelithiasis, and colon and liver diseases increase the risk of posttransplant morbidity. Potential renal transplantation (RT) candidates need a multidisciplinary assessment of coexisting illnesses, which may affect the perioperative risk and survival after transplantation. Successful outcome of RT depends on careful selection of the recipients by a thorough medical evaluation and screening. This review summarizes the role of gastroenterologists and hepatologists in preoperative assessment and management of renal transplant recipients.

How to cite this article

Giri S, Dash KA, Varghese J, et al. The Role of Gastroenterologists in Preoperative Assessment and Management of Prospective Renal Transplantation Candidates. Euroasian J Hepato-Gastroenterol 2023;13(1):18-25.

Diagnostic evaluation and assessment of anemia in a patient with chronic kidney disease and gastrointestinal angioectasias undergoing hemodialysis

Anemia in patients with chronic kidney disease may have underlying causes that require a broad approach. Here, we present a clinical case of anemia in a patient with chronic kidney disease and gastrointestinal angioectasias undergoing hemodialysis.

Appetite-stimulating effects of once-daily omeprazole in cats with chronic kidney disease: Double-blind, placebo-controlled, randomized, crossover trial

Background

Cats with moderate to advanced chronic kidney disease (CKD) often display clinical signs such as vomiting and decreased appetite, and frequently receive omeprazole or other acid suppressants despite a lack of evidence to support their use.

Hypothesis/Objectives

To evaluate the effect of once‐daily PO omeprazole on appetite in cats with CKD. We hypothesized that omeprazole would improve subjective appetite assessments in cats with CKD.

Animals

Fourteen client‐owned cats with International Renal Interest Society (IRIS) stage 2 or 3 CKD and hyporexia.

Methods

Cats were prospectively enrolled in a multi‐institutional, double‐blinded, randomized, crossover study to evaluate the effect of a 14‐day trial of once‐daily PO omeprazole (1 mg/kg) or placebo (lactose gel capsule) on vomiting frequency and appetite. A daily log was completed by the owner during all treatment and rest periods to assess appetite using a subjective, qualitative, and 5‐point scoring system. Mixed model analyses of variance were performed to determine if average daily percentage food consumed or appetite score, as measured by subjective owner assessment, differed between treatments.

Results

Compared to placebo, a negligible but statistically significant difference in percentage of food consumed was observed between treatments (P = .04) with once‐daily omeprazole treatment resulting in a 2.7% increase in food consumption compared to placebo. No significant difference, however, was found in appetite score, body weight, or serum creatinine concentration between treatments.

Conclusions and Clinical Importance

Once‐daily omeprazole does not markedly increase appetite in cats with CKD and should not be used as a first‐line treatment in the absence of evidence of gastrointestinal ulceration.

Comparison of endoscopic and pathological findings of the upper gastrointestinal tract in transplant candidate patients undergoing hemodialysis or peritoneal dialysis treatment: a review of literature

BACKGROUND

Dyspepsia is a common disorder in kidney transplant recipients, and the risk of post-transplant complications is increased in candidates with upper gastrointestinal disease. We evaluated gastrointestinal lesions of kidney transplant candidates on dialysis.

METHODS

In this study, endoscopic and pathological findings in hemodialysis (HD) and peritoneal dialysis (PD) patients with gastrointestinal symptoms on the waiting list were compared.

RESULTS

The most common non-ulcerous lesions in the endoscopic examination were gastritis (62.3%), erosive gastritis (38.7%), duodenal erosion or duodenitis (18.9%) and esophagitis (13.2%). The ulcerous lesion was present in only 3 patients. Gastroesophageal reflux disease, ulcerated lesion and non-ulcerated lesion rates were similar in both dialysis groups. Histopathological examination revealed Helicobacter pylori (HP) positivity in 28.3% of patients. HP positivity rate was significantly higher in PD patients than in HD patients (38.7% vs. 13.6%, p = 0.046). Chronic gastritis (75.5%) was the most common pathological finding. HP positivity rate was 37.5% in patients with chronic gastritis, but HP was negative in patients without chronic gastritis. In multivariate analysis, male gender, urea and albumin levels were associated with the presence of pathological chronic gastritis. The presence of gastritis, total cholesterol and ferritin levels were found significant for HP positivity. A total cholesterol > 243 mg/dL was significantly related to an increased risk of the presence of HP positivity.

CONCLUSIONS

Gastrointestinal lesions and HP infection are common in dialysis patients. Dialysis modality may affect the frequency of some lesions. It may be useful to have an endoscopic examination before entering the transplant waiting list for all candidates.

Angiodysplasia in Renal Disease Patients: Analysis of Risk Factors and Approach to Manage Such Patients

Gastrointestinal bleeding due to angiodysplasia is a common problem in patients with renal insufficiency. There are several theories to explain the increased occurrence of these lesions in this specific group of patients, including various metabolic factors and existence of comorbidities. Advancements made in diagnostic measures have helped route the approach in patients with different risk factors and have also helped solve the dual purpose involving therapeutic intervention with endoscopy. We conducted a thorough literature search on PubMed to extract relevant data. A total of 29 articles were chosen after applying the inclusion and exclusion criteria. Although the clinical presentations may vary in this cohort of patients, and bleeding is known to stop spontaneously, a conservative approach may not be enough. Endoscopic treatment, use of hormones like estrogen, octreotide, and vasopressin, arterial embolization, and lastly surgery are valuable therapeutic tools.

Endoscopic findings in hemodialysis patients upon workup for kidney transplantation

Upper gastrointestinal (GI) abnormality is believed to be higher in patients with end-stage renal disease (ESRD) which can make a big trouble for whom undergo kidney transplant. We conducted this study to assess upper GI findings of patients with ESRD. In the present retrospective study we recorded upper GI endoscopy results in hemodialysis patients who were candidate for renal transplantation during a 10-year period. We reviewed files of 1256 patients with a mean age of 37.6 ± 13.4 years. Half of patients (50.6%) had an abnormal endoscopy. Two most common abnormalities were mild gastritis (35.6%) and gastro-esophageal reflux disease (16.7%). GI ulcers were observed in 11% of patients. Duodenal ulcer was the most common ulcer which was seen in 6.8% of patients. Helicobacter pylori was positive in 32.9% of patients and correlated with GI lesions (P = 0.000, r = 0.371). Longer dialysis duration and older patients revealed more upper GI abnormality (P = 0 .032, <0.001). As long as more than half of our patients have at least one upper GI involvement, we recommended that endoscopy must be done as a pretransplantation evaluation for patients without symptoms who have risk factors for ulcers.

Helicobacter pylori, Endoscopic, And Histologic Features Among Kidney Transplant Candidates In Southern Iran

BACKGROUND

The risks of gastrointestinal disorders and cancer are higher in chronic kidney disease (CKD) patients than the general population. There are only a few published reports on the association of helicobacter pylori (H. pylori) infection, endoscopic findings, and histology in these patients. This study was designed to address these controversial topics among kidney transplant candidates as the first study in southern Iran.

