Risk of Post-Polypectomy Bleeding After Colorectal Endoscopic Mucosal Resection in Patients with Chronic Kidney Disease: A Propensity-Matched Analysis of the US Collaborative Network

Risk of Post-Polypectomy Bleeding After Colorectal Endoscopic Mucosal Resection in Patients with Chronic Kidney Disease: A Propensity-Matched Analysis of the US Collaborative Network | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk of Post-Polypectomy Bleeding After Colorectal Endoscopic Mucosal Resection in Patients with Chronic Kidney Disease: A Propensity-Matched Analysis of the US Collaborative Network Azizullah Beran, Khaled Elfert, Feenalie Patel, Mouhand Mohamed, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6398416/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jun, 2025 Read the published version in Digestive Diseases and Sciences → Version 1 posted 11 You are reading this latest preprint version Abstract Background Studies evaluating the risk of post-polypectomy bleeding (PPB) after colorectal endoscopic mucosal resection (EMR) in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) are limited. Methods This retrospective cohort study utilized the U.S. Collaborative Network to assess the risk of PPB after colorectal EMR in patients with CKD compared to controls. Using one-to-one propensity score matching (PSM), the primary outcome measured was PPB within 30 days after colorectal EMR. The PPB risk was further stratified by CKD severity: non-advanced CKD and advanced CKD. Results After PSM, each cohort included 7,460 patients. Overall, CKD was associated with increased risk of PPB following colorectal EMR (5.5% vs. 4%, odds ratio [OR] 1.38, 95% confidence interval [CI] 1.19–1.61, p < 0.001). The PPB risk was significantly higher in patients with advanced CKD (8.1% vs, 4.6%, OR 1.83, 95% CI 1.43–2.34, p < 0.001), while those with non-advanced CKD showed modest increase in risk of PPB (4.7% vs. 3.9%, OR 1.21, 95% CI 1.001–1.46, p = 0.049). Conclusion Patients with CKD had higher risk of PPB than patients without CKD, but absolute risk remained low. The PPB risk was notably increased in patients with advanced CKD. Optimizing patients with CKD, especially advanced CKD, before colorectal EMR and monitoring for post-procedure bleeding remains important. INTRODUCTION Colorectal cancer is the third most commonly diagnosed cancer and the third most common cause of cancer-related death in the United States 1 . Colonoscopy is the gold standard method for screening for colorectal cancer and allows for resection of colon polyps, which reduces the incidence and mortality of colorectal cancer 2 , 3 . The lifetime risk of developing chronic kidney disease (CKD) stage 3 or higher in the United States is 7–10% 4 . Patients with advanced CKD and end-stage renal disease (ESRD) are more likely to have colorectal adenomas and advanced adenomas than control patients 5 , 6 . Dialysis and kidney transplantation prolong life. For patients on dialysis, the American Society of Nephrology recommends colon cancer screening only for individuals who are transplant candidates. Colonoscopy is a routine part of evaluation prior to kidney transplant 7 . Endoscopic Mucosal Resection (EMR) is the preferred technique for resecting benign large (≥ 20 millimeters [mm] in size) colorectal polyps. Colorectal polyps 10–19 mm in size are also frequently resected using EMR per endoscopist discretion 8 , 9 . The most frequent major adverse event after colorectal EMR is post-polypectomy bleeding (PPB) 10 – 12 . The risk of PPB following endoscopic resection of gastrointestinal lesions has been evaluated in several cohort studies of patients with varying stages of renal disease and found that patients with advanced CKD stage ≥ 4 are more likely to suffer from gastrointestinal (GI) bleeding after endoscopy 13 – 15 . The safety of colorectal EMR in patients with CKD remains understudied. We have previously evaluated the safety of colorectal EMR in patients with cirrhosis, another group who typically have increased risk of bleeding with procedures 16 . We conducted a retrospective United States-based, propensity-matched cohort study to assess the risk of PPB after colorectal EMR in patients with CKD. METHODS Study design and data source This large, population-based, retrospective