Geographic differences in serious bleeding event rates and clinical profiles among patients with ESKD who receive peritoneal or hemodialysis, 2009-2022
Authors: Bonaca M P , Coyle C , Bash L D , Barash I , Ramey D R , Guedes M , Zhao J , Karaboyas A , Pecoits-Filho R , Atkins G B 
Published: November 2023

Abstract

Background
Patients with end-stage kidney disease (ESKD) have higher rates of bleeding compared to the general population. Therapies to manage risk of thrombosis in patients with ESKD, like anticoagulants, can further increase this risk. Despite these risks, there are limited epidemiological data on bleeding rates in ESKD patients including how this risk varies across geographies. Our aim was to quantify serious bleeding event rates among patients with ESKD who are on dialysis across 5 global regions.

Methods
Data for this analysis come from 21 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS; 2009-2022) and 8 countries in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS; 2014-2022), both prospective studies among patients treated with hemodialysis (HD) and peritoneal (PD), respectively. Patient characteristics and bleeding rates across 5 regions were analyzed: Australia/New Zealand (ANZ), Europe, Gulf Coast Countries (GCC) (only HD), North America (NA), and Other Asia-Pacific (AP). Counts of first serious bleeding event (i.e., leading to death or inpatient hospitalization) were calculated as event rates per 100 person-years.

Results
In all, 32,396 and 6,068 patients on HD and PD, respectively were included (Table 1). Of patients receiving HD, 3% were from ANZ, 4% were from GCC, 14% were from North America, 28% were from AP, and 51% were in Europe. Of patients on PD, 8% were from ANZ, 7% were from Europe, 26% lived in NA, and 60% were in the AP region. Mean age for HD and PD patients generally ranged from 59-66 with PD patients tending to be a few years younger. GCC patients on HD had a mean age of 55. Both cohorts had similar distribution of sex and race. Anticoagulant use was lowest in AP and highest in NA; with lower use in PD compared to HD.
Serious bleeding rates were highest in ANZ and lowest in AP. Bleeding rates leading to hospitalizations followed a similar trend. Gastrointestinal (GI) bleeding resulted in the highest bleeding event rates for hospitalizations across all regions but was highest in NA. Access bleeding was a more common reason for hospitalization in ANZ and Europe than other regions. The rate of fatal bleeding events was somewhat higher in Europe and AP than other regions with the most common fatal bleeding event being hemorrhagic stroke (Table 2), the highest of which was in AP.

Conclusion
These data highlight the large regional variations and inconsistent patterns in the clinical profiles, treatment patterns, and serious bleeding event rates among patients with ESKD receiving dialysis. Further research is needed to better understand factors that contribute to individual patients’ bleeding risk and to these geographic differences as a mechanism to improve risk management and quality care provided to these patients.Table 1.Patient CharacteristicsTable 2.Bleeding Rates