PATIENTS AND METHODS

In this cross-sectional study, patients undergoing renal transplantation in the largest center of southern Iran during 2016-2017 were evaluated for the frequency of H. pylori infection, endoscopic findings, and histology. Gastric endoscopic findings (normal, abnormal non-ulcerative, ulcerative) and histological findings of gastric biopsy (normal/non-significant, inflammation, premalignant lesions (PMLs), malignant lesions) were studied.

RESULTS

In total, 293 patients underwent endoscopy for transplant work up. The mean age (SD) was 47.37 (13.14) years. The most common endoscopic finding was abnormal gastric lesions. Overall, 78.8% patients had abnormal gastric histologic findings, of which 6.1% had PMLs. There was no significant association between laboratory data of patients with H. pylori infection. Of these, 147 (50.2%) patients were positive and the others were H. Pylori negative. Positive H. pylori infection was significantly associated with gastric ulcerative lesions. Positive H. pylori infection was also strongly associated with inflammation (P<0.01), but not significantly associated with PMLs (P=0.99) in gastric histology.

CONCLUSION

The present study showed that abnormal endoscopic and histologic findings as well as positive H. pylori infection were observed in a large number of kidney transplant candidates, so upper endoscopy with biopsy is an acceptable procedure for these patients. However, further studies are recommended to determine the relationship of H. pylori with abnormal endoscopic and histologic findings considering other confounding factors in kidney transplant candidates as well as the efficacy of H. pylori eradication therapy to improve these abnormal findings.

Risk factors for incidentally detected and symptomatic angiodysplasias: a case-control study with the general population as reference

BACKGROUND

There is no literature on risk factors for incidentally found angiodysplasias. In clinical practice, endoscopists may defer treatment owing to uncertainty about a causal role of any found angiodysplasia and overt or occult bleeding. The objective is to identify risk factors that distinguish incidental angiodysplasias from angiodysplasias that are the cause of symptomatic bleeding.

PARTICIPANTS AND METHODS

A case-control study was conducted to compare angiodysplasia groups and a random sample from the general population. Patients with angiodysplasia were diagnosed between 2010 and 2015. Controls were from a 2005 population survey. Determinants were demographics, past medical history, lifestyle, medication and angiodysplasia characteristics. Multivariable logistic regression analyses were performed to identify independent risk factors.

RESULTS

A total of 270 (59% men, mean age 65 years) patients with angiodysplasia and 5594 (46% men, mean age 58 years) controls were included in this study. Independent risk factors for incidental angiodysplasias are male sex [odds ratio (OR): 1.6; 95% confidence interval (CI): 1.02-2.6], thyroid dysfunction (OR: 4.1; 95% CI: 2.0-8.4), autoimmune disease (OR: 2.3; 95% CI: 1.2-4.1), chronic obstructive pulmonary disease (OR: 1.8; 95% CI: 1.0-3.2), and blood thinners (OR: 2.8; 95% CI: 1.6-4.8). Besides angiodysplasia characteristics, factors independently associated with symptomatic angiodysplasias are increased age (OR: 1.7/10 years age band; 95% CI: 1.3-2.5), valvular heart disease (OR: 10.4; 95% CI: 1.6-69.2), diabetes mellitus (OR: 2.6; 95% CI: 1.03-6.7) and hyperlipidemia (OR: 3.7; 95% CI: 1.1-12.1).

CONCLUSION

The risk factor profile for incidental angiodysplasias differs from symptomatic angiodysplasias and is more profound for the latter. This knowledge could help endoscopists in the decision-making process to treat an endoscopically detected angiodysplasia.

Lanthanum-Induced Mucosal Alterations in the Stomach (Lanthanum Gastropathy): a Comparative Study Using an Animal Model

Lanthanum (La) carbonate (LC) is one of the most potent phosphate binders that prevents the elevation of serum phosphate levels in patients with end-stage renal diseases undergoing dialysis. LC binds strongly to dietary phosphate and forms insoluble complexes that pass through the gastrointestinal tract. La deposition in patients treated with LC is a recently documented finding particularly observed in gastric mucosa. We herein describe the detailed gastric mucosal lesions in 45 LC-treated patients and address the potential underlying pathologic mechanism using oral LC administration in rats. Microscopically, La deposition, as shown by subepithelial collections of plump eosinophilic histiocytes or small foreign body granulomas containing coarse granular or amorphous inclusion bodies, was found in the gastric mucosa of 44 (97.8%) of the 45 dialysis patients in the study cohort, which was most frequently associated with foveolar hyperplasia (37.8%). Using oral administration of rats with 1000 mg/day LC for 2 or more weeks, La deposition was consistently detectable in the gastric mucosa but not in other organs examined. In addition, various histologic alterations such as glandular atrophy, stromal fibrosis, proliferation of mucous neck cells, intestinal metaplasia, squamous cell papilloma, erosion, and ulcer were demonstrated in the rat model. Thus, orally administered LC can induce mucosal injury, designated here as La gastropathy, which may alter the local environment and result in La deposition in the gastric mucosa, thereby potentially inducing abnormal cell proliferation or neoplastic lesions.

Gastrointestinal lesions in chronic kidney disease patients with anaemia

INTRODUCTION

Despite the frequency with which anaemia is present in patients with chronic kidney disease (CKD), its relationship with gastrointestinal lesions has not been studied.

METHOD

A cross-sectional, analytical, observational study involving one year of recruitment was carried out to determine the prevalence of endoscopic gastrointestinal lesions and associated risk factors in asymptomatic patients with chronic kidney disease stages 1-5 and anaemia who had a positive qualitative immunochemical faecal occult blood test.

RESULTS

A total of 9,658 patients with CKD were analysed, of which 286 (2.9%) had anaemia; 198 had a positive faecal occult blood test (47% male, 71.1±11.8 years). The endoscopic study revealed 255 lesions, with at least one lesion in 68.2% of patients, with the most prevalent being: adenomatous colorectal polyps (39.6%), acute lesions of the gastric mucosa (22.6%), neoplastic lesions 15.1%), angiodysplasia (14.4%), oesophagitis (8.4%), inflammatory bowel disease (4.8%) and ischaemic colitis (3.1%). Uraemia and acetylsalicylic acid were identified as risk factors for acute gastric mucosal lesions. Angiodysplasia was associated with alcoholism, a more advanced stage of chronic kidney disease, anaemia, and lack of response to erythropoiesis-stimulating agents. Age and refractory anaemia were risk factors for adenomatous polyps and colorectal cancer.

CONCLUSION

Renal patients with anaemia could benefit from an endoscopic study due to their high prevalence of gastrointestinal lesions, particularly adenomatous polyps and colorectal cancer, which are more common in those over 50 years of age with CKD stages 3-5.

Upper gastrointestinal alterations in kidney transplant candidates

Introduction:

The incidence of gastrointestinal disorders among patients with chronic kidney disease (CKD) is high, despite the lack of a good correlation between endoscopic findings and symptoms. Many services thus perform upper gastrointestinal (UGI) endoscopy on kidney transplant candidates.

Objectives:

This study aims to describe the alterations seen on the upper endoscopies of 96 kidney-transplant candidates seen from 2014 to 2015.