cohort study was conducted using the U.S. Collaborative Network in the TriNetX platform (Cambridge, MA, USA). TriNetX is a federated multicenter research network that provides real-time access to a deidentified dataset from participating healthcare organizations' electronic health records (EHR). Clinical data is obtained directly from EHRs and supplemented by a built-in natural language processing system, which extracts relevant variables from clinical documents. Rigorous quality control is applied at the point of data extraction to ensure accuracy before inclusion in the database. The platform displays only aggregate counts and statistical summaries to protect patient privacy, keeping data de-identified at all stages, with additional anonymity safeguards, such as masking patient counts below 11. Details of the TriNetX network are described in previous studies 17 , 18 . We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline 19 . Study participants and cohorts A real-time search and analysis of the U.S. Collaborative Network on the TriNetX platform was conducted from its inception through November 30, 2024. The CKD cohort included all adults (≥ 18 years) with a diagnosis of CKD (stage 1–5, ESRD, and dependence on renal dialysis) who underwent colorectal EMR, identified by International Classification of Diseases-10 (ICD-10) codes for CKD and the Current Procedural Terminology (CPT) codes for renal dialysis and colorectal endoscopic mucosal resection performed via colonoscopy or flexible sigmoidoscopy. Patients who had undergone renal transplantation were excluded from the study. To ensure colorectal EMR occurred after the CKD diagnosis, TriNetX's functionality for defining index events and excluding prior outcomes was applied, including only patients who received colorectal EMR following a CKD ICD-10 code. The control cohort consisted of all adults (≥ 18 years) who underwent colorectal EMR in the same period and did not have an ICD-10 code for CKD. Details of Further details on data sources and diagnosis codes used for patient selection and outcomes (according to predefined ICD-10, CPT, and RxNorm codes) are described in Supplementary Table 1. Study outcomes and definitions The primary outcome was the risk of PPB within 30 days of colorectal EMR between CKD and control groups. PPB was identified using ICD-10 codes for “Gastrointestinal hemorrhage, unspecified” (K92.2) or “Hemorrhage of anus and rectum” (K62.5). Secondary outcomes included endoscopic reintervention for hemostasis, blood transfusion, and intensive care unit (ICU) admissions within 30 days of the procedure. We further stratified the risk of clinical outcomes after colorectal EMR by the severity of CKD (non-advanced CKD and advanced CKD) compared to the matched control group. The non-advanced CKD cohort was defined as patients with CKD stages 1, 2, and 3. The advanced CKD cohort was defined as patients with CKD stages 4 and 5, ESRD, or dependence on dialysis. Statistical analysis All statistical analyses were conducted using the real-time analytics capabilities of the TriNetX Live platform (TriNetX LLC, Cambridge, MA). Baseline characteristics of the study cohorts were summarized using means, standard deviations, and proportions. To ensure comparability between cohorts, one-to-one propensity score matching (PSM) was employed to balance demographic variables (age, race, ethnicity, gender), comorbidities (such as hypertension, diabetes, cirrhosis, and obesity), thrombocytopenia, and the use of anticoagulants and antiplatelets. Further details of the PSM process are provided in Supplementary Table 2. Propensity scores for individual subjects were generated using logistic regression analysis based on the specified covariates. Matching was performed with a greedy nearest-neighbor algorithm, applying a caliper width of 0.1 pooled standard deviations, which was determined to be optimal. To minimize potential bias, TriNetX randomized the row order before matching. Following PSM, outcome risks were calculated and expressed as odds ratios (OR) with 95% confidence intervals (CIs). Statistical significance was defined as a two-sided p-value of less than 0.05. RESULTS Patient baseline characteristics Initially, we identified 7,804 patients in the CKD cohort and 54,758 patients in the