Recurrence of peptic ulcer in uraemic and non-uraemic patients after Helicobacter pylori eradication: a 2-year study

Monocyte-to-lymphocyte ratio and gastrointestinal disorder-related hospitalization in patients on maintenance hemodialysis

INTRODUCTION

To explore the association between monocyte-to-lymphocyte ratio (MLR) and the risk of hospitalization due to gastrointestinal (GI) disorder in hemodialysis (HD) patients.

METHODS

In this multicenter, observational cohort study, 1626 patients were enrolled in 2019 and followed up to 2 years. Cox regression models were performed to estimate the association of MLR with GI disorder-related hospitalization risk. Receiver-operating characteristic (ROC) analyses were conducted to evaluate the cutoff value of MLR in identifying GI disorder-related hospitalization.

RESULTS

During a median follow-up of 24 months, GI disorder-related hospitalization occurred in 107 patients. Higher MLR was independently associated with greater risks of GI disorder-related hospitalization. Furthermore, a cut-off value of 0.42 differentiated patients with GI disorder-related hospitalization from those without GI involvement.

CONCLUSION

MLR was associated with the occurrence of GI disorder-related hospitalization in HD patients. The blood MLR could be monitored as a useful marker to predict GI disorder-related hospitalization.

A Comparative Analysis of Bleeding Peptic Ulcers in Hospitalizations With and Without End-Stage Renal Disease

Background

End-stage renal disease (ESRD) patients are highly susceptible to peptic ulcer bleeding (PUB). We aimed to assess the influence of ESRD status on PUB hospitalizations in the United States (USA).

Methods

We analyzed the National Inpatient Sample to identify all adult PUB hospitalizations in the USA from 2007 to 2014, which were divided into two subgroups based on the presence or absence of ESRD. Hospitalization characteristics and clinical outcomes were compared. Furthermore, predictors of inpatient mortality for PUB hospitalizations with ESRD were identified.

Results

Between 2007 and 2014, there were 351,965 PUB hospitalizations with ESRD compared to 2,037,037 non-ESRD PUB hospitalizations. PUB ESRD hospitalizations had a higher mean age (71.6 vs. 63.6 years, P < 0.001), and proportion of ethnic minorities i.e., Blacks, Hispanics, and Asians compared to the non-ESRD cohort. We also noted higher all-cause inpatient mortality (5.4% vs. 2.6%, P < 0.001), rates of esophagogastroduodenoscopy (EGD) (20.7% vs. 19.1%, P < 0.001), and mean length of stay (LOS) (8.2 vs. 6 days, P < 0.001) for PUB ESRD hospitalizations compared to the non-ESRD cohort. After multivariate logistic regression analysis, Whites with ESRD had higher odds of mortality from PUB compared to Blacks. Furthermore, the odds of inpatient mortality from PUB decreased by 0.6% for every 1-year increase in age for hospitalizations with ESRD. Compared to the 2011 - 2014 study period, the 2007 - 2010 period had 43.7% higher odds (odds ratio (OR): 0.696, 95% confidence interval (CI): 0.645 - 0.751) of inpatient mortality for PUB hospitalizations with ESRD.

Conclusions

PUB hospitalizations with ESRD had higher inpatient mortality, EGD utilization, and mean LOS compared to non-ESRD PUB hospitalizations.

Impact of Social Isolation on Subsequent Peptic Ulcer Recurrence in Older Adults With Mild Cognitive Impairment: The Role of Change in Severity of Depression

OBJECTIVE

This study aimed to examine the association between social isolation, change in severity of depression, and subsequent recurrence of peptic ulcer disease (PUD) in older adults with mild cognitive impairment.

METHODS

Older adults (≥55 years) with mild cognitive impairment and Helicobacter pylori-infected PUD (N = 2208) were recruited between 2010 and 2014 from 12 hospitals in the People's Republic of China. H. pylori was eradicated and PUD was cleared in 2015 participants by the end of 2014; 1900 of these were followed up for up to 36 months. The Kaplan-Meier method was used to assess how PUD recurrence varied with social engagement levels and changes in depression severity. Multivariate Cox proportional hazard models were used to examine associations between social isolation, changes in depression severity, and PUD recurrence.

RESULTS

PUD recurrence was more prevalent in socially isolated (10.8%) than in socially engaged participants (5.5%). However, the rates of PUD were lower in socially isolated individuals without (absence of) depression (7.2%) and those with decreased depression (8.2%), whereas socially isolated individuals with unchanged and increased depression had substantially higher rates of PUD (16.3% and 17.8%, respectively; the social isolation by depression group for PUD recurrence was significant (p < .001). Specifically, although social isolation was associated with PUD recurrence during the 36-month follow-up period (hazard ratio [HR] = 2.665 [1.602-4.518]), it did not increase PUD recurrence risk in participants without depression or with reduced depression. However, in participants with unchanged or increased depression, PUD recurrence was more likely to occur in socially isolated (HR = 1.587 [1.125-2.588]; HR = 1.886 [1.012, 3.522] respectively) than in socially engaged participants.

CONCLUSIONS

Social isolation is associated with a greater risk of PUD recurrence; however, the absence of or decreased severity of depression may alter this relationship.

