Chronic kidney disease (CKD) is associated with an increased risk of major hemorrhage among older adults, a new study finds.
In a post hoc analysis of data from the Aspirin in Reducing Events in the Elderly (ASPREE) trial, major hemorrhage occurred at a higher rate among adults older than 65 years with than without CKD: 10.4 vs. 6.3 per 1000 person-years, Suzanne E. Mahady, MBBS, PhD, of Monash University in Melbourne, Australia, and colleagues reported in Kidney International Reports. In adjusted analyses, CKD was independently associated with a 37% increased risk of bleeding compared with no CKD. By component, albuminuria was significantly associated with a 74% increased risk of bleeding once the urinary albumin to creatinine ratio (UACR) reached 3 mg/mmoL or higher. As a continuous variable, each doubling of the UACR increased bleeding risk by 18%. Bleeding risk also increased when the estimated glomerular filtration rate (eGFR) fell below 40 mL/min/1.73 m2.
Bleeding risks were higher among patients who were aged 80 years or older, male, smokers, hypertensive, and aspirin users. Aspirin use did not mediate the relationship between CKD and bleeding, the investigators reported.
Major hemorrhage included intracranial or extracranial bleeding and hemorrhagic stroke requiring transfusion, hospitalization, or surgery or resulting in death. A total of 595 patients experienced 244 gastrointestinal bleeding events, 169 intracranial bleeding events, and 250 “other” bleeding events including hematuria, trauma-related bleeding, epistaxis, and gynecological bleeding.
Among 17,976 participants in ASPREE, 11.5% had a UACR of at least 3 mg/mmoL and 18.4% had an eGFR less than 60 mL/min/1.73 m2. Patients with anemia were excluded from this study.
According to Dr Mahady’s team, “CKD in otherwise healthy older people is associated with elevated risk of major bleeding as albuminuria increases or when eGFR is reduced to <40 ml/min per 1.73 m2. Given the association of CKD and bleeding in older persons, preemptive strategies to reduce bleeding risk such as discontinuation of unnecessary aspirin use, smoking cessation, and blood pressure control are warranted.”
The investigators noted that bleeding scoring systems such as HAS-BLED (Hypertension, Abnormal liver/renal function, stroke history, bleeding history or predisposition, Labile INR, Elderly, Drug/alcohol usage) use reduced eGFR to indicate CKD, but “albuminuria may be a more sensitive predictor.”
Mahady SE, Polekhina G, Woods RL, Cloud GC, Murray AM, Polkinghorne KR. Association between CKD and major hemorrhage in older persons: Data from the Aspirin in Reducing Events in the Elderly randomized trial. Kidney Int Rep. Published online January 18, 2023. doi:10.1016/j.ekir.2023.01.012