Upper Gastrointestinal System Complications in Pediatric Hemodialysis Patients

Seza Ozen. MD, Associate Professor of Pediatric Nephrology, Kuleli sok. 9/2, Gazi Osman Pasa, TR-06700 Ankara (Turkey) Dear Sir, Bleeding of the upper gastrointestinal system (GIS) is a major cause of morbidity and mortality in uremic patients [1]. Several factors are held responsible for the relative frequency of upper GIS bleeding in these patients including disturbances in serum gas-trin, in gastric acid excretion, defects in the clotting process, hypercalcemia associated with secondary hyperparathyroidism and adverse effects of uremia on GIS epithelium as well as chronic anticoagulation of hemodialysis and drug therapy [2, 3]. Upper GIS bleeding has been described in 10-60% of uremic patients [ 1 ] whereas gastric and duodenal ulcers were reported in 5-10% of these patients which has been suggested to be a percentage similar to the general population [2], Gurland et al. [4] have reported that GIS bleeding secondary to peptic ulcer disease is responsible for 3-5% of all deaths in dialysis patients. Figures in children are scarce. We have performed a routine X-ray survey of the esophagus, stomach and duodenum in our 19 pediatric hemodialysis patients after the upper GIS bleeding observed in one of our asymptomatic patients. Nineteen children (9 girls and 10 boys) with end-stage renal disease and on long-term dialysis treatment were the subject of this study. The mean age of the patients was 13.6 with an age range of 8-16 years. The mean duration of maintenance hemodialysis was 33 months (range 4-82 months). Hemodialysis was performed thrice weekly in all. Dia-lyzer membranes were cellulosic cuprophane membranes. Anticoagulation was achieved by a routine heparin, repeated-bolus regimen in most of the patients whereas a constant infusion at a dose of 10-15 units/kg/h was applied to patients at risk for bleeding. None of these patients were receiving corticoste-roids or nonsteroidal anti-inflammatory drugs. Evaluation of the upper gastrointestinal tract was carried out by a single-contrast barium meal Xray. The primary disease of the patient who presented with upper GIS bleeding was reflux nephropathy. This patient developed severe hyperkalemia during the bleeding episode which was only controlled by a strict dialysis programme. Subsequent X-ray examinations of the upper gastrointestinal tract in the 18 hemodialysis patients revealed marked peptic ulcus in 5 yielding a peptic ulcus percentage of 26 in this study group. Furthermore 3 patients had marked edema in the duodenal bulbus. Thus, together with the first