Uremic and Post-Transplant Gastropathy in Patients With Chronic Kidney Disease and End-Stage Renal Disease

Gastrointestinal (GI) mucosal lesions are common in chronic kidney disease (CKD), end-stage renal disease (ESRD), and in post-renal transplant period. However, etiology of mucosal lesions pre- and post-transplant is very different. Gastropathy in non-transplant ESRD patients usually develops because of uremia, chronic anemia, and fluctuations in the gastric blood supply during hemodialysis, eventually leading to uremic gastritis. Gastropathy in post-transplant patients tends to be associated with immunosuppressive therapies. Helicobacter pylori infection is more prevalent in uremic patients than in post-transplant patients. Uremia can also lead to uremic arteriolopathy and autonomic nervous system dysfunction, which can present with GI symptoms mimicking uremic gastropathy. Post-transplantation immunosuppressive therapies have been linked to GI mucosal lesions as well. These lesions carry a poor prognostic factor disrupting the function of the GI tract, which in turn affects the pharmacokinetics of the immunosuppressive drugs eventually leading to poor graft survival and increased mortality. Mycophenolate mofetil is one of the agents more associated with intestinal erosions. Recognizing uremic gastropathy and intervening early helps prevent post-transplant GI complications. Acid controlling therapies can be an effective prophylaxis against both gastropathies. Using enteric-coated formulation for immunosuppressive agents may slow down the mucosal insult. Treatment of H. pylori in both patient populations may help prevent further mucosal injury. Lastly, timely screening for symptoms may help start treatment early and prevent progression to serious gastropathy.

Helicobacter pylori, Endoscopic, And Histologic Features Among Kidney Transplant Candidates In Southern Iran

Background

The risks of gastrointestinal disorders and cancer are higher in chronic kidney disease (CKD) patients than the general population. There are only a few published reports on the association of helicobacter pylori (H. pylori) infection, endoscopic findings, and histology in these patients. This study was designed to address these controversial topics among kidney transplant candidates as the first study in southern Iran.

Patients and methods

In this cross-sectional study, patients undergoing renal transplantation in the largest center of southern Iran during 2016–2017 were evaluated for the frequency of H. pylori infection, endoscopic findings, and histology. Gastric endoscopic findings (normal, abnormal non-ulcerative, ulcerative) and histological findings of gastric biopsy (normal/non-significant, inflammation, premalignant lesions (PMLs), malignant lesions) were studied.

Results

In total, 293 patients underwent endoscopy for transplant work up. The mean age (SD) was 47.37 (13.14) years. The most common endoscopic finding was abnormal gastric lesions. Overall, 78.8% patients had abnormal gastric histologic findings, of which 6.1% had PMLs. There was no significant association between laboratory data of patients with H. pylori infection. Of these, 147 (50.2%) patients were positive and the others were H. Pylori negative. Positive H. pylori infection was significantly associated with gastric ulcerative lesions. Positive H. pylori infection was also strongly associated with inflammation (P<0.01), but not significantly associated with PMLs (P=0.99) in gastric histology.

Conclusion

The present study showed that abnormal endoscopic and histologic findings as well as positive H. pylori infection were observed in a large number of kidney transplant candidates, so upper endoscopy with biopsy is an acceptable procedure for these patients. However, further studies are recommended to determine the relationship of H. pylori with abnormal endoscopic and histologic findings considering other confounding factors in kidney transplant candidates as well as the efficacy of H. pylori eradication therapy to improve these abnormal findings.

Effect of Subjective and Objective Sleep Quality on Subsequent Peptic Ulcer Recurrence in Older Adults

OBJECTIVE

To examine the effect of subjective and objective sleep quality on subsequent recurrence of peptic ulcer disease (PUD) among older patients after Helicobacter pylori eradication.

SETTING

Eight grade A hospitals in China.

PARTICIPANTS

Of 1689 older Chinese with H. pylori-infected PUD recruited between January 2011 and October 2014, H. pylori were eradicated and PUD was cleared in 1538 patients by the end of 2014; 1420 of these patients were followed up for up to 36 months.

MEASUREMENTS

Using multiple measures at 6-month intervals, PUD recurrence was determined with esophagogastroduodenoscopy. Subjective sleep quality was measured using the Pittsburgh Sleep Quality Index. Objective sleep quality domains were measured using an accelerometer, including sleep onset latency, sleep efficiency, total sleep time, and number of awakenings.

RESULTS

This study documented a 36-month cumulative PUD recurrence of 8.3% (annual rate = 2.8%). Multivariate analyses showed that participants who reported poorer sleep quality were more likely to experience PUD recurrence during the 36-month follow-up period (hazard ratio [HR] = 1.895; 95% confidence interval [CI] = 1.008-3.327). Regarding objective sleep quality domains, longer sleep onset latency (HR = 1.558; 95% CI = 1.156-2.278) and more nighttime awakenings (HR = 1.697; 95% CI = 1.168-2.665) increased the risk of PUD recurrence. However, a longer total sleeping time protected against PUD recurrence (HR = 0.768; 95% CI = 0.699-0.885).

CONCLUSIONS

Poor sleep quality predicts a greater risk of PUD recurrence. Accurate diagnosis and effective treatments should, therefore, be provided for older adults afflicted with poor sleep, particularly for those who previously had PUD. It is equally important to include sleep assessment as an integral part while dealing with these patients.