control cohort who underwent colorectal EMR during the study period. The CKD cohort was older (69 ± 9.7 vs. 62.2 ± 11.1, p < 0.001) and had a higher proportion of male patients (53.4% vs. 45.7%, p < 0.001), Black or African American race (15.5% vs. 7.6%, p < 0.001), type 2 diabetes mellitus (45.7% vs. 13.6%, p < 0.001), hypertension (79.4% vs. 38.9%, p < 0.001), cirrhosis (5.9% vs. 2.1%, p < 0.001), obesity (31.7% vs. 14.9%, p < 0.001), and thrombocytopenia (10.3% vs. 2.3%, p < 0.001) compared to the control cohort. Additionally, a greater proportion of patients in the CKD cohort were on antiplatelets: aspirin (51.7% vs. 23.2%, p < 0.001) and clopidogrel (16.7% vs. 4.2%, p < 0.001), ticagrelor (2.3% vs. 0.7%, p < 0.001), and prasugrel (0.8% vs. 0.2%, p < 0.001), and on anticoagulants: warfarin (11.5% vs. 2.8%, p < 0.001), apixaban (11.8% vs. 3.5%, p < 0.001), rivaroxaban (25.9% vs. 2.3%, p < 0.001), and dabigatran (1% vs. 0.4%, p < 0.001) (Supplementary Table 2). After PSM for age, sex, race, ethnicity, comorbidities (hypertension, diabetes, obesity, and cirrhosis), thrombocytopenia, and medications (anticoagulants and antiplatelets), each cohort included 7,460 patients. Patients in the control cohort had a higher proportion of patients with hypertension (80% vs. 78.5%, p = 0.03) compared to the CKD cohort. In contrast, a greater proportion of patients in the CKD cohort were on Rivaroxaban (5.6% vs. 4.6%, p = 0.01). The remaining variables were balanced between the two groups after PSM. The details of PSM are shown in Supplementary Table 2. Post-polypectomy outcomes after colorectal EMR in CKD After PSM, a total of 410 (5.5%) patients in the CKD cohort had PPB after colorectal EMR compared to 301 (4%) patients in the control cohort. The risk of PPB after colorectal EMR was higher in the CKD cohort compared to the control cohort (OR 1.38, 95% CI 1.19–1.61, p < 0.001) (Table 1 ). Furthermore, the endoscopic reinterventions for hemostasis (1.5% vs. 1%, OR 1.50, 95% CI 1.11–2.03, p = 0.01), blood transfusion (0.8% vs. 0.4%, OR 2.04, 95% CI 1.30–3.20, p = 0.002), and ICU admission (1.3% vs. 0.6%, OR 2.29, 95% CI 1.57–3.34, p < 0.001) were higher in the CKD cohort compared to the control cohort (Table 1 ). Table 1 Clinical outcomes within 30 days of colorectal EMR in CKD compared to matched control group. Outcomes Cohort Events/Total (%) OR 95% CI p-value Post-polypectomy bleeding after colorectal EMR CKD 410/7,460 (5.5%) 1.38 1.19–1.61 < 0.001 Control 301/7,460 (4%) Endoscopic reintervention for hemostasis CKD 108/7,163 (1.5%) 1.50 1.11–2.03 0.01 Control 73/7,236 (1%) Blood transfusion CKD 56/6,827 (0.8%) 2.04 1.30–3.20 0.002 Control 29/7,183 (0.4%) ICU admission CKD 85/6,365 (1.3%) 2.29 1.57–3.34 < 0.001 Control 40/6,803 (0.6%) Abbreviations : CKD: chronic kidney disease, CI: confidence interval, EMR: endoscopic mucosal resection, ICU: intensive care unit, OR: odds ratio. Post-polypectomy outcomes after colorectal EMR in non-advanced CKD The non-advanced CKD cohort had higher rates of PPB (4.7% vs. 3.9%, OR 1.21, 95% CI 1.001–1.46, p = 0.049), endoscopic reintervention for hemostasis (1.4% vs. 0.9%, OR 1.47, 95% CI 1.02–2.11, p = 0.04), blood transfusion (1% vs. 0.5%, OR 1.94, 95% CI 1.21–3.09, p = 0.01), and ICU admission (1.7% vs. 0.9%, OR 1.91, 95% CI 1.34–2.72, p < 0.001) following colorectal EMR compared to the matched control cohort (Table 2 ). Table 2 Clinical outcomes within 30 days of colorectal EMR in advanced and non-advanced CKD compared to matched control group. Outcomes Cohort Events/Total (%) OR 95% CI p-value Advanced CKD PPB after colorectal EMR Advanced CKD 187/2,316 (8.1%) 1.83 1.43–2.34 < 0.001 Control 106/2,316 (4.6%) Endoscopic reintervention for hemostasis Advanced CKD 48/2,183 (2.2%) 1.78 1.11–2.85 0.02 Control 28/2,247 (1.2%) Blood transfusion Advanced CKD 26/1,977 (1.3%) 2.08 1.08–3.99 0.03 Control 14/2,195 (0.6%) ICU admission Advanced CKD 32/1,773 (1.8%) 2.66 1.42-5.00 0.002 Control 14/2,040 (0.7%) Non-advanced CKD PPB after colorectal EMR Non-advanced CKD 247/5,270 (4.7%) 1.21 1.001–1.46 0.049 Control 206/5,270 (3.9%) Endoscopic reintervention for hemostasis Non-advanced CKD 73/5,270 (1.4%) 1.47 1.02–2.11 0.04 Control 50/5,270 (0.9%) Blood transfusion Non-advanced CKD 52/5,270 (1%) 1.94 1.21–3.09 0.01 Control 27/5,270 (0.5%) ICU admission Non-advanced CKD 89/5,270 (1.7%) 1.91 1.34–2.72 < 0.001 Control 47/5,270 (0.9%) Abbreviations : CKD: chronic kidney disease CI: confidence interval, EMR: endoscopic mucosal resection, ICU: intensive care unit, OR: odds ratio, PPB: post-polypectomy bleeding. Post-polypectomy outcomes after colorectal EMR in advanced CKD The advanced CKD cohort had significantly higher rates of PPB (8.1% vs. 4.6%, OR 1.83, 95% CI 1.43–2.34, p < 0.001), endoscopic reintervention for hemostasis (2.2% vs. 1.2%, OR 1.78, 95% CI 1.11–2.85, p = 0.02), blood transfusion (1.3% vs. 0.6%, OR 2.08, 95% CI 1.08–3.99, p = 0.03), and ICU admission (1.8% vs. 0.7%, OR 2.66, 95% CI 1.42-5.00, p = 0.002) following colorectal EMR compared to the matched control cohort (Table 2 ). DISCUSSION Our findings suggest that patients with CKD are at an increased risk of PPB following colorectal EMR compared to those without CKD, but the absolute risk was low. This increased risk is associated with a greater need for endoscopic interventions to control bleeding, along with increased rates of blood transfusions and ICU admissions. The risk of PPB was particularly pronounced in patients with advanced CKD, whereas those with non-advanced CKD experienced a more modest increase in risk compared to the matched control group. CKD, especially advanced CKD and ESRD, has been identified as an independent risk factor for bleeding in several population studies 20 – 22 . The increased risk of PPB associated with CKD is likely multifactorial including impaired platelet function 23 and presence of albuminuria 20 , 21 . Additionally, the uremic environment resulting from declining kidney function, along with changes in the gut microbiome observed in CKD, may contribute to this risk 24 . A recent retrospective study noted immediate PPB and delayed bleeding in 26.1% and 2.2% of patients with end-stage renal disease, respectively 25 . Data from a large retrospective cohort study examining colonoscopy with any polypectomy demonstrated that the risk of significant immediate PPB in patients with ESRD is higher than non-ESRD patients (4.94% vs. 1.36%, p < 0.001); however, the rate of delayed PPB was similar (0.64% vs. 0.40%, p = 0.08) 26 . Similarly, patients with advanced CKD and ESRD undergoing endoscopic submucosal resection for gastric neoplasms had a higher risk of bleeding and longer hospital stay than non-CKD patients. Despite this higher risk of bleeding, patients with ESRD were observed to respond to endoscopic hemostatic interventions similarly to a control group (OR 6.1, 95% CI 2.7–13.6, p < 0.001) 13 . A study of colorectal endoscopic submucosal dissection included 118 patients with CKD stage ≥ 3 and demonstrated lower en bloc resection rates with advancing kidney disease; however, complications including bleeding and perforation were not different between groups. Due to a small number of patients with CKD stages 4 and 5, predictive modeling was performed, which did not show changes in complications based on decreasing glomerular filtration rates 15 . Our study findings indicate that patients with CKD, particularly those with advanced stages, have an increased risk of PPB, aligning with previous studies 14 , 15 . This study has some limitations. By utilizing a large, deidentified database, we were unable to identify the size of lesion for which patient underwent EMR, the use of electrocautery, and if prophylactic closure was performed. Clip closure of large polyp EMR defects removed with electrocautery proximal to the splenic flexure has been shown to reduce the risk of delayed bleeding 27 . There may also be variability amongst endoscopists in clip closure 28 . The technique used for EMR also influences post-polypectomy bleeding risk. Two randomized controlled trials have found that cold EMR significantly lowered post-procedure bleeding compared to hot EMR, though it increased the risk of polyp recurrence 29 , 30 . In select patients with advanced CKD, cold EMR may be preferred to minimize bleeding risk, accepting a higher risk of residual or recurrent polyp 31 . Additionally, as a retrospective cohort design, despite one-to-one PSM, this study is subject to selection and confounding biases. A dedicated ICD-10 code for PPB after EMR is not available. We defined PPB following