Methods:

Ninety-six CKD patients underwent upper endoscopic examination as part of the preparation to receive kidney grafts. The data collected from the patients' medical records were charted on Microsoft Office Excel 2016 and presented descriptively. Mean values, medians, interquartile ranges and 95% confidence intervals of the clinic and epidemiological variables were calculated. Possible associations between endoscopic findings and infection by H. pylori were studied.

Results:

Males accounted for 54.17% of the 96 patients included in the study. Median age and time on dialysis were 50 years and 50 months, respectively. The most frequent upper endoscopy finding was enanthematous pangastritis (57.30%), followed by erosive esophagitis (30.20%). Gastric intestinal metaplasia and peptic ulcer were found in 8.33% and 7.30% of the patients, respectively. H. pylori tests were positive in 49 patients, and H. pylori infection was correlated only with non-erosive esophagitis (P = 0.046).

Conclusion:

Abnormal upper endoscopy findings were detected in all studied patients. This study suggested that upper endoscopy is a valid procedure for kidney transplant candidates. However, prospective studies are needed to shed more light on this matter.

Nutrition status and Helicobacter pylori infection in patients receiving hemodialysis

Chronic kidney disease (CKD) patients receiving hemodialysis (HD) often develop gastrointestinal abnormalities over their long treatment period. In general, prognosis in such patients is poor due to the development of protein-energy wasting (PEW). Therefore, it is important to clarify the etiology of PEW and to establish better strategies to deal with this condition. Chronic Helicobacter pylori (H. pylori) infection in the gastric mucosa has a close association with not only the development of peptic ulcer disease and gastric cancer, but is also associated with abnormal plasma and gastric mucosal ghrelin levels that are seen in malnutrition. It is unclear whether H. pylori infection of the gastric mucosa is directly associated with prognosis in HD patients by affecting ghrelin levels. Recent studies show that the prevalence of H. pylori infection in HD patients is significantly lower than in subjects with normal renal function. In the natural history of H. pylori infection in HD patients, the prevalence of infection decreases as the length of time on HD increases. The severity of gastric mucosal atrophy has been suggested as the major determinant of ghrelin levels in these patients, and eradication therapy of H. pylori improves nutritional status by increasing serum cholinesterase and cholesterol levels, especially in patients with mild-to-moderate gastric mucosal atrophy. Prompt H. pylori eradication to inhibit the progress of gastric atrophy may be required to prevent this decrease in ghrelin levels and subsequent PEW and improve the prognosis of HD patients by improving their nutritional status.

Efficacy of Reduced Dosage of Amoxicillin in an Eradication Therapy for Helicobacter pylori Infection in Patients on Hemodialysis: A Randomized Controlled Trial

BACKGROUND

An optimum Helicobacter pylori-eradication regimen for hemodialysis patients is yet to be established because of different pharmacokinetics of amoxicillin involved between hemodialysis patients and healthy subjects. We investigated to establish appropriate doses of amoxicillin for H. pylori infection eradication in hemodialysis patients.

METHODS

Of 409 hemodialysis patients screened for H. pylori infection, 37 H. pylori-positive patients were randomized to different 1-week eradication regimens: esomeprazole 20 mg twice a day (b.i.d.) and clarithromycin 200 mg b.i.d., plus amoxicillin at either 750 mg b.i.d. (group A; conventional) or 250 mg b.i.d. (group B; experimental). Sixty-three patients with normal renal function received the conventional regimen (group C). Successful eradication was confirmed by urea breath testing.

RESULTS

Eradication rates of group B (reduced amoxicillin-regimen) were 84.2% in intention-to-treat analysis and 88.9% in per-protocol analysis, which were similar with group A (77.8 and 77.8%) and group C (74.6 and 81.0%). However, the incidence of adverse events in group A was significantly higher than that in group C (22.2 vs. 5.1%, p = 0.027).

CONCLUSIONS

In H. pylori-positive hemodialysis patients, amoxicillin at 250 mg b.i.d. may be an appropriate scheme for eradication with equivalent effects to the conventional therapy and safety effects for adverse events.

Evaluation of Gastric pH and Serum Gastrin Concentrations in Cats with Chronic Kidney Disease

Background

Chronic kidney disease (CKD) is a highly prevalent condition in cats. Advanced CKD is associated with hyporexia and vomiting, which typically are attributed to uremic toxins and gastric hyperacidity. However, gastric pH studies have not been performed in cats with CKD.

Hypothesis/Objectives

To determine if cats with CKD have decreased gastric pH compared to age‐matched, healthy cats. Based on previous work demonstrating an association of hypergastrinemia and CKD, we hypothesized that cats with CKD would have decreased gastric pH compared to healthy, age‐matched control cats.

Animals

10 CKD cats; 9 healthy control cats.

Methods

All cats with concurrent disease were excluded on the basis of history, physical examination, CBC, plasma biochemistry profile, urinalysis, urine culture, serum total thyroxine concentration, and serum symmetric dimethylarginine concentration (controls only) obtained within 24 hours of pH monitoring and assessment of serum gastrin concentrations. Serum for gastrin determination was collected, and 12‐hour continuous gastric pH monitoring was performed in all cats. Serum gastrin concentration, mean pH, and percentage time that gastric pH was strongly acidic (pH <1 and <2) were compared between groups.

Results

No significant differences in serum gastrin concentrations were observed between groups (medians [range]: CKD, 18.7 ng/dL [<10–659.0]; healthy, 54.6 ng/dL [<10–98.0]; P‐value = 0.713) or of any pH parameters including mean ± SD gastric pH (CKD, 1.8 ± 0.5; healthy, 1.6 ± 0.3; P‐value = 0.23).

Conclusions and Clinical Importance

These findings suggest that cats with CKD may not have gastric hyperacidity compared to healthy cats and, therefore, may not need acid suppression. Thus, further studies to determine if there is a benefit to acid suppression in cats with CKD are warranted.

Upper Gastrointestinal Bleeding in Patients with End Stage Renal Disease: Causes, Characteristics and Factors Associated with Need for Endoscopic Therapeutic Intervention

BACKGROUND AND OBJECTIVES

The risk of upper gastrointestinal bleeding (UGIB) is increased among the end-stage renal disease (ESRD) patients. The aim of the current study was to describe the causes and characteristics of UGIB in ESRD patients at our center and to assess the need for endoscopic therapeutic intervention (ETI) using Rockall (RS) and Glasgow Blatchford scores (GBS).

MATERIAL AND METHODS

All patients with ESRD and UGIB with age ≥14 years were included. Frequencies and percentages were computed for categorical variables. Chi square test or Fischer's exact test was used for statistical analysis.

RESULTS

A total of 59 subjects had a mean age of 47.25 ± 15 years.The most common endoscopic findings seen were erosions in 33 (55.9%) patients, followed by ulcers in 18 (30.3%) patients. ETI was required in 33 (55.9%) patients, which included adrenaline injection in 19 (32.3%), hemoclip in 9 (15.2%) and argon plasma coagulation in 5 (8.4%) patients. Factors associated with the need of ETI were identified as: a combined presentation of hematemesis and melena (P=0.033), ulcer (P=0.002) and associated chronic liver disease (P=0.015). Six (10.1%) patients died. Death was more common if ETI was not performed (P=0.018).