Risk factors for peptic ulcer disease in patients with end-stage renal disease receiving dialysis

Background

Compared to the general population, patients with end-stage renal disease have more gastrointestinal symptoms and a higher prevalence of peptic ulcer. Risk factors for peptic ulcer disease in patients with end-stage renal disease, however, remain poorly defined. This study aims to better identify those risk factors.

Methods

We analyzed 577 patients with end-stage renal disease from 2004 to 2016. We excluded patients with life-threatening conditions. All patients underwent upper endoscopy. We analyzed patient medical records, medication history, and endoscopic findings. Independent sample t test, chi-square test, Fisher’s exact test, and multiple logistic regression analysis were used in statistical analyses.

Results

Of the 577 patients with end-stage renal disease, 174 had peptic ulcer disease (gastric or duodenal ulcer). Patients on hemodialysis had a higher prevalence of peptic ulcer disease than those on peritoneal dialysis. Patients with peptic ulcer disease had lower serum albumin level and higher blood urea nitrogen level than those without peptic ulcer disease. Positive scores on two or more nutritional indices (albumin, serum cholesterol, uric acid, and creatinine levels) were associated with peptic ulcer disease in end-stage renal disease.

Conclusion

Hemodialysis, hypoalbuminemia, and multiple malnutrition indices were associated with the prevalence of peptic ulcer disease in patients with end-stage renal disease receiving dialysis.

Association between Poor Sleep Quality and Subsequent Peptic Ulcer Recurrence in Older Patients with Mild Cognitive Impairment: Examining the Role of Social Engagement

This study aims to examine whether perceived poor sleep quality predicts subsequent recurrence of peptic ulcer disease (PUD) in older patients with mild cognitive impairment following Helicobacter pylori eradication and to investigate whether social engagement status alters this association. Of 1,689 older patients with H. pylori-infected PUD recruited from eight Grade-A hospitals in the People's Republic of China between 2011 and 2014, H. pylori was eradicated and PUD cleared in 1,538 patients by the end of 2014; 1,420 of these were followed for up to 36 months. The Kaplan-Meier method was used to compare the proportion of PUD recurrence, as confirmed with esophagogastroduodenoscopy, among older patients with different levels of sleep quality and social engagement statuses. Multivariate Cox-proportional hazards models were performed to examine the association between sleep quality and PUD recurrence, and the role of social engagement in altering this relationship. The results showed that PUD recurrence was more prevalent in poor (10.8%) compared with good sleepers (5.5%). However, increased and continued social engagement reduced the proportion to 7.2% and 8.2% among poor sleepers, respectively. Poor sleep quality was associated with subsequent PUD recurrence (hazard ratio [HR] 1.965 (1.002, 3.518)). However, no significant difference was observed between good and poor sleepers who reported increased (HR 1.428 (0.736, 2.380)) and continued (HR 1.273 (0.915, 2.492)) social engagement, suggesting that increased and continued social engagement prevented the effect of poor sleep quality on PUD recurrence. To conclude, poor sleep quality is associated with subsequent PUD recurrence. However, increased and continued social engagement may moderate this association.

Chronic kidney disease (CKD) patients are exposed to more proton pump inhibitor (PPI)s compared to non-CKD patients

BACKGROUND

Proton pump inhibitor use is associated with incident chronic kidney disease, chronic kidney disease progression and end-stage renal disease. However, the extent of proton pump inhibitor prescriptions to chronic kidney disease patients is still unclear.

METHOD

In a retrospective study, we enrolled patients (>18 years old) who received proton pump inhibitor in the out-patient setting from 2014 through 2015. All data was obtained from electronical medical records of Soonchunhyang Medical Center. The prescription patterns and characteristics of proton pump inhibitors were analyzed according to individual estimated glomerular filtration rate of the patients.

RESULT

During the study period 178,228 patients visited the out-patient clinic. Proton pump inhibitors were prescribed to 9,109 (5.11%) patients. In our sample, 50% were females and 9.8% were chronic kidney disease (eGFR<60mL/min/1.73 m2) patients. Among the patients with chronic kidney disease, 730 (8.0%) were categorized as stage 3 or 4 and 166 (1.8%) were categorized as stage 5 or end-stage renal disease. The prevalence of proton pump inhibitors prescription among chronic kidney disease patients was higher than in the non-chronic kidney disease group (p<0.001). Median duration of usage was 120 [interquartile range 63-273] days in the stage 3-4 group, 106 [56-266] days in the stage 5-end-stage renal disease group and 90 [56-176] days in the non-chronic kidney disease group. Patients in stage 3-4 group were prescribed longer duration of proton pump inhibitors than the non-chronic kidney disease group even after adjusting for age and sex (p<0.001). The main departments of medicine which prescribed proton pump inhibitors for the stage 3-4 group were gastroenterology (40.0%), cardiology (29.6%), nephrology (9.5%) and neurology (4.8%). Compared to the non-chronic kidney disease group, the stage 3-4 and stage 5-end-stage renal disease group were taking larger number of drugs simultaneously (6.90±4.17 vs4.54±2.43; p<0.001, 5.64±2.87 vs 4.54±2.34; p<0.001, respectively).