EMR as lower gastrointestinal bleeding recorded with ICD-10 codes occurring within 30 days of colorectal EMR, but this bleeding may not always be attributable to EMR. We also could not capture the timing of anticoagulant and antiplatelet discontinuation before the procedure or their resumption afterward, which could influence PPB risk following EMR. However, we assume that most patients adhered to standard guidelines for discontinuing these medications, given that EMR is an elective procedure 32 . As with any database study, there are inherent concerns regarding potential misdiagnosis, underreporting of certain variables, and inaccuracies in diagnosis entry. There may be under-reporting of complications if patients received care outside any of the health networks participating in the TriNetX, particularly for post-procedure complications. Despite its limitations, our study has several notable strengths. It is a large-scale, multicenter, U.S.-based population study involving a diverse cohort, which improves the generalizability of our findings. To our knowledge, this is the first study to provide a comparative analysis of PPB risk in patients with CKD undergoing colorectal EMR in comparison to a matched control group. We employed rigorous one-to-one PSM, carefully balancing relevant comorbidities, demographic factors, and the use of anticoagulants and antiplatelet agents between the cohorts. These efforts enhance the robustness of our findings, which provide valuable insights to inform clinical decision-making and serve as a foundation for future research on the safety of EMR in patients with CKD. In conclusion, patients with CKD exhibited an increased risk of post-polypectomy bleeding following colorectal EMR compared to controls, although the absolute risk remained low. The risk was notably increased in patients with advanced CKD. Optimizing patients with CKD, especially advanced CKD, prior to colorectal EMR and monitoring for post-procedure bleeding remains important. Further prospective studies are needed to confirm these findings, explore the benefits of prophylactic lesion closure, and assess the potential use of cold resection in this select population. Declarations Conflicts of interest: FNP: Travel Support - Boston Scientific DKR: Consultant- Olympus Corporation, Boston Scientific, Braintree Laboratories, Norgine, Medtronic, Acacia Pharmaceuticals; Research Support - Olympus Corporation, Medivators, Erbe USA Inc, Braintree Laboratories; Shareholder - Satisfai Health JJG: Travel Support - Boston Scientific Corporation, Olympus Corporation, Ovesco Endoscopy AG Other authors: no disclosures Funding: None Contributions: Conceptualization and design: AB, JJG. Manuscript drafting: AB, KE, FP, DR, KS, and JJG. Data collection: AB, KE, and IB. Statistical analysis: AB and KE. Tables: DR, AC, and AB. Critical revision of manuscript: ST, KS, DS, DKR, IB, and JJG . Guarantor of article: JG. Final review and approval of the manuscript: All authors. References Siegel RL, Wagle NS, Cercek A, Smith RA, Jemal A. Colorectal cancer statistics, 2023. CA Cancer J Clin . 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Supplementary Files SupplementaryTables.docx Cite Share Download PDF Status: Published Journal Publication published 01 Jun, 2025 Read the published version in Digestive Diseases and Sciences → Version 1 posted Editorial decision: Revision requested 28 Apr, 2025 Reviews received at journal 28 Apr, 2025 Reviews received at journal 27 Apr, 2025 Reviews received at journal 27 Apr, 2025 Reviewers agreed at journal 19 Apr, 2025 Reviewers agreed at journal 18 Apr, 2025 Reviewers agreed at journal 18 Apr, 2025 Reviewers invited by journal 17 Apr, 2025 Editor assigned by journal 15 Apr, 2025 Submission checks completed at journal 09 Apr, 2025 First submitted to journal 07 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Shaik","email":"","orcid":"","institution":"Geisinger Health System","correspondingAuthor":false,"prefix":"","firstName":"Danial","middleName":"H.","lastName":"Shaik","suffix":""},{"id":446897122,"identity":"f68c547a-9e87-486e-8f04-5fc4e75dba81","order_by":8,"name":"Shyam Thakkar","email":"","orcid":"","institution":"Houston