CONCLUSION

ETI was more commonly required in patients on maintenance hemodialysis with UGIB, who had presence of combined hematemesis and melena, ulcers and associated chronic liver disease. A Glasgow Blatchford score of >14 was helpful in assessing the need for ETI in these patients.

Natural Course of Helicobacter pylori Infection in Japanese Hemodialysis Patients

INTRODUCTION

Helicobacter pylori (H. pylori) infection is one of the major risk factors for gastrointestinal morbidity in hemodialysis patients. Primary end point is to investigate H. pylori infection rate in hemodialysis patients. As secondary end point, we clarified whether pepsinogen (PG) level was related with H. pylori infection status in hemodialysis patients.

METHODS

Serum levels of PG I, II, and anti-H. pylori IgG antibody were assessed in 500 Japanese hemodialysis patients.

RESULTS

H. pylori infection rate was 15.0% (75/500; 95% CI 12.0-18.4). The duration of hemodialysis in H. pylori-positives was 4.6 ± 3.8 years, which was significantly shorter than in H. pylori-negatives (7.3 ± 6.9, p = 0.001). PG I levels positively correlated with the PG II level and PG I/II ratio (|R| = 0.661, p < 0.001, and |R| = 0.544, p <0.001, respectively). Using a cutoff value of 7.75, the sensitivity and specificity of PG I/II ratio for predicting H. pylori-negatives were 86.3 and 87.8%, respectively (area under the curve 0.930).

CONCLUSIONS

In hemodialysis patients, infection rate with H. pylori was <20%, with lower rates in patients receiving hemodialysis for longer terms. A PG I/II ratio with a cutoff value of 7.75 may be useful for screening for H. pylori status.

Association between Helicobacter pylori and end-stage renal disease: A meta-analysis

AIM

To investigate the prevalence and association of Helicobacter pylori (H. pylori) with end-stage renal disease (ESRD).

METHODS

SA comprehensive literature search was completed from inception until October 2016. Studies that reported prevalence, relative risks, odd ratios, hazard ratios or standardized incidence ratio of H. pylori among ESRD patients were included. Participants without H. pylori were used as comparators to assess the association between H. pylori infection and ESRD. Pooled risk ratios and 95%CI was calculated using a random-effect model. Adjusted point estimates from each study were combined by the generic inverse variance method of DerSimonian and Laird.

RESULTS

Of 4546 relevant studies, thirty-seven observational studies met all inclusion criteria. Thirty-five cross-sectional studies were included in the analyses to assess the prevalence and association of H. pylori with ESRD. The estimated prevalence of H. pylori among ESRD patients was 44% (95%CI: 40%-49%). The pooled RR of H. pylori in patients with ESRD was 0.77 (95%CI: 0.59-1.00) when compared with the patients without ESRD. Subgroup analysis showed significantly reduced risk of H. pylori in adult ESRD patients with pooled RR of 0.71 (95%CI: 0.55-0.94). The data on the risk of ESRD in patients with H. pylori were limited. Two cohort studies were included to assess the risk of ESRD in patients with H. pylori. The pooled risk RR of ESRD in patients with H. pylori was 0.61 (95%CI: 0.03-12.20).

CONCLUSION

The estimated prevalence of H. pylori in ESRD patients is 44%. Our meta-analysis demonstrates a decreased risk of H. pylori in adult ESRD patients.

Black Spot, a Novel Gastric Finding Potentially Induced by Proton Pump Inhibitors

Objective We have recently discovered new gastric lesions with black spots. There have been no reports about black spots and their clinicopathological features. We therefore report the clinicopathological features of black spots and assess their causes and mechanisms. Methods Sixty-four patients with black spots among 26,620 Japanese patients that underwent endoscopy between May 2012 and October 2014 were enrolled. Endoscopic findings of black spots were defined as black pigmentations in the gastric mucosa by conventional endoscopy. We investigated the clinicopathological characteristics, including gender, age, underlying diseases and medications, endoscopic and pathologic findings of patients with black spots. Results The prevalence of patients with black spots was 0.24%. Of sixty-four cases, 44 (68.8%) were taking proton pump inhibitors (PPIs). Eight (12.5%) were taking corticosteroids. There were 10 cases (15.6%) with decreased renal function. All black spots were identified only in the fundic gland region. Forty-one (64.1%) patients had multiple (more than ten) black spots. There were two different types: black spots on the flat mucosa and black spots on fundic gland polyps. Pathologically, parietal cell protrusions, fundic gland cysts and brownish pigmentation in fundic gland cysts were seen in 26 (76.5%), 23 (67.6%) and 6 (17.6%) patients, respectively. Conclusion We herein describe gastric black spots as a new gastric mucosal finding that arises only in the fundic gland region. The black spots are pathologically brownish pigmentations in fundic gland cysts. Adverse events of PPIs and parietal cell protrusion caused by PPI use are strongly considered to be one of the etiologies of black spots.

Patients with end-stage renal disease were at an increased risk of hospitalization for acute diverticulitis

Patients with end-stage renal disease (ESRD) show a high incidence of bacterial translocation and impaired gastrointestinal motility. The intestinal tract is believed to be the most crucial source of translocated bacteria. To evaluate the risk of colonic diverticulitis in patients with ESRD, we conducted a nationwide population-based cohort study. Patients who met the following 3 criteria were defined as patients with ESRD: patients diagnosed with ESRD who received regular hemodialysis between 2000 and 2005, patients who received hemodialysis for more than 90% of the time during the observation period (2000-2011), and patients with no prior history of hemodialysis between 1997 and 1999. We matched every patient with ESRD with 1 matched control on the basis of propensity scores. The first diagnosis of diverticulitis (ICD-9-CM codes 562.11 and 562.13) within the follow-up period was defined as the primary endpoint. Hazard ratios (HRs) and their 95% confidence intervals (CIs) were calculated using the patients in the control group as the reference. We included 32,547 and 32,547 patients in the ESRD and matched control cohorts, respectively. The 12-year cumulative incidence of acute colonic diverticulitis for patients with ESRD was significantly higher than that for the controls (P < 0.001). After adjustment for age, sex, comorbidities, and medication use, the HR of acute colonic diverticulitis in the ESRD cohort was 11.20 times greater than that in the control cohort (95% CI: 8.14-15.42). The results indicated that patients with ESRD are at an increased risk for acute colonic diverticulitis.

Cross-sectional small intestinal surveillance of maintenance hemodialysis patients using video capsule endoscopy: SCHEMA study

BACKGROUND AND STUDY AIMS

Small intestinal pathology in hemodialysis (HD) patients has been studied in only a small number of retrospective case series. One method for noninvasively surveying small intestinal disorders is video capsule endoscopy (VCE). The primary aim of this study was to investigate the prevalence of small intestinal abnormalities among asymptomatic maintenance HD outpatients using VCE. The secondary aim was to assess the clinical impact of these abnormalities.