CONCLUSION

Chronic kidney disease patients are taking proton pump inhibitors for a much longer duration compared to non-chronic kidney disease patients. Physicians should pay careful attention when prescribing proton pump inhibitors to high risk groups.

Peptic ulcer bleeding patients with Rockall scores ≥6 are at risk of long-term ulcer rebleeding: A 3.5-year prospective longitudinal study

BACKGROUND AND AIM

Patients with high Rockall scores have increased risk of rebleeding and mortality within 30 days after peptic ulcer bleeding, but long-term outcomes deserve follow-up after cessation of proton pump inhibitors. The paper aimed to validate whether patients with high Rockall scores have more recurrent ulcer bleeding in a 3.5-year longitudinal cohort.

METHODS

Between August 2011 and July 2014, 368 patients with peptic ulcer bleeding were prospectively enrolled after endoscopic hemostasis to receive proton pump inhibitors for at least 8 to 16 weeks. These subjects were categorized into either a Rockall scores ≥6 group (n = 257) or a Rockall scores <6 group (n = 111) and followed up until July of 2015 to assess recurrent ulcer bleeding.

RESULTS

The proportion of patients with rebleeding during the 3.5-year follow-up was higher in patients with Rockall scores ≥6 than in those with scores <6 (10.51 vs. 3.63 per 100 person-year, P = 0.004, log-rank test). Among patients with Rockall scores ≥6, activated partial thromboplastin time prolonged ≥1.5-fold (P = 0.045), American Society of Anesthesiologists physical status class ≥III (P = 0.02), and gastric ulcer (P = 0.04) were three additional independent factors found to increase rebleeding risk. The cumulative rebleeding rate was higher in patients with Rockall scores ≥6 with more than or equal to any two additional factors than in those with fewer than two additional factors (15.69 vs. 7.63 per 100 person-year, P = 0.012, log-rank test).

CONCLUSIONS

Patients with Rockall scores ≥6 are at risk of long-term recurrent peptic ulcer bleeding. The risk can be independently increased by the presence of activated partial thromboplastin time prolonged ≥1.5-fold, American Society of Anesthesiologists class ≥III, and gastric ulcer in patients with Rockall scores ≥6.

Systematic review with meta-analysis: the global recurrence rate of Helicobacter pylori

BACKGROUND

Up-to-date information regarding the recurrence rate of Helicobacter pylori (H. pylori) after eradication therapy is not available.

AIM

To evaluate the global recurrence rate following H. pylori eradication therapy and confirm its association with socioeconomic and sanitary conditions.

METHODS

A systematic search of PubMed, EMBASE and the Cochrane library was performed to identify potentially relevant publications using the following keywords: "Helicobacter pylori" or "H. pylori" or "Hp" and "recurrence" or "recrudescence" or "reinfection" or "recurrent" or "recurred" or "re-infect*" or "relapse*."

RESULTS

A total of 132 studies (53 934 patient-years) were analysed. Each study was weighted according to the duration of patient-years. The global annual recurrence, reinfection and recrudescence rate of H. pylori were 4.3% (95% CI, 4-5), 3.1% (95% CI, 2-5) and 2.2% (95% CI, 1-3), respectively. The H. pylori recurrence rate was inversely related to the human development index (HDI) (ie, 3.1% [95% CI, 2-4], 6.2% [95% CI, 4-8] and 10.9% [95% CI, 6-18] in countries with a very high, high and medium or low HDI) (P <.01) and directly related to H. pylori prevalence (10.9% [95% CI, 7-16], 3.7% [95% CI, 3-5], 3.4% [95% CI, 2-5] and 1.6% [95% CI, 0.5-3] in countries with a very high, high, medium or low local H. pylori prevalence) (P <.01). Global recurrence rates remained relatively stable between 1990s, 2000s and 2010s but varied across different regions (P <.05).

CONCLUSIONS

H. pylori recurrence remains a problem closely associated with socioeconomic and sanitary conditions. Methods to reduce recurrence in developing countries are needed.

Long-Term Recurrence Rates of Peptic Ulcers without Helicobacter pylori

Background/Aims

The purpose of this study is to investigate the recurrence rate of peptic ulcer disease (PUD) over a long follow-up period with PUD patients without Helicobacter pylori.

Methods

We retrospectively reviewed patients diagnosed with PUD on endoscopy and divided them into two groups: a H. pylori-negative group (HP-negative group), and a group of patients with untreated H. pylori (HP noneradicated group). We compared the recurrence rates of PUD in these two groups and analyzed the factors that affected ulcer recurrence.

Results

Total of nine hospitals in Korea participated, and a total of 1,761 patients were retrospectively reviewed. The HP-negative group included 553 patients, and the HP noneradicated group included 372 patients. The 5-year cumulative probabilities of PUD recurrence were 36.4% in the HP-negative group and 43.8% in the HP noneradicated group (p=0.113). The factors that were found to affect recurrence in the HP-negative group were elder, male, and comorbid chronic kidney disease.

Conclusions

The 5-year cumulative probability of PUD recurrence without H. pylori infection after a long-term follow-up was 36.4% and the factors that affected recurrence were elder, male, and comorbid chronic kidney disease.