Methodist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shyam","middleName":"","lastName":"Thakkar","suffix":""},{"id":446897123,"identity":"f9b21e2e-29cd-4f78-ae8c-ef6fda37a222","order_by":9,"name":"Douglas K. Rex","email":"","orcid":"","institution":"Indiana University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Douglas","middleName":"K.","lastName":"Rex","suffix":""},{"id":446897124,"identity":"33cdf858-a02a-49a5-90df-e2b7114ea02c","order_by":10,"name":"Indira Bhavsar-Burke","email":"","orcid":"","institution":"University of Texas Southwestern Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Indira","middleName":"","lastName":"Bhavsar-Burke","suffix":""},{"id":446897125,"identity":"62abcc8e-eb2d-4621-b974-3c60e68f4227","order_by":11,"name":"John J. Guardiola","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAApklEQVRIiWNgGAWjYBACxgYwZcMDIiVI0ZJGghYoOMxAvBbm9vZrEj/3nJcxOMB88DYPUQ7rOVMm2fPsNo/BAbZka+K0zMhJk+A5ANLCYyZNtBbJPwfOAbXwfyNWS/oxaZ4DB0C2sBGppecMs7XMgWQeycNsxpZziNFi2N7+8OabA3b2fMebH954Q5SWBh4DCIuZGOUgIM/A/oBYtaNgFIyCUTBSAQAcBy8rNjhVvQAAAABJRU5ErkJggg==","orcid":"","institution":"Indiana University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"John","middleName":"J.","lastName":"Guardiola","suffix":""}],"badges":[],"createdAt":"2025-04-08 02:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6398416/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6398416/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10620-025-09122-8","type":"published","date":"2025-06-01T15:56:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83782703,"identity":"9c535798-8b75-4417-adaa-f98a48922d2c","added_by":"auto","created_at":"2025-06-02 15:59:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":835163,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6398416/v1/a387706b-9286-4814-9145-29cac2066177.pdf"},{"id":81353176,"identity":"bd013121-cf8e-4460-93ae-b6b75726d5a3","added_by":"auto","created_at":"2025-04-25 06:55:49","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20931,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6398416/v1/0c572526208c0b645821d9f2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk of Post-Polypectomy Bleeding After Colorectal Endoscopic Mucosal Resection in Patients with Chronic Kidney Disease: A Propensity-Matched Analysis of the US Collaborative Network","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eColorectal cancer is the third most commonly diagnosed cancer and the third most common cause of cancer-related death in the United States\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Colonoscopy is the gold standard method for screening for colorectal cancer and allows for resection of colon polyps, which reduces the incidence and mortality of colorectal cancer\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The lifetime risk of developing chronic kidney disease (CKD) stage 3 or higher in the United States is 7\u0026ndash;10%\u003csup\u003e4\u003c/sup\u003e. Patients with advanced CKD and end-stage renal disease (ESRD) are more likely to have colorectal adenomas and advanced adenomas than control patients\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Dialysis and kidney transplantation prolong life. For patients on dialysis, the American Society of Nephrology recommends colon cancer screening only for individuals who are transplant candidates. Colonoscopy is a routine part of evaluation prior to kidney transplant\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEndoscopic Mucosal Resection (EMR) is the preferred technique for resecting benign large (\u0026ge; 20 millimeters [mm] in size) colorectal polyps. Colorectal polyps 10\u0026ndash;19 mm in size are also frequently resected using EMR per endoscopist discretion\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. The most frequent major adverse event after colorectal EMR is post-polypectomy bleeding (PPB)\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The risk of PPB following endoscopic resection of gastrointestinal lesions has been evaluated in several cohort studies of patients with varying stages of renal disease and found that patients with advanced CKD stage\u0026thinsp;\u0026ge;\u0026thinsp;4 are more likely to suffer from gastrointestinal (GI) bleeding after endoscopy\u003csup\u003e\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. The safety of colorectal EMR in patients with CKD remains understudied. We have previously evaluated the safety of colorectal EMR in patients with cirrhosis, another group who typically have increased risk of bleeding with procedures\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. We conducted a retrospective United States-based, propensity-matched cohort study to assess the risk of PPB after colorectal EMR in patients with CKD.