PATIENTS AND METHODS

This study consisted of two phases. In phase I, a cross-sectional study, a cohort of patients who received maintenance HD three times weekly at an outpatient hemodialysis clinic were studied using VCE. Phase II was a prospective cohort study with follow up for 1 year after VCE.

RESULTS

Fifty-six patients were enrolled in this study, and two were excluded from analysis due to capsule retention in the stomach. The prevalence of small bowel abnormalities in HD patients was 64.8 % (35/54) (95 % confidential interval 52.1 % - 77.6 %). Of 54 patients, 21 (38.9 %) had mucosal lesions, 10 (18.5 %) had vascular lesions, and 4 (7.4 %) had both lesion types. During the 1-year follow-up period, events occurred in four patients. A small bowel-associated event was observed in one patient, who underwent laparoscopy-assisted small intestinal partial resection 3 months after diagnosis by VCE. All patients in whom events were seen had small bowel abnormalities; no events were observed in the VCE-negative group.

CONCLUSIONS

Although asymptomatic maintenance HD patients had a high prevalence of small bowel abnormalities (64.8 %), they did not have a high incidence of small bowel-associated events during the 1-year follow-up.

Helicobacter pylori: Effect of coexisting diseases and update on treatment regimens

The presence of concomitant diseases is an independent predictive factor for non-Helicobacter pylori (H. pylori) peptic ulcers. Patients contracting concomitant diseases have an increased risk of developing ulcer disease through pathogenic mechanisms distinct from those of H. pylori infections. Factors other than H. pylori seem critical in peptic ulcer recurrence in end stage renal disease (ESRD) and cirrhotic patients. However, early H. pylori eradication is associated with a reduced risk of recurrent complicated peptic ulcers in patients with ESRD and liver cirrhosis. Resistances to triple therapy are currently detected using culture-based and molecular methods. Culture susceptibility testing before first- or second-line therapy is unadvisable. Using highly effective empiric first-line and rescue regimens can yield acceptable results. Sequential therapy has been included in a recent consensus report as a valid first-line option for eradicating H. pylori in geographic regions with high clarithromycin resistance. Two novel eradication regimens, namely concomitant and hybrid therapy, have proven more effective in patients with dual- (clarithromycin- and metronidazole-) resistant H. pylori strains. We aim to review the prevalence of and eradication therapy for H. pylori infection in patients with ESRD and cirrhosis. Moreover, we summarized the updated H. pylori eradication regimens.

Some physiological and histological aspects of the gastrointestinal tract in a mouse model of chronic renal failure

INTRODUCTION

It has been reported that mice with 5/6 nephrectomy- induced chronic renal failure (CRF) have reduced gastrointestinal transit (GIT) and increased fecal moisture content (FMC). We have recently shown that feeding adenine (0.2%, w/w) to mice can be used as a model of CRF. Here, we investigated the possible effects of adenine-induced CRF on several in vivo and in vitro aspects of GIT physiology and histology of the stomach, duodenum, ileum and colon in mice.

METHODS

The effects of CRF induced by feeding adenine (0.2%, w/w for 2 or 4 weeks) on the gastric emptying index (GEI), GIT, FMC and bead expulsion test (BET) were investigated. GIT was measured by the charcoal meal test and GEI by the difference between full and empty stomach weights. Fresh and dried feces were weighed to calculate the FMC. Renal function was assessed histologically, and biochemically in plasma and urine. The light microscopic histology of the different parts of the gut, as well as the in vitro contractility of the isolated ileum was also assessed.

RESULTS

Feeding adenine for 2 or 4 weeks resulted in CRF. The BET was significantly increased in mice given adenine for 2 but not 4 weeks, while the GEI was significantly increased in mice treated with adenine for 4 but not 2 weeks. No significant differences between control and adenine-treated mice were found in GIT, FMC or the histology of the different parts of the gut. Acetylcholine-induced contractions of the ileum of adenine-treated rats were not significantly different from those of the controls.

DISCUSSION

Feeding adenine for either 2 or 4 weeks resulted in CRF, but it would appear that this model produces effects on the gastrointestinal tract that are milder than those reported before in animal models with 5/6 nephrectomy-induced-CRF.

Accuracy of endoscopic diagnosis of Helicobacter pylori infection according to level of endoscopic experience and the effect of training

BACKGROUND

Accurate prediction of Helicobacter pylori infection status on endoscopic images can contribute to early detection of gastric cancer, especially in Asia. We identified the diagnostic yield of endoscopy for H. pylori infection at various endoscopist career levels and the effect of two years of training on diagnostic yield.

METHODS

A total of 77 consecutive patients who underwent endoscopy were analyzed. H. pylori infection status was determined by histology, serology, and the urea breast test and categorized as H. pylori-uninfected, -infected, or -eradicated. Distinctive endoscopic findings were judged by six physicians at different career levels: beginner (<500 endoscopies), intermediate (1500-5000), and advanced (>5000). Diagnostic yield and inter- and intra-observer agreement on H. pylori infection status were evaluated. Values were compared between the two beginners after two years of training. The kappa (K) statistic was used to calculate agreement.

RESULTS

For all physicians, the diagnostic yield was 88.9% for H. pylori-uninfected, 62.1% for H. pylori-infected, and 55.8% for H. pylori-eradicated. Intra-observer agreement for H. pylori infection status was good (K > 0.6) for all physicians, while inter-observer agreement was lower (K = 0.46) for beginners than for intermediate and advanced (K > 0.6). For all physicians, good inter-observer agreement in endoscopic findings was seen for atrophic change (K = 0.69), regular arrangement of collecting venules (K = 0.63), and hemorrhage (K = 0.62). For beginners, the diagnostic yield of H. pylori-infected/eradicated status and inter-observer agreement of endoscopic findings were improved after two years of training.

CONCLUSIONS

The diagnostic yield of endoscopic diagnosis was high for H. pylori-uninfected cases, but was low for H. pylori-eradicated cases. In beginners, daily training on endoscopic findings improved the low diagnostic yield.

Predictive findings for Helicobacter pylori-uninfected, -infected and -eradicated gastric mucosa: validation study

AIM

To validate the usefulness of screening endoscopy findings for predicting Helicobacter pylori (H. pylori) infection status.

METHODS

H. pylori infection status was determined by histology, serology, and the urea breast test in 77 consecutive patients who underwent upper endoscopy. Based on the findings, patients were categorized as H. pylori-uninfected, -infected, or -eradicated cases. Using six photos of certain sites in the stomach per case, we determined the presence or absence of the following endoscopic findings: regular arrangement of collecting venules (RAC), linear erythema, hemorrhage, fundic gland polyp (FGP), atrophic change, rugal hyperplasia, edema, spotty erythema, exudate, xanthoma, and mottled patchy erythema (MPE). The diagnostic odds ratio (DOR) and inter-observer agreement (Kappa value) for these 11 endoscopic findings used in the determination of H. pylori infection status were calculated.