Early eradication has a lower risk of peptic ulcer bleeding in Helicobacter pylori-infected chronic kidney disease patients

BACKGROUND

End stage renal disease (ESRD) contributes to a higher mortality rate in peptic ulcer bleeding (PUB) patients. A crucial question is whether early Helicobacter pylori (H. pylori) eradication therapy is necessary for H. pylori-infected chronic kidney disease (CKD) patients. To explore whether H. pylori eradication therapy has a lower risk of PUB at the pre-ESRD stage than at the ESRD stage.

METHODS AND PATIENTS

Patients meeting 2 criteria were defined as newly diagnosed ESRD cases: (1) patients diagnosed with ESRD and receiving regular dialysis between 2000 and 2009; and (2) patients with no history of dialysis between 1997 and 1999. We divided the study participants into pre-ESRD and ESRD groups on the basis of the time between H. pylori eradication and dialysis. The date of the first PUB diagnosis was defined as the primary endpoint. Stratified Cox proportional hazard regression analysis was used to estimate the effect of H. pylori eradication at the pre-ESRD and ESRD stage on the occurrence of PUB.

RESULTS

We included 476 patients in the pre-ESRD cohort and 476 patients in the matched ESRD cohort. After adjustment for age, sex, the presence of comorbidities, and medication use, the hazard ratio of PUB was 0.66 times less in the pre-ESRD cohort than in the ESRD cohort. Factors such as Charlson's score more than 3, and nonsteroidal anti-inflammatory drugs were associated with an increased risk of PUB.

CONCLUSION

Our result supports that early H. pylori eradication has a lower risk of PUB in H. pylori-infected CKD patients.

Helicobacter pylori Eradication within 120 Days Is Associated with Decreased Complicated Recurrent Peptic Ulcers in Peptic Ulcer Bleeding Patients

Background/Aims

The connection between Helicobacter pylori and complicated peptic ulcer disease in peptic ulcer bleeding (PUB) patients taking nonsteroidal anti-inflammatory drugs has not been established. In this study, we sought to determine whether delayed H. pylori eradication therapy in PUB patients increases complicated recurrent peptic ulcers.

Methods

We identified inpatient PUB patients using the Taiwan National Health Insurance Research Database. We categorized patients into early (time lag ≤120 days after peptic ulcer diagnosis) and late H. pylori eradication therapy groups. The Cox proportional hazards model was used. The primary outcome was rehospitalization for patients with complicated recurrent peptic ulcers.

Results

Our data indicated that the late H. pylori eradication therapy group had a higher rate of complicated recurrent peptic ulcers (hazard ratio [HR], 1.52; p=0.006), with time lags of more than 120 days. However, our results indicated a similar risk of complicated recurrent peptic ulcers (HR, 1.20; p=0.275) in time lags of more than 1 year and (HR, 1.10; p=0.621) more than 2 years.

Conclusions

H. pylori eradication within 120 days was associated with decreased complicated recurrent peptic ulcers in patients with PUB. We recommend that H. pylori eradication should be conducted within 120 days in patients with PUB.

Helicobacter pylori: Effect of coexisting diseases and update on treatment regimens

The presence of concomitant diseases is an independent predictive factor for non-Helicobacter pylori (H. pylori) peptic ulcers. Patients contracting concomitant diseases have an increased risk of developing ulcer disease through pathogenic mechanisms distinct from those of H. pylori infections. Factors other than H. pylori seem critical in peptic ulcer recurrence in end stage renal disease (ESRD) and cirrhotic patients. However, early H. pylori eradication is associated with a reduced risk of recurrent complicated peptic ulcers in patients with ESRD and liver cirrhosis. Resistances to triple therapy are currently detected using culture-based and molecular methods. Culture susceptibility testing before first- or second-line therapy is unadvisable. Using highly effective empiric first-line and rescue regimens can yield acceptable results. Sequential therapy has been included in a recent consensus report as a valid first-line option for eradicating H. pylori in geographic regions with high clarithromycin resistance. Two novel eradication regimens, namely concomitant and hybrid therapy, have proven more effective in patients with dual- (clarithromycin- and metronidazole-) resistant H. pylori strains. We aim to review the prevalence of and eradication therapy for H. pylori infection in patients with ESRD and cirrhosis. Moreover, we summarized the updated H. pylori eradication regimens.

Association between early Helicobacter pylori eradication and a lower risk of recurrent complicated peptic ulcers in end-stage renal disease patients

End-stage renal disease (ESRD) patients exhibit an increased incidence of peptic ulcer disease. Helicobacter pylori plays a central role in the development of peptic ulcers. The effect of early H pylori eradication on the recurrence of complicated peptic ulcer disease in ESRD patients remains unclear. The aim of the present study was to explore whether early H pylori eradication therapy in ESRD patients can reduce the risk of recurrent complicated peptic ulcers.We conducted a population-based cohort study and recruited patients with ESRD who had developed peptic ulcers. We categorized patients into early (time lag ≦120 days after peptic ulcer diagnosis) and late H pylori eradication therapy groups. The Cox proportional hazards model was used. The endpoint was based on hospitalization for complicated recurrent peptic ulcers.The early and late H pylori eradication therapy groups consisted of 2406 and 1356 ESRD patients, respectively, in a time lag of 120 days. After adjusting for possible confounders, the early eradication group exhibited a lower rate of complicated recurrent peptic ulcer disease (hazard ratio [HR] = 0.76, 95% confidence interval [CI] = 0.64-0.91, P = 0.003) in a time lag of ≦120 days, but a similar rate of complicated recurrent peptic ulcer disease in time lags of ≦1 year (HR = 0.97, 95% CI 0.79-1.19, P = 0.758) and 2 years (HR = 1.11, 95% CI 0.86-1.44, P = 0.433) compared with the late eradication group.We recommend administering H pylori eradication within 120 days after peptic ulcer diagnosis to H pylori infected ESRD patients who have developed peptic ulcers.

