Gastrointestinal disorders in patients with renal failure

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Gastrointestinal disorders in patients with renal
failure

• Dr Joseph BAROUD
• Mars 2006

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• 1/1000 people is on dialysis
• 30 are in end-stage renal disease (ESRD)
• 75 of patients with ESRD have gastrointestinal
  complaints

Etemad Gastroenterol Clin N Am, 1998
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Prevalence of gastrointestinal symptoms in
patients on hemodialysis
Abu Farsakh et al. Nephrol Dial Transplant, 1996
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Most frequent causes of chronic renal failure

• Diabetes
• Hypertension
• Glomerulonephritis
• Cystic / hereditary
• Interstitial / pyelonephritis

Etemad Gastroenterol Clin N Am, 1998
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Esophagitis

• The uremic state does not appear to lead to
  grossly observable direct toxic injury to the
  esophageal mucosa.
• Treatment PPI

Margolis et al Arch int Med, 1978 Peterson
Scand J Gastroenterol, 1995 Fernandez et al.Clin
Nephrol, 1996 Dyer et al Gut, 1968
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Motility disorder of the esophagus

• Achalasia
• in 4 of 56 symptomatic patients ( 7)
• Treatment
• Surgical myotomy
• Pneumatic dilatation
• Botulinum toxin

Francos et al Lancet, 1984 Dogan et al Nephron,
1996
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Gastritis and Duodenitis
Jaffe, laing Arch Intern Med, 1934 Vaziri et al
Am J Gastroenterol 1985
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Helicobacter pylori

• The prevalence rate is similar to the general
  population

Alakaila et al Ann Med, 1991 Moustafa et al Am
J Nephrol, 1997
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Gastric Emptying

• Conflicting results
• Diabetes mellitus (autonomic neuropathy)
• Alteration in GI hormone profiles
• Gastrin
• Cholecystokinin
• Secretin
• Pancreatic polypeptide
• Change in intra-abdominal pressure in peritoneal
  dialysis
• Uremic toxins induce symptoms centrally?

Owyang et al Gut, 1982 Dumitracus et al Dig Dis
Sci, 1995
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Peptic ulcer disease

• Early studies suggest an increased prevalence of
  ulcer disease in the presence of uremia
  (radiologic studies, presence or absence of H.
  pylori in study and control)
• In recent studies the incidence of peptic ulcer
  in ESRD approximate that of the general
  population

Goldstein et al Arch Intern Med, 1967 Kang et
al Dig Dis Sci 1988
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Gastrointestinal bleeding

• Gastrointestinal bleeding is usually a secondary
  event the use of aspirin to prevent fistula
  thrombosis may result in GI lesions that may
  bleed in the presence of heparin and bleeding
  diathesis

Etemad Gastroenterol Clin N Am, 1998
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Vascular ectasias

• Some studies suggested that vascular ectasias are
  more common in ESRD
• Others suggested that the prevalence is no
  different than that of the general population
• Age
• Patient population
• Concomitant illnesses
• Definition of angiodyaplasia
• Duration and severity of renal insufficiency
• Extent of evaluation (upper endoscopy vs push
  enteroscopy vs colonoscopy vs surgery)
• ? Electrocoagulation
• ? Argon plasma
• ?Emobilisation

Chalasani et al Am J Gastroenterol, 1996 Yorioka
et al Perit Dial Int 1996 Ginsberg et al
Gastrointest Endosc, 2002
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Amyloidosis

• Distinct form (B-microglobulin)
• Does not appear to develop in patients who obtain
  renal transplants early
• Prevalence decrease (related to longer dialysis
  using high-flux synthetic membrane?)
• Osteoarticular involvement
• GI involvement (less frequently) but may be
  symptomatic (tongue, esophagus, stomach,
  intestine, colon, rectum)
• -Small bowel bleeding -Diarrhea, constipation
• -Intestinal infraction / perforation -Incontinence
  
• -Gastric dilation,gastroparesis -Severe
  paralytic ileus
• Difficult to diagnose deposit of protein was
  found only in the serosal surface and muscularis
  propria with normal mucosa
• ? deep biopsy (rectum)
• ? consider that patient with ESRD need evaluation
  with these particular issue when experiencing
  unexplained symptoms

Shimisu et al J Clin Pathol, 1997 Araki et al
Am J Nephrol, 1996
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Pancreas in ESRD

• Abnormal glandular morphology in 55 vs 20 of
  controls
• Dilatation of individual acini
• Flattening of acinar cells with loss of zymogen
  granules
• Dilatation of smaller ductules
• Interlobular fibrosis -- ductal proliferation /
  metaplasia
• Abnormal exocrine function
• Elevated trypsin output
• Clinical correlation
• Acute pancreatitis may be increased in patients
  with ESRD
• Clinically significant chronic pancreatitis is
  rare despite morphologic change
• Abnormal clearance of amylase and lipase
• asymptomatic elevation without correlation with
  pancreatic injury
• Evaluation of ESRD patients with abdominal pain
  is more complex

Seno et al Am J Gastroenterol, 1995 Araki et al
Int J pancreatol 1992
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Peritoneal dialysis

• Peritonitis
• Infectious
• Chemical
• Sclerosing peritonitis
• Pancreatitis
• Ischemic bowel

Vas Peritoneal Dialysis, 1989 Campbell et al Am
J Kidney Dis, 1992
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Hepatitis B C

• Prevalence of hepatitis B and C in hemodialysis
  patient (in Lebanon)

A. Abou Rached, J. Bou Jaoude, P. Saniour., 2005
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Transplant Immunosuppression
Helderman Goral J Am Soc Nephrol, 2002
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Conclusion