Introduction
Patients with chronic renal disease are more likely to experience gastrointestinal (GI) bleeding, which is linked to a greater death rate compared to the general population. A typical characteristic of people with chronic renal disease is anemia. Due to decreased erythropoietin production and red blood cell survival, it is typically normocytic normochromic. Nevertheless, the use of erythropoietin-stimulating medications, gastrointestinal bleeding, or blood loss during hemodialysis can all result in concurrent iron deficient anemia.
Therefore, a peripheral blood smear, iron tests, hemolytic anemia work-up, red blood cell indices, absolute reticulocyte count, and, if necessary, a gastrointestinal source of blood loss evaluation should all be part of these individuals' first work-up for anemia. The use of antiplatelet medicines, anticoagulants, intermittent heparin usage during dialysis, and uremic platelet dysfunction are among the physiological factors linked to an increased bleeding tendency in patients with end-stage renal disease (ESRD).
Anemia causes bleeding diathesis because circulating red blood cells push platelets toward the vessel wall. At the locations of damage, this aids in keeping them in contact with the subendothelium. Red blood cells improve platelet activity by inactivating prostacyclin (PGI) and generating adenosine diphosphate (ADP). Therefore, determining and treating the source of anemia is crucial for correcting the bleeding diathesis.
What Is Chronic Kidney Disease?
An anomaly in the kidneys' structure or function that impairs health for longer than three months is known as chronic kidney disease (CKD), it affects 9.1 percent of the world's population. Numerous physiological systems are upset, and numerous organs are negatively impacted by the reduction of kidney function in chronic kidney disease (CKD). The uremic milieu can weaken the intestinal barrier as renal function deteriorates, causing an increase in nitrogen metabolic wastes that cannot be eliminated from the body. Because of their systemic and local chronic circulatory failure, patients with chronic kidney disease (CKD) may be more vulnerable to damage to their stomach mucosa than patients with adequate renal function.
What Is Gastrointestinal Bleeding?
Patients with chronic kidney disease (CKD) who experience gastrointestinal bleeding (GIB), a common but frequently misdiagnosed medical illness, have higher rates of morbidity and death. The rising issue of GIB in CKD patients has been documented in multiple studies. Three to seven percent of patients with end-stage renal disease (ESRD) die from GIB, one of the most commonly reported causes of death in CKD and ESRD. In addition, studies have shown that patients undergoing hemodialysis have an increased risk of bleeding and that long-term hemodialysis treatment is linked to much higher rates of mortality and morbidity when compared to the general population.
What Are the Causes of Gastrointestinal Bleeding in CKD Patients?
The following conditions were identified as causes of upper gastrointestinal bleeding:
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Gastric antral vascular ectasia (is an uncommon illness that affects the stomach and makes the little blood vessels more prone to bleeding).
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Gastritis (it is an ulceration of the lining of the stomach).
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Esophageal varices.
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Gastroesophageal reflux disease.
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Hemorrhagic gastritis (this phrase refers to multiple stomach mucosal hemorrhages).
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Anastomotic ulcer (this is an uncommon but potentially fatal side effect following intestinal resection).
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Gastric cancer.
Lower gastrointestinal hemorrhage was caused by:
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Colon cancer.
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Gastric antral vascular ectasia.
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Diverticulitis (it is an infection or inflammation in one or more of the digestive tract's tiny pouches).
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Ischemic enteritis(ischemia-induced colon inflammation is known as ischemic colitis).
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Rectal ulcer.
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CMV colitis (it is an infection with the cytomegalovirus that causes inflammation of the stomach or intestine).
Gastritis antral vascular ectasia was present in a CAPD (continuous ambulatory peritoneal dialysis) patient who experienced lower gastrointestinal hemorrhage. For the remaining four individuals, the reason for the gastrointestinal bleeding was not known.
What Are the Signs of Gastrointestinal Bleeding in CKD Patients?
Common signs and symptoms could be:
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Weariness and general discomfort.
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Drying skin.
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Headache.
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Losing weight naturally.
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Appetite decline.
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Feeling sick.
Additional signs and symptoms could be:
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Unusual light or dark complexion.
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Nail alterations.
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Bone aches.
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Fatigue and perplexity.
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Issues with focus or thought.
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Fingers, feet, or other parts of the body are numb.
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Cramping or spasming of the muscles.
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Foul breath.
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Stool bleeding, nosebleeds.
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Thirst excessively.
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Sporadic interruptions.
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Difficulties with sex.
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The cessation of menstrual cycles.
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Issues with sleeping.
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Edema, or swollen hands and feet.
How to Treat Gastrointestinal (GI) Bleeding in CKD Patients?
By Following ways, one can treat gastrointestinal (GI) bleeding in CKD patients
1. Local treatment options for angiogenesis dysplasias (it characterizes the presence of capillary as a unique morphological feature found in pre-invasive bronchial diseases) include bipolar/heater probes and argon plasma coagulation (APC). When therapeutic embolization or vasopressin injection is used, angiography may make it possible to locate a significant bleeding lesion. Patients with end-stage renal disease (ESRD) who are not surgical candidates have been given estrogen, either with or without progesterone.
2. However, the effectiveness of this medication is still up for debate. By lowering splanchnic blood flow, long-term octreotide therapy may reduce the need for transfusions and avoid recurrence. Although there is no evidence to support their significance, angiogenesis inhibitors have also been mentioned as a form of treatment.
3. Since 90 percent of these episodes end on their own, patients with hemodynamically stable active bleeding from angiodysplasia can be treated conservatively with fluid support, blood transfusions, and, if present, treatment of bleeding diathesis. One must take replacement erythropoietin and iron into account. On the other hand, hemodynamically unstable individuals might need to undergo surgery or endoscopic oblivion.
4. Volume resuscitation is part of the management of colonic diverticular hemorrhage. Colonoscopy can be used for therapeutic and diagnostic purposes if bleeding diverticula are found. Because bleeding occurs sporadically, this is only sometimes feasible.
5. Patients in whom endoscopy is not practical or who have ongoing or recurrent bleeding along with a nondiagnostic colonoscopy are typically candidates for artery angiography with vasopressin infusion or embolization.
Conclusion
Patients with chronic renal disease are more likely to experience gastrointestinal (GI) bleeding, which is linked to a greater death rate compared to the general population. In this patient group, blood losses can occasionally be extremely substantial. Thus, it's critical to distinguish between anemia from chronic illnesses and anemia from gastrointestinal bleeding. While there are many contributing factors to the pathophysiology of excessive bleeding in end-stage renal disease patients, a major contributing component is believed to be a failure of primary hemostasis brought on by platelet dysfunction, namely in the form of altered platelet-vessel-wall interaction and decreased platelet adhesiveness.
Patients with uremia often have moderate thrombocytopenia as well, albeit rarely to the point where bleeding occurs. In individuals with uremia, cryoprecipitate can stop bleeding, although the impact is transient and ineffective in half of the cases. Therefore, it is mainly reserved for GI hemorrhages that pose a serious risk to life.
For individuals with gastrointestinal bleeding, Tranexamic acid, a strong inhibitor of the fibrinolytic system, has been investigated as an adjuvant treatment to routine care. It stabilizes clots by blocking plasminogen's binding to fibrin and plasminogen activation.