Upper gastrointestinal bleeding in patients with CKD

BACKGROUND AND OBJECTIVES

Patients with CKD receiving maintenance dialysis are at risk for upper gastrointestinal bleeding. However, the risk of upper gastrointestinal bleeding in patients with early CKD who are not receiving dialysis is unknown. The hypothesis was that their risk of upper gastrointestinal bleeding is negatively linked to renal function. To test this hypothesis, the association between eGFR and risk of upper gastrointestinal bleeding in patients with stages 3-5 CKD who were not receiving dialysis was analyzed.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients with stages 3-5 CKD in the CKD program from 2003 to 2009 were enrolled and prospectively followed until December of 2012 to monitor the development of upper gastrointestinal bleeding. The risk of upper gastrointestinal bleeding was analyzed using competing-risks regression with time-varying covariates.

RESULTS

In total, 2968 patients with stages 3-5 CKD who were not receiving dialysis were followed for a median of 1.9 years. The incidence of upper gastrointestinal bleeding per 100 patient-years was 3.7 (95% confidence interval, 3.5 to 3.9) in patients with stage 3 CKD, 5.0 (95% confidence interval, 4.8 to 5.3) in patients with stage 4 CKD, and 13.9 (95% confidence interval, 13.1 to 14.8) in patients with stage 5 CKD. Higher eGFR was associated with a lower risk of upper gastrointestinal bleeding (P=0.03), with a subdistribution hazard ratio of 0.93 (95% confidence interval, 0.87 to 0.99) for every 5 ml/min per 1.73 m(2) higher eGFR. A history of upper gastrointestinal bleeding (P<0.001) and lower serum albumin (P=0.004) were independently associated with higher upper gastrointestinal bleeding risk.

CONCLUSIONS

In patients with CKD who are not receiving dialysis, lower renal function is associated with higher risk for upper gastrointestinal bleeding. The risk is higher in patients with previous upper gastrointestinal bleeding history and low serum albumin.

Different peptic ulcer bleeding risk in chronic kidney disease and end-stage renal disease patients receiving different dialysis

BACKGROUND

End stage renal disease (ESRD) patients receiving hemodialysis (HD) have a higher risk of peptic ulcer bleeding (PUB).

AIMS

Whether ESRD patients receiving peritoneal dialysis (PD) also carries a higher risk of PUB has not been studied.

METHODS

This was a cohort study using Taiwan's National Health Insurance research database, whereby 11,408 patients, including 2,239 PD, 2,328 HD, 2,267 chronic kidney disease (CKD) and 4,574 controls with age-sex matching were recruited. The log-rank test was used to analyze differences in accumulated PUB-free survival rates between groups. Cox proportional hazard regression was performed to evaluate independent risk factors for PUB in all the enrollees.

RESULTS

During the 7-year follow-up, PD and CKD patients had a significantly higher rate of PUB than matched controls. The risk of PUB between PD and CKD was not significantly different. Moreover, patients receiving HD carried a higher risk of PUB than those receiving PD, with CKD and controls (p all <0.05, by log-rank test). Cox proportional hazard regression analysis showed that CKD (HR 3.99, 95 % CI 2.24-7.13), PD (HR 3.71, 95 % CI 2.00-6.87) and HD (HR 11.96, 95 % CI 7.04-20.31) were independently associated with an increased risk of PUB. Being elderly, male, having hypertension, diabetes, cirrhosis, and nonsteroidal anti-inflammatory drugs and steroid use were other independent risk factors of PUB in all enrollees.

CONCLUSIONS

Patients with CKD and ESRD receiving PD or HD carried a higher risk for PUB. They should be screened for risk factors for PUB and receive some protective measures to prevent PUB.

Peptic ulcer disease risk in chronic kidney disease: ten-year incidence, ulcer location, and ulcerogenic effect of medications

Objectives

We aimed at determining peptic ulcer disease (PUD) incidence among chronic kidney disease (CKD) patients during 1998–2008, compared to patients without CKD, and at examining associations between CKD and PUD.

Methods

Data for 1998–2008 were extracted from the National Health Insurance Research Database in Taiwan. The annual PUD incidence (cases per thousand persons per year) was calculated separately for patients with and without CKD. Characteristics of patients with newly diagnosed PUD (n = 16322) were compared to those of a control group without PUD (n = 32644). The 2 groups were matched for age, sex, and index year. Odds ratios (OR) and 95% confidence intervals (CI) were estimated by logistic regression.

