Management of upper non-variceal gastrointestinal bleeding in patients on renal replacement therapy: a two-center retrospective study

Background. Patients with kidney failure receiving renal replacement therapy (RRT) have a 3–5-fold higher risk of gastrointestinal bleeding than the general population.
Aim. To evaluate treatment outcomes in patients with non-variceal upper gastrointestinal bleeding (NVUGIB) receiving RRT.
Materials and methods. We retrospectively analyzed 106 patients with NVUGIB receiving hemodialysis-based RRT who were treated in 2019–2025 at Samara City Clinical Hospital No. 1 (N.I. Pirogov) and Togliatti City Clinical Hospital No. 5. Two clinical groups were defined: Group I—acute kidney injury (AKI; n=33) and Group II—end-stage kidney disease (ESKD) on maintenance hemodialysis (n=73). Categorical variables were compared using the χ² test; Fisher’s exact test was used for 2×2 tables with small expected cell counts. Continuous variables were compared using the Mann–Whitney U test. A two-sided p value <0.05 was considered statistically significant.
Results. In Group I (AKI), 13 patients (39.4%) required endoscopic and/or surgical treatment, whereas 20 (60.6%) were managed conservatively; in-hospital mortality was 21.2% (7/33). In Group II (ESKD), 26 patients (35.6%) underwent endoscopic and/or surgical intervention and 47 (64.4%) received conservative therapy; in-hospital mortality was 15.1% (11/73). Mortality did not differ significantly between the AKI and ESKD groups (χ²=0.61; p=0.40). When patients were regrouped by definitive treatment strategy, mortality was 58.8% (10/17) after surgery, 9.1% (2/22) after endoscopic hemostasis, and 9.0% (6/67) with conservative management (χ²=25.1; df=2; p<0.001). In pairwise comparisons, surgery was associated with higher mortality than endoscopic hemostasis (Fisher’s exact test, p=0.001; OR=14.29, 95% CI 2.49–81.82; RR=6.47, 95% CI 1.63–25.72).
Conclusion. Management of NVUGIB in patients receiving RRT should follow a structured pathway, prioritizing early endoscopy after hemodynamic stabilization, individualized anticoagulation management, and multidisciplinary decision-making. Endoscopic hemostasis was associated with low in-hospital mortality, whereas surgical intervention was linked to markedly worse outcomes and should be reserved for life-threatening situations when endoscopic control fails or is not feasible. Conservative therapy should be viewed as a temporary or selective option rather than an equivalent alternative to endoscopic treatment.

1. Elrggal ME, Naga YS. Gastrointestinal Bleeding in Patients with CKD: The Renalism Continues! Kidney360. 2025 Mar 1;6(3):337-339. https://doi.org/10.34067/KID.0000000686

2. Lin, Y., Li, C., Waters, D., & Kwok, C. S. (2023). Gastrointestinal bleeding in chronic kidney disease patients: a systematic review and meta-analysis. Renal Failure, 45(2). https://doi.org/10.1080/0886022X.2023.2276908

3. Larkin, J.W., Lama, S., Chaudhuri, S. et al. Prediction of gastrointestinal bleeding hospitalization risk in hemodialysis using machine learning. BMC Nephrol 25, 366 (2024). https://doi.org/10.1186/s12882-024-03809-2

4. Huang, CH., Chao, JY., Ling, TC. et al. Effect of dialysis modalities on risk of hospitalization for gastrointestinal bleeding. Sci Rep 13, 52 (2023). https://doi.org/10.1038/s41598-022-26476-5

5. Boccardo, P., Remuzzi, G., & Galbusera, M. (2004). Platelet dysfunction in renal failure. Seminars in thrombosis and hemostasis, 30(5), 579–589. https://doi.org/10.1055/s-2004-835678

6. Lutz J., Menke J., Sollinger D., Schinzel H., Thürmel K. Haemostasis in chronic kidney disease. Nephrol Dial Transplant. 2014;29(1):29–40. https://doi.org/10.1093/ndt/gft209

7. Weng, S. C., Shu, K. H., Tarng, D. C., Tang, Y. J., Cheng, C. H., Chen, C. H., Yu, T. M., Chuang, Y. W., Huang, S. T., Sheu, W. H., & Wu, M. J. In-hospital mortality risk estimation in patients with acute nonvariceal upper gastrointestinal bleeding undergoing hemodialysis: a retrospective cohort study. Renal failure, 35(2), 243–248. https://doi.org/10.3109/0886022X.2012.747140

8. Huang, Y., Chen, Q., Chen, R. et al. Endoscopic intervention for patients of renal insufficiency with upper gastrointestinal bleeding: efficacy evaluation and predictive model construction. BMC Gastroenterol 25, 773 (2025). https://doi.org/10.1186/s12876-025-04149-7

9. Riveros, C., Ranganathan, S., Shah, Y.B. et al. Association of chronic kidney disease with postoperative outcomes: a national surgical quality improvement program (NSQIP) multi-specialty surgical cohort analysis. BMC Nephrol 25, 305 (2024). https://doi.org/10.1186/s12882-024-03753-1

10. Acedillo, R. R., Shah, M., Devereaux, P. J., Li, L., Iansavichus, A. V., Walsh, M., & Garg, A. X. The risk of perioperative bleeding in patients with chronic kidney disease: a systematic review and meta-analysis. Annals of surgery, 258(6), 901–913. https://doi.org/10.1097/SLA.0000000000000244

11. Done J.Z., Ostertag-Hill C.A., Ziegler O., Vithiananthan S. Major perioperative bleeding in patients on dialysis undergoing nonelective abdominal surgeries. Journal of Surgical Research. — 2025. — Vol. 305. — P. 356–366. https://doi.org/10.1016/j.jss.2024.11.029

12. Gralnek I.M., Dumonceau J.-M., Kuipers E.J. et al. 2021 ESGE Guideline: Management of non-variceal upper gastrointestinal bleeding — update 2021. Endoscopy. — 2021. — Vol. 53, No. 11. — P. 1175–1206. — DOI: 10.1055/a-1380-9103. https://www.esge.com/assets/downloads/pdfs/guidelines/2021_a_1369_5274.pdf

13. Muftah, M., Mulki, R., Dhere, T., Keilin, S., & Chawla, S. (2019). Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease. Annals of gastroenterology, 32(2), 113–123. https://doi.org/10.20524/aog.2018.0341

14. Abd El-Maguid A., Walenga J., Swaim R. et al. Evaluation of novel coagulation and platelet function assays in patients with chronic kidney disease. Journal of Thrombosis and Haemostasis. — 2022. — Vol. 20, № 4. — P. 742–753. https://doi.org/10.1111/jth.15653