What is the initial management for upper GI bleeding in patients with Chronic Kidney Disease (CKD) on hemodialysis?

Initial Management of Upper GI Bleeding in Hemodialysis Patients

The initial management of upper GI bleeding in CKD patients on hemodialysis should focus on immediate resuscitation, risk stratification, and pharmacological therapy while considering the unique risks and complications in this population. 1, 2

Initial Assessment and Resuscitation

• Immediate fluid resuscitation with crystalloids should be initiated to restore end-organ perfusion and tissue oxygenation in hemodynamically unstable patients 1, 2
• Blood transfusion is recommended for patients with a hemoglobin level <80 g/L in those without cardiovascular disease, with a higher threshold for those with underlying cardiovascular disease 1, 2
• CKD patients on hemodialysis have up to three times higher risk of all-cause in-hospital mortality from upper GI bleeding compared to non-CKD patients, warranting heightened vigilance 3
• Consider timing of hemodialysis sessions when planning management, as the bleeding risk is higher during and immediately after dialysis due to anticoagulation 4

Risk Stratification

• Use prognostic scales such as the Glasgow Blatchford score to stratify patients into low and high-risk categories for rebleeding and mortality 1, 5
• High-risk factors specific to CKD patients include lower eGFR, previous history of upper GI bleeding, and low serum albumin levels 6
• The incidence of upper GI bleeding increases with declining renal function, with rates of 3.7,5.0, and 13.9 per 100 patient-years in CKD stages 3,4, and 5, respectively 6
• Patients with ESRD on hemodialysis have an OR of 1.84 for hospitalization with primary UGIB compared to non-CKD patients 3

Pre-Endoscopic Management

• Start intravenous proton pump inhibitors immediately upon presentation with upper GI bleeding 1, 2
• For suspected variceal bleeding, initiate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) as soon as bleeding is suspected 1
• Consider placement of a nasogastric tube in selected patients as findings may have prognostic value, with the presence of bright blood being an independent predictor of rebleeding 1, 2
• Correct coagulopathy, which is common in hemodialysis patients due to uremic platelet dysfunction and intermittent heparinization 4

Endoscopic Management

• Perform endoscopy within 24 hours of presentation for most patients with upper GI bleeding 1, 2
• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 1
• For high-risk stigmata, use combination endoscopic therapy (injection plus thermal coagulation or clips) rather than monotherapy 1, 2
• Be aware that angiodysplasia is a common cause of recurrent lower-intestinal hemorrhage in patients with renal failure and may require specific endoscopic treatment such as argon plasma coagulation 7

Post-Endoscopic Care

• Administer high-dose PPI therapy for 3 days for patients with high-risk stigmata who have had successful endoscopic therapy 1, 2
• Test all patients for Helicobacter pylori and provide eradication therapy if infection is present 1, 2
• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1
• Conservative treatment is often successful in CKD patients with upper GI bleeding, with studies showing high success rates without the need for endoscopic or surgical hemostasis 8

Special Considerations for Hemodialysis Patients

• Consider dialytic modalities that minimize or eliminate systemic anticoagulation for patients who are actively bleeding, such as peritoneal dialysis, heparin-free HD, or HD with regional anticoagulation 4
• For patients requiring continued hemodialysis, regional heparin anticoagulation or minimal heparinization strategies can reduce bleeding risk 4
• Desmopressin acetate (DDAVP) or conjugated estrogens may be used to limit bleeding risk in hemodialysis patients with an active bleeding focus 4
• Schedule endoscopic procedures on non-dialysis days to minimize bleeding risk from residual anticoagulation effects 5

Secondary Prophylaxis

• For patients requiring antiplatelet therapy for cardiovascular prophylaxis, restart acetylsalicylic acid (ASA) as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) 1, 2
• ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding risk 1, 2
• PPI therapy is recommended for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 1, 2
• Only 10% of CKD patients with GI bleeding are on oral anticoagulant treatment prior to the bleeding episode, suggesting other factors contribute significantly to bleeding risk 8