Nonsteroidal antiinflammatory drugs and risk of gastrointestinal bleeding among patients on hemodialysis

Background: Both use of nonsteroidal antiinflammatory drugs (NSAIDs) and chronic renal insufficiency are significant independent risk factors for gastrointestinal bleeding. Objective: The aim of our study was to investigate whether regular use of NSAIDs further increases the risk of gastrointestinal bleeding among patients with end-stage renal insufficiency on hemodialysis. Methods: This was a case-control study. Case and control patients were selected from the lists of patients on hemodialysis during the period of 4 months (n=650), at 3 secondary care general hospitals in Serbia. Cases (n=33) were chosen from the study population if they had experienced at least 1 episode of gastrointestinal bleeding during the last 3 years. For each case, at least 1 sexand age-matched control patient (n=45) was randomly selected from the source population. Results: Among patients on hemodialysis, NSAIDs users had approximately 3 times higher risk of developing gastrointestinal bleeding, than non-users (crude odds ratio = 3.29; 95% confidence interval [95% CI], 1.28-8.45). After adjustment for potential confounders (sex, age, use of erythropoietin or parenteral iron, frequency of NSAID use, smoking, drinking alcohol, heart failure, arterial hypertension, diabetes mellitus, chronic obstructive pulmonary disease, and use of anticoagulants, antiplatelet agents, β-blockers, angiotensinconverting enzyme inhibitors or diuretics), the only significant association that remained was between gastrointestinal bleeding and use of NSAIDs (ORadjusted = 5.8; 95% CI, 1.3-26.9; p=0.024). IntroductIon It is well known that use of nonsteroidal antiinflammatory drugs (NSAIDs) is associated with increased risk of both upper and lower gastrointestinal bleeding. More than a fivefold increase in relative risk of gastrointestinal bleeding was observed in patients with peptic ulcer disease using nonselective NSAIDs (1), and a similar increase in risk was shown in case-control studies of patients with lower gastrointestinal bleeding and history of NSAIDs use (odds ratio ranging from 1.9 to 18.4) (2). Risk of gastrointestinal bleeding is also increased in patients with chronic renal insufficiency; from 3% to 7% of all deaths among patients with end-stage renal disease are attributed to upper gastrointestinal bleeding (3). Particularly, among patients with end-stage renal disease on hemodialysis, mortality due to upper gastrointestinal bleeding is 3.5% (4). However, it is not known what the risk factors are for both upper and lower gastrointestinal bleeding in this specific population (although these are well known for the general population) (3). Especially, the association between NSAID use and risk of gastrointestinal bleeding in dialysis patients remains controversial. Although some studies Conclusion: There is a need for development of effective strategies to prevent gastrointestinal bleeding in patients on hemodialysis who use NSAIDs.