RESULTS

Of the 77 patients [32 men and 45 women; mean age (SD), 39.7 (13.4) years] assessed, 28 were H. pylori uninfected, 28 were infected, and 21 were eradicated. DOR values were significantly high (< 0.05) for the following H. pylori cases: uninfected cases with RAC (11.5), linear erythema (24.5), hemorrhage (4.1), and FGP (34.5); for infected cases with atrophic change (8.67), rugal hyperplasia (15.8), edema (14.2), spotty erythema (11.5), and exudate (3.52); and for eradicated cases with atrophic change (32.4) and MPE (103.0). Kappa values were excellent for FGP (0.93), good for RAC (0.63), hemorrhage (0.79), atrophic change (0.74), and MPE (0.75), moderate for linear erythema (0.51), rugal hyperplasia (0.49), edema (0.58), spotty erythema (0.47), and exudate (0.46), and poor for xanthoma (0.19).

CONCLUSION

The endoscopic findings of RAC, hemorrhage, FGP, atrophic change, and MPE will be useful for predicting H. pylori infection status.

Gut bacterial translocation is associated with microinflammation in end-stage renal disease patients

AIM

To investigate whether gut bacteria translocation occurs in end-stage renal disease patients and contributes to microinflammation in end-stage renal disease (ESRD).

METHODS

The subjects were divided into two groups: nondialysed ESRD patients (n = 30) and healthy controls (n = 10). Blood samples from all participants were subjected to bacterial 16S ribosomal DNA amplification and DNA pyrosequencing to determine the presence of bacteria, and the alteration of gut microbiomes were examined with the same methods. High-sensitive C-reactive protein and interleukin-6 were detected. Plasma D-lactate was tested for gut permeability.

RESULTS

Bacterial DNAs were detected in the blood of 20% (6/30) of the ESRD patients. All the observed genera in blood (Klebsiella spp, Proteus spp, Escherichia spp, Enterobacter spp, and Pseudomonas spp) were overgrown in the guts of the ESRD patients. Plasma D-lactate, High-sensitive C-reactive protein, and interleukin-6 levels were significantly higher in patients with bacterial DNA than those without. The control group showed the same results as that of patients without bacterial DNA.

CONCLUSION

Bacterial translocation occurs in ESRD patients and is associated with microinflammation in end stage renal disease.

Nonpeptic ulcer, nonvariceal gastrointestinal bleeding in hemodialysis patients

OBJECTIVES

Hemodialysis patients carry a higher risk of peptic ulcer bleeding. Whether hemodialysis patients also have a higher occurrence of nonpeptic ulcer, nonvariceal gastrointestinal bleeding needs further evaluation.

METHODS

Using Taiwan's National Health Insurance research database, the occurrence of nonpeptic ulcer, nonvariceal gastrointestinal bleeding was compared among the hemodialysis patients, chronic kidney disease patients, and controls using log-rank test. Risk factors were identified by Cox regression analysis.

RESULTS

A total of 20,830 patients were enrolled, including 8210 hemodialysis and 4190 chronic kidney disease patients and 8430 age- and sex-matched controls in a 2:1:2 ratio. In the 7-year follow-up period, hemodialysis patients had a significantly higher cumulative hazard of nonpeptic ulcer, nonvariceal gastrointestinal bleeding than chronic kidney disease patients and controls (P <.001, by log-rank test). The hazard also was significantly higher in the chronic kidney disease patients than in controls. Cox regression analysis revealed that older age, the comorbidities of diabetes mellitus, cirrhosis, and chronic obstructive pulmonary disease, history of uncomplicated peptic ulcer disease, chronic kidney disease (hazard ratio 5.17), hemodialysis (hazard ratio 9.43), and use of selective serotonin reuptake inhibitors were independent risk factors for nonpeptic ulcer, nonvariceal gastrointestinal bleeding in all study patients. Old age, diabetes mellitus, cirrhosis, chronic obstructive pulmonary disease, history of uncomplicated peptic ulcer disease, and use of selective serotonin reuptake inhibitors were independent risk factors in hemodialysis patients.

CONCLUSIONS

There is a higher risk of developing nonpeptic ulcer, nonvariceal gastrointestinal bleeding in hemodialysis patients after adjustments for age, sex, underlying comorbidities, and ulcerogenic medication. The risk has increased since patients had chronic kidney disease.

Serum gastrin levels and gastroduodenal lesions in children with chronic renal failure on continuous ambulatory peritoneal dialysis: a single-center experience

OBJECTIVE

The aim of this study was to determine serum gastrin levels and gastroduodenal lesions in children with chronic renal failure (CRF) on continuous ambulatory peritoneal dialysis (CAPD).

METHODS

A total of 19 patients (mean age: 11.7±3.9 years, M/F: 1.37) with CRF on CAPD and 20 age-matched and sex-matched patients (mean age: 10.2±1.4 years, M/F: 1.5) with peptic ulcers were included in the study. Serum gastrin, creatinine, phosphate, and parathormone levels were determined. Upper gastrointestinal endoscopy was performed in all patients.

RESULTS

The basal gastrin concentrations of CAPD patients were significantly higher than those of patients with peptic ulcer disease without CRF (124.2±59.1 and 53.0±9.4 pg/ml, respectively) (P<0.001). A significant correlation was found between age, duration of uremia, and serum gastrin levels (r=0.59, P<0.01; r=0.60, P<0.01, respectively). No correlation was found between the duration of CAPD and serum gastrin levels in the patient group. Of the patients, 73.6% had abnormal upper gastrointestinal endoscopic findings. The gastroduodenal lesion observed was hemorrhagic gastritis (31.5%), followed by hemorrhagic gastroduodenitis (26.3%), gastric nodular gastritis (10.5%), and polyps (10.5%).

CONCLUSION

On the basis of our findings, such as higher serum gastrin levels in patients with CRF than those of the control group and the frequent endoscopic findings of gastroduodenal lesions in most of the patients, we recommend that an endoscopic examination should be considered for all the children with CRF on CAPD awaiting renal transplantation even if they are asymptomatic.

Clinical and pathologic features of nodular duodenum: An analysis of 17 cases

AIM: To investigate the incidence, clinical presentations, histopathological features, natural history, and response to therapy of nodular duodenum.

METHODS: The clinical data for 17 patients with nodular duodenum were analyzed retrospectively, including age, sex, disease type, symptoms, final diagnosis, histopathology, hemoglobin, SF, AL, IG, and OVA.

RESULTS: Of 17 patients with nodular duodenum, 9 were male and 8 were female. Their mean age was 28.1 years. Approximately 47% of patients had stomachache. Sinus tubercle was most frequently seen endoscopically. Histology of duodenal nodules revealed chronic inflammation in all cases, intraepithelial eosinophilic granulocyte proliferation in 70.5% of cases, and villous atrophy in 47% of cases. Six patients had flagellate. Clinical diagnostic features included diarrhea, giardiasis, secretory IgA deficiency, and Helicobacter pylori-associated gastritis.

CONCLUSION: Nodular duodenum is an endoscopically distinct entity that may respond clinically to antisecretory therapy but is difficult to eradicate.