Results

Over the 10-year period, the PUD incidence was ∼10–12 times higher in CKD patients than in those without CKD. Its incidence in elderly CKD patients increased rapidly over time. For CKD patients, most PUD events (>95%) were managed during hospitalization. Peptic ulcer risk, adjusted for all potential confounders, was much higher in CKD patients undergoing hemodialysis (adjusted OR, 9.74; 95% CI, 7.11–13.31). Maintenance hemodialysis patients were 2 times more likely to have gastric ulcers than duodenal ulcers, while CKD patients not on dialysis had similar risks for both. There were no significant interactions between medications and CKD status on the peptic ulcer risk. Unlike CKD patients on nonsteroidal anti-inflammatory drugs and clopidogrel, those on aspirin did not have a higher peptic ulcer risk (adjusted OR, 0.88; 95% CI, 0.44–1.77).

Conclusions

CKD patients have a substantially increased PUD risk, and the majority of CKD patients with PUD require hospital management. Further, peptic ulcer risk is affected by hemodialysis therapy, patient status (inpatient vs. outpatient), and ulcerogenic medications.

Iodinated contrast media can induce long-lasting oxidative stress in hemodialysis patients

PURPOSE

Due to their comorbidities, dialysis patients have many chances to undergo radiologic procedures using iodinated contrast media. We aimed to assess time-sequenced blood oxidative stress level after contrast exposure in hemodialysis (HD) patients compared to those in the non-dialysis population.

MATERIALS AND METHODS

We included 21 anuric HD patients [HD-coronary angiography (CAG) group] and 23 persons with normal renal function (nonHD-CAG group) scheduled for CAG, and assessed 4 oxidative stress markers [advanced oxidation protein products (AOPP); catalase; 8-hydroxydeoxyguanosine; and malondialdehyde] before and after CAG, and subsequently up to 28 days.

RESULTS

In the nonHD-CAG group, only AOPP increased immediately after CAG and returned to baseline within one day. However, in the HD-CAG group, all four oxidative stress markers were significantly increased starting one day after CAG, and remained elevated longer than those in the nonHD-CAG group. Especially, AOPP level remained elevated for a month after contrast exposure.

CONCLUSION

Our study showed that iodinated contrast media induces severe and prolonged oxidative stress in HD patients.

Prophylactic use of omeprazole associated with a reduced risk of peptic ulcer disease among maintenance hemodialysis patients

BACKGROUND

Patients undergoing maintenance hemodialysis (MHD) have a high prevalence of peptic ulcer disease (PUD). Omeprazole is a proton pump inhibitor with proven efficacy in the prevention and treatment of PUD. However, there is little data on the prophylactic use of omeprazole in reducing the risk of PUD among MHD patients.

METHODS

This prospective study included 93 patients undergoing MHD at Zen-Ho Dialysis Center between July 2008 and December 2009. Fifty-three patients were assigned to receive 20 mg of omeprazole daily for 18 months and 40 patients served as control. The Kaplan-Meier method was applied to calculate the cumulative incidence of PUD.

RESULTS

The per-protocol population comprised 85 patients (omeprazole group, 49; control group, 36). Both groups had similar baseline characteristics. The need for endoscopy was found to be significantly less (10.2 vs. 44.4%, p = 0.001) in the omeprazole group than in the control group. Dialysis patients in the omeprazole group required fewer blood transfusions and erythropoietin doses than did the control group patients. Kaplan-Meier analysis revealed a higher cumulative ulcer rate in the control group (log-rank test, p = 0.04). However, omeprazole did not reduce the risk of PUD in MHD patients on regular aspirin or warfarin.

CONCLUSIONS

We conclude that prophylactic use of omeprazole might be effective to lower the incidence of PUD among MHD patients without regular aspirin or warfarin use. Further large-scale controlled trials should be carried out to confirm our findings.

Review of Helicobacter pylori infection and chronic renal failure

Chronic renal failure patients receiving hemodialysis and continuous ambulatory peritoneal dialysis often encounter gastrointestinal troubles over their long treatment period. Helicobacter pylori infection has close association with development of peptic ulcer, gastric cancer and gastric lymphoma, and is thought to be one of the major risk factors for gastrointestinal troubles in dialysis patients. However, it is unclear whether H. pylori infection is directly associated with progression of renal dysfunction and prognosis of chronic renal failure patients. Recent consensus shows that the prevalence of H. pylori infection in chronic renal failure patients is significantly lower than in subjects with normal renal function. In the natural history of H. pylori infection in hemodialysis patients, the prevalence of infection decreases as dialysis periods progressed, in particular within the first four years after the start of treatment. However, the chance of natural eradication becomes rare for patients receiving dialysis treatment for a long time. Moreover, chronic renal failure patients with H. pylori infection have a higher incidence of gastroduodenal diseases, and therefore, are recommended to receive eradication therapies, especially for those receiving treatment for a long time and with higher risks of complication. Intensive endoscopic check-ups for the prevention of gastrointestinal events and the discovery of peptic ulcer and neoplastic diseases at an early phase may be required.

