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Gastrointestinal Bleeding in Maintenance Dialysis Patients

Gastrointestinal disease is commonly present in patients with chronic renal failure (1). Gastrointestinal bleeding accounts for a significant number of hospital admissions in end-stage renal disease (ESRD) patients (unpublished data, ESRD Network #25). Certain aspects of gastrointestinal bleeding in ESRD are unique, and these features will be highlighted in this review. Most of the literature in this field refers to ESRD patients supported by hemodialysis rather than peritoneal dialysis. The difference between the procedures makes uncertain the extent to which these data apply to peritoneal dialysis patients. Unselected chronic hemodialysis patients have been reported to have twice the blood loss of a group of azotemic nondialysis patients (6.3 versus 3.2 ml/ day) who, in turn, had more blood loss than normals (0.8 ml/day) (2). One of 10 in the dialysis group had sufficient blood loss to give a positive test for occult blood (Hematest). Azotemia and uremia are thus associated with an increased level of subclinical gastrointestinal bleeding. The heparinization required for hemodialysis may, of course, magnify such blood loss. In a large autopsy series of patients dying of uremia, hemorrhages were more common in the lower gastrointestinal tract than the upper tract (3). Jaffe and Laing (3) suggested that hemorrhage predisposed to mucosal necrosis and ulceration. In 1902, Mathieu and Roux (4) observed marked dilation of venules and capillaries and suggested that this predisposed to injury from the toxic effects of bacteria resulting in mucosal ulceration and necrosis. Mason (5) found hemorrhagic lesions most frequently in the esophagus, stomach, cecum, ascending colon, and rectum but also noted lesions in the jejunum and ileum. He observed that renal diseases characterized by vascular degeneration such as nephrosclerosis were more frequently associated with gastrointestinal hemorrhage and necrosis. A number of studies have described an increased