Review of Helicobacter pylori infection and chronic renal failure

Chronic renal failure patients receiving hemodialysis and continuous ambulatory peritoneal dialysis often encounter gastrointestinal troubles over their long treatment period. Helicobacter pylori infection has close association with development of peptic ulcer, gastric cancer and gastric lymphoma, and is thought to be one of the major risk factors for gastrointestinal troubles in dialysis patients. However, it is unclear whether H. pylori infection is directly associated with progression of renal dysfunction and prognosis of chronic renal failure patients. Recent consensus shows that the prevalence of H. pylori infection in chronic renal failure patients is significantly lower than in subjects with normal renal function. In the natural history of H. pylori infection in hemodialysis patients, the prevalence of infection decreases as dialysis periods progressed, in particular within the first four years after the start of treatment. However, the chance of natural eradication becomes rare for patients receiving dialysis treatment for a long time. Moreover, chronic renal failure patients with H. pylori infection have a higher incidence of gastroduodenal diseases, and therefore, are recommended to receive eradication therapies, especially for those receiving treatment for a long time and with higher risks of complication. Intensive endoscopic check-ups for the prevention of gastrointestinal events and the discovery of peptic ulcer and neoplastic diseases at an early phase may be required.

Helicobacter pylori status and esophagogastroduodenal mucosal lesions in patients with end-stage renal failure on maintenance hemodialysis

OBJECTIVES

The aim of this study was to elucidate the impact of Helicobacter pylori infection on esophagogastroduodenal mucosal lesions in patients with end-stage renal failure on maintenance hemodialysis (HD).

METHODS

An upper endoscopy and the (13)C-urea breath test were performed in 198 patients on maintenance HD. Clinical features, serum pepsinogen levels and esophagogastroduodenal mucosal lesions were compared between H. pylori-positive and H. pylori-negative patients. Risk factors associated with esophagogastroduodenal mucosal lesion were determined by multivariate analyses.

RESULTS

The upper endoscopy revealed that gastric erosion was the most frequent (58%) type of esophagogastroduodenal mucosal lesion, followed by duodenal erosion (18%), gastric ulcer (14%), gastroesophageal reflux disease (10%), and duodenal ulcer (7%). Of the 198 patients enrolled in the study, 81 were positive and 117 patients were negative for H. pylori infection. The time duration after the introduction of HD was significantly longer and serum pepsinogen I/II ratio was significantly higher in H. pylori-negative patients than in H. pylori-positive patients. Multivariate analyses revealed that the H. pylori infection was an independent, protective factor for gastric erosion (odds ratio 0.38; 95% confidence interval 0.21-0.70), while the infection was unrelated to other mucosal lesions.

CONCLUSIONS

The most common mucosal lesion observed in our study cohort, all of whom were patients on maintenance HD, was gastric erosion. The high prevalence of this type of lesion may be explained partly by the cure of H. pylori infection during the clinical course of maintenance HD.

Prevalence of Helicobacter pylori infection in long-term hemodialysis patients

Patients on hemodialysis often have gastrointestinal complications; however, it is unclear if Helicobacter pylori infection is present in these patients. Here we determined the prevalence of H. pylori infection in 539 Japanese hemodialysis patients by measuring serum anti-H. pylori IgG antibodies. Endoscopy was performed on 299 of these patients and the results were compared to 400 patients with normal renal function who had also undergone endoscopy and sero-testing. A second cohort of 478 dialysis patients, within the original group, was checked serologically for H. pylori infection three times over a four-year observation period. The prevalence of infection in these patients was significantly lower than in those patients with normal renal function, irrespective of the clinical outcomes. The prevalence of H. pylori infection significantly decreased as the duration of dialysis increased, particularly within the first four years following initiation of dialysis. About one-third of patients on dialysis for less than four years became serologically negative for H. pylori infection within this observation period. Our study suggests that although long-term dialysis patients have low prevalence of H. pylori, they still have significant gastroduodenal diseases, such as peptic ulcers, that require endoscopic follow-up.

Endoscopic findings and Helicobacter pylori in children on long-term hemodialysis

The aim of this study is to evaluate the prevalence of GI symptoms, endoscopic abnormalities, histologic gastritis and Helicobacter pylori infection in children with End Stage Renal Disease (ESRD) undergoing maintenance hemodialysis. Upper endoscopy and gastric biopsy were performed in 31 consecutive ESRD children from 2002-2007, before renal transplantation. H. pylori status was determined by urease test and histology. The mean age of patients was 11 +/- 3.3 years (4-16 year). The mean duration of dialysis was 12.4 +/- 11 months (1.5-54 months). Seventeen patients (54.8%) were symptomatic. Twenty patients (64.5%) had endoscopic abnormalities. Antral erythema, esophagitis, antral nodularity and diffuse gastritis were common endoscopic findings. Endoscopic abnormalities were more common in symptomatic patients than asymptomatic patients (p < 0.05). Twenty patients (64.5%) were H. pylori positive. There was no statistical correlation between age, sex, serum creatinine level, presence of any symptoms and endoscopic abnormalities with H. pylori positivity. The mean duration of dialysis in H. pylori negative patients was significantly longer in comparison with H. pylori positive patients. High prevalence of eodoscopic abnormalities and H. pylori infection in both symptomatic and asymptomatic patients emphasize the necessity of upper GI evaluation in ESRD children before renal transplantation.

Dyspepsia in Turkish patients on continuous ambulatory peritoneal dialysis

BACKGROUND AND AIMS

Although dyspepsia is very common in uremic patients, there is not much data on the prevalence of dyspepsia undergoing continuous ambulatory peritoneal dialysis (CAPD). The aims of this study are to assess the prevalence of dyspepsia, Helicobacter pylori, and the association between dyspeptic symptoms and diabetes.

METHODS

One hundred and thirty CAPD patients were included in the study. The presence or absence of dyspepsia was assessed by using the Hong Kong Index of Dyspepsia (HKID) Questionnaire. A score of >or=16 indicates the presence of dyspepsia. The patients who were diagnosed with dyspepsia had endoscopic examination and were judged to be infected with H. pylori if the organism was demonstrated in the biopsy.

RESULTS

Sixty-four of 130 CAPD patients (49.2%) had a HKID score of 16 or more. H. pylori was identified in 17 of 64 CAPD patients with dyspepsia (26.6%). Thirty-four patients (25.8%) were diabetic, and there was no association between diabetes and dyspepsia (P=0.68). The most frequent finding in patients with dyspepsia was gastritis or gastric ulcer in endoscopic evaluation. The mean serum albumin level was also not statistically significantly different between the two groups.

CONCLUSIONS

Dyspepsia is common and the prevalence of H. pylori infection is 26.6% in our CAPD patients with dyspepsia. Dyspepsia is not associated with the presence of H. pylori and diabetes in CAPD patients. Large-scale studies are needed to elucidate dyspepsia related risk factors and physiopathological mechanisms.