[Guidelines of treatment for peptic ulcer disease in special conditions]

The pathogenesis, incidence, complication rates, response to acid suppression and Helicobacter pylori (H. pylori) eradication therapy in peptic ulcer associated with chronic disease such as liver cirrhosis, chronic renal failure, diabetes mellitus, and critically ill conditions are different from those with general population, so that the management strategies also should be differentiated. The eradication of H. pylori are not so effective for preventing recurrence of peptic ulcer in liver cirrhosis patients as shown in general population, and conservative managements such as preventing deterioration of hepatic function and decrease in portal pressure are mandatory to reduce the risk of ulcer recurrence. The standard triple therapy for H. pylori eradication are as effective in chronic renal failure patients as in normal population, but the frequency of side effects of amoxicillin is higher in the patients not receiving dialysis therapy. Delay in eradication therapy until beginning of dialysis therapy or modification of eradication regimen should be considered in such cases. High prevalence of asymptomatic peptic ulcers and increased mortality in complicated peptic ulcer disease warrant regular endoscopic surveillance in diabetic patients, especially with angiopathy. The prolongation of duration of eradication therapy also should be considered in diabetic patients with angiopathic complication because of lower eradication rate with standard triple regimens as compared to normal population. Prophylactic acid suppressive therapy is highly recommended in critically ill patients with multiple risk factors. Herein, we propose evidence-based treatment guidelines for the management of peptic ulcer disease in special conditions based on literature review and experts opinion.

Review article: Helicobacter pylori-negative duodenal ulcer disease

BACKGROUND

Helicobacter pylori infection rates in duodenal ulcer (DU) patients may be lower than previously estimated.

AIM

To review the real prevalence of H. pylori-negative DUs and its possible causes.

METHODS

Bibliographical searches in MEDLINE looking for the terms 'H. pylori' and 'duodenal ulcer'.

RESULTS

Mean prevalence of H. pylori infection in DU disease, calculated from studies published during the last 10 years including a total of 16 080 patients, was 81%, and this figure was lower (77%) when only the last 5 years were considered. Associations with H. pylori-negative DU were: (1) False negative results of diagnostic methods, (2) NSAID use (21% in studies with <90% infection rate), (3) Complicated DU (bleeding, obstruction, perforation), (4) Smoking, (5) Isolated H. pylori duodenal colonization, (6) Older age, (7) Gastric hypersecretion, (8) Diseases of the duodenal mucosa, (9) Helicobacter'heilmanii' infection and (10) Concomitant diseases.

CONCLUSION

In patients with H. pylori-negative DU disease, one should carefully confirm that the assessment of H. pylori status is reliable. In truly H. pylori-negative patients, the most common single cause of DU is, by far, the use of NSAIDs. Ulcers not associated with H. pylori, NSAIDs or other obvious causes should, for the present, be viewed as 'idiopathic'. True idiopathic DU disease only exceptionally exists.

Efficacy of an intravenous proton pump inhibitor after endoscopic therapy with epinephrine injection for peptic ulcer bleeding in patients with uraemia: a case-control study

BACKGROUND

Patients with peptic ulcer bleeding and uraemia are prone to re-bleeding.

AIM

To compare the efficacy of an intravenous proton pump inhibitor in treating peptic ulcer bleeding in patients with uraemia and those without uraemia.

METHODS

High-risk peptic ulcer bleeding patients received endoscopic therapy with epinephrine (adrenaline) injection plus intravenous omeprazole (40 mg bolus followed by 40 mg infusion every 12 h) for 3 days. Re-bleeding, volume of blood transfusion, hospital stay, need for surgery, and mortality were analysed.

RESULTS

The uraemic group had similar 7-day re-bleeding rate (6/42, 14.29% vs. 6/46, 13.04%, P = 0.865) to that of non-uraemic patients, but more re-bleeding episodes beyond 7 days (4/42, 9.52% vs. 0/46, 0%, P = 0.032, OR [95% CI] = 1.105 [1.002-1.219]) and all-cause mortality (4/42 vs. 0/46 P = 0.032, OR [95% CI] = 1.105 [1.002-1.219]). The uraemic group also had more units of blood transfusion after endoscopic therapy (mean +/- s.d. 4.33 +/- 3.35 units vs. 2.15 +/- 1.65 units, P < 0.001), longer hospital stay (mean +/- s.d. 8.55 +/- 8.12 days vs. 4.11 +/- 1.60 days, P < 0.001) and complications during hospitalization (9/42 vs. 0/46, P = 0.001, OR [95% CI] = 1.273 [1.087-1.490]).

CONCLUSION

Endoscopic therapy with epinephrine injection plus an intravenous proton pump inhibitor can offer protection against early re-bleeding in uraemic patients with peptic ulcer bleeding, but has a limited role beyond 7 days.

Helicobacter pylori and non-malignant diseases

In 2007 Helicobacter pylori research continued to deal with some controversies raised in the last decade. The main problems remain unsolved: peptic ulcer disease negative for H. pylori, synergism of H. pylori infection and aspirin and other nonsteroidal anti-inflammatory drugs or cyclooxygenase 2 specific inhibitors, the role of H. pylori eradication in uninvestigated and nonulcer dyspepsia, and the possible protective effect of H. pylori infection against gastroesophageal reflux disease and its complications such as Barrett's esophagus and adenocarcinoma. The incidence and prevalence of peptic ulcer disease as well as ulcer-related mortality are continuing to decline all over the world. The increasing consumption of anti-inflammatory and antisecretory drugs was not found to change the trend over the last period and therefore H. pylori was considered the key factor in causing ulcer-related mortality. Some progress has been achieved in understanding H. pylori-induced immunological processes, and attack mechanisms, as well as specific pathogenesis in uremic and cirrhotic patients. There is still a lot to learn about the bacterium and host factors related to H. pylori infection and its complications.