Proton-pump inhibitor therapy in patients with gastro-oesophageal reflux disease: putative mechanisms of failure

Proton-pump inhibitor (PPI) failure in gastro-oesophageal reflux disease (GORD) patients has become the main reason for referral of these patients to gastroenterology specialists. It is estimated that 30% of GORD patients requiring a PPI once daily will experience treatment failure. Patients with non-erosive reflux disease are the most common GORD-related group in which once-daily PPI therapy fails. Various mechanisms have been suggested to underlie PPI failure in GORD patients. The most pertinent include weakly acidic reflux, duodenogastro-oesophageal reflux, visceral hyperalgesia, delayed gastric emptying, psychological co-morbidity and concomitant functional bowel disorders, as well as others. Because of the importance of PPI failure as a target for future drug development, further understanding of the most relevant underlying mechanisms is needed.

Recurrence of peptic ulcer in uraemic and non-uraemic patients after Helicobacter pylori eradication: a 2-year study

BACKGROUND

The role of Helicobacter pylori in the pathogenesis of peptic ulcer disease in patients with uraemia remains unclear.

AIM

To evaluate the long-term effect of H. pylori eradication in these patients.

METHODS

Uraemic and non-uraemic patients with peptic ulcer were enrolled in this study. Patients having history of non-steroidal anti-inflammatory drugs use or cardiovascular disease that need aspirin use were excluded. After confirmation of H. pylori infection, they received a triple therapy and were followed up for 2 years.

RESULTS

Between September 1999 and December 2005, 34 patients (41%) of the end-stage renal disease [H. pylori (+) group] and 67 (84%) of the non-uraemic patients with peptic ulcer disease (PU group) received anti-H. pylori therapy. After triple therapy, 32 (94%) from the end-stage renal disease group and 64 (96%) from the peptic ulcer group obtained successful eradication. During the 2-year follow-up, three patients in the end-stage renal disease group were excluded because of the presence of cardiovascular disease and aspirin use in two cases and died of heart failure in one case; two patients in peptic ulcer group refused follow-up. Finally, 29 uraemic and 62 non-uraemic patients had achieved the follow-up. Recurrence of peptic ulcer was more in the end-stage renal disease group than in the peptic ulcer group with intention-to-treat analysis (eight of 32, 25% vs. two of 64, 3%, P = 0.001, OR: 10.0, 95% CI: 1.979-50.540) or per-protocol analysis (eight of 29, 28% vs. two of 62, 3%, P < 0.001, OR: 11.4, 95% CI: 2.245-58.168).

CONCLUSIONS

Peptic ulcer recurrence after H. pylori eradication is higher in end-stage renal disease patients with peptic ulcer than in peptic ulcer patients without renal disease. Factors aside from H. pylori play an important role in peptic ulcer recurrence in end-stage renal disease patients.

Predictive Value of a Positive Fecal Occult Blood Test Increases as the Severity of CKD Worsens

BACKGROUND

Because chronic kidney disease (CKD) may be associated with gastrointestinal bleeding from trivial mucosal lesions, we hypothesized that the predictive value of a positive fecal occult blood test (FOBT) result for clinically important colonic lesions would decrease as the stage of CKD worsened.

METHODS

We prospectively identified 1,225 consecutive asymptomatic average-risk patients who were referred for colonoscopy to evaluate a positive FOBT result. Using the Modification of Diet in Renal Disease equation, we estimated glomerular filtration rate (GFR) and staged the severity of CKD by using standard criteria as follows: normal/stage 1 (GFR > or = 90 mL/min/1.73 m2 [> or = 1.50 mL/s]), stage 2/3 (GFR 30 to 89 mL/min/1.73 m2 [0.50 to 1.48 mL/s]), and stage 4/5 (GFR < 30 mL/min/1.73 m2 [< 0.50 mL/s] or dialysis).

RESULTS

Clinically important lesions were identified in 23.9% of 531 individuals with none/stage 1 CKD, 32.8% of 497 subjects with stage 2/3 CKD, and 42.6% of 197 patients with stage 4/5 CKD (P < 0.001). Compared with patients with none/stage 1 CKD, adjusted odds of identifying a clinically important lesion were 1.61 (95% confidence interval, 1.21 to 2.15) in subjects with stage 2/3 CKD and 2.33 (95% confidence interval, 1.62 to 3.36) in patients with stage 4/5 CKD. Prevalences of adenomas of 1 cm or greater (15.1% versus 20.1% versus 22.8%; P = 0.007), carcinomas (5.1% versus 10.1% versus 13.2%; P < 0.001), and vascular ectasias (1.7% versus 2.4% versus 6.1%; P = 0.003) increased with the severity of CKD.

CONCLUSION

Contrary to our initial hypothesis, we found that the predictive value of a positive FOBT result for clinically important colonic lesions increased as the severity of CKD worsened.

Wireless capsule endoscopy in the investigation of patients with chronic renal failure and obscure gastrointestinal bleeding (preliminary data)

AIM: To investigate the role of wireless capsule endoscopy (WCE) in detection of small bowel (SB) pathology in patients with chronic renal failure (CRF) and obscure bleeding.

METHODS: Consecutive CRF patients with obscure bleeding were prospectively studied. Patients with normal renal function and obscure bleeding, investigated during the same period with WCE, were used for the interpretation of results.

RESULTS: Seventeen CRF patients (11 overt, 6 occult bleeding) and 51 patients (33 overt, 18 occult bleeding) with normal renal function were enrolled in this study. Positive SB findings were detected in 70.6% of CRF patients and in 41.2% of non-CRF patients (P < 0.05). SB angiodysplasia was identified in 47% of CRF patients and in 17.6% of non-CRF patients. Univariate logistic regression revealed CRF as a significant predictive factor for angiodysplasia (P < 0.05). Therapeutic measures were undertaken in 66% of the patients with the positive findings.

CONCLUSION: According to our preliminary results, SB angiodysplasia was found in an increased prevalence among CRF patients with obscure bleeding. WCE is useful in diagnosis of gastrointestinal pathologies and in planning appropriate therapeutic intervention and, therefore, should be included in the work-up of this group of patients.

Nonvariceal upper gastrointestinal bleeding: epidemiology and diagnosis

Nonvariceal upper gastrointestinal bleeding remains an important cause of patient morbidity, mortality, and use of considerable health care resources. An early and accurate diagnosis is critical for guiding appropriate management and facilitating patient care. This article reviews the most recent epidemiologic data on acute nonvariceal upper gastrointestinal bleeding and outlines important aspects of making the diagnosis.

Gastric angiodysplasia in a child with Bernard-Soulier syndrome: efficacy of octreotide in long-term management

Gastrointestinal angiodysplasia in association with Bernard-Soulier syndrome has been previously described in adults. The authors report on a 14year-old boy presenting with massive upper gastrointestinal bleeding due to a large gastric angiodysplasia, in whom medical history and laboratory investigations were consistent with Bernard-Soulier syndrome. The vascular lesion was so widespread that surgical or endoscopic therapy was not considered. Therefore, treatment with octreotide, a somatostatin analog, was commenced, following a short course of tranexamic acid and proton pump inhibitor. During the 16-month follow-up with octreotide therapy, no occult or gross bleeding occurred. This case illustrates the utility of using octreotide for the long-term treatment of children with bleeding disorders and angiodysplasia.