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and data source\u003c/h2\u003e \u003cp\u003eThis large, population-based, retrospective cohort study was conducted using the U.S. Collaborative Network in the TriNetX platform (Cambridge, MA, USA). TriNetX is a federated multicenter research network that provides real-time access to a deidentified dataset from participating healthcare organizations' electronic health records (EHR). Clinical data is obtained directly from EHRs and supplemented by a built-in natural language processing system, which extracts relevant variables from clinical documents. Rigorous quality control is applied at the point of data extraction to ensure accuracy before inclusion in the database. The platform displays only aggregate counts and statistical summaries to protect patient privacy, keeping data de-identified at all stages, with additional anonymity safeguards, such as masking patient counts below 11. Details of the TriNetX network are described in previous studies\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy participants and cohorts\u003c/h3\u003e\n\u003cp\u003eA real-time search and analysis of the U.S. Collaborative Network on the TriNetX platform was conducted from its inception through November 30, 2024. The CKD cohort included all adults (\u0026ge;\u0026thinsp;18 years) with a diagnosis of CKD (stage 1\u0026ndash;5, ESRD, and dependence on renal dialysis) who underwent colorectal EMR, identified by International Classification of Diseases-10 (ICD-10) codes for CKD and the Current Procedural Terminology (CPT) codes for renal dialysis and colorectal endoscopic mucosal resection performed via colonoscopy or flexible sigmoidoscopy. Patients who had undergone renal transplantation were excluded from the study. To ensure colorectal EMR occurred after the CKD diagnosis, TriNetX's functionality for defining index events and excluding prior outcomes was applied, including only patients who received colorectal EMR following a CKD ICD-10 code. The control cohort consisted of all adults (\u0026ge;\u0026thinsp;18 years) who underwent colorectal EMR in the same period and did not have an ICD-10 code for CKD. Details of Further details on data sources and diagnosis codes used for patient selection and outcomes (according to predefined ICD-10, CPT, and RxNorm codes) are described in Supplementary Table\u0026nbsp;1.\u003c/p\u003e\n\u003ch3\u003eStudy outcomes and definitions\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was the risk of PPB within 30 days of colorectal EMR between CKD and control groups. PPB was identified using ICD-10 codes for \u0026ldquo;Gastrointestinal hemorrhage, unspecified\u0026rdquo; (K92.2) or \u0026ldquo;Hemorrhage of anus and rectum\u0026rdquo; (K62.5). Secondary outcomes included endoscopic reintervention for hemostasis, blood transfusion, and intensive care unit (ICU) admissions within 30 days of the procedure.\u003c/p\u003e \u003cp\u003eWe further stratified the risk of clinical outcomes after colorectal EMR by the severity of CKD (non-advanced CKD and advanced CKD) compared to the matched control group. The non-advanced CKD cohort was defined as patients with CKD stages 1, 2, and 3. The advanced CKD cohort was defined as patients with CKD stages 4 and 5, ESRD, or dependence on dialysis.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were conducted using the real-time analytics capabilities of the TriNetX Live platform (TriNetX LLC, Cambridge, MA). Baseline characteristics of the study cohorts were summarized using means, standard deviations, and proportions. To ensure comparability between cohorts, one-to-one propensity score matching (PSM) was employed to balance demographic variables (age, race, ethnicity, gender), comorbidities (such as hypertension, diabetes, cirrhosis, and obesity), thrombocytopenia, and the use of anticoagulants and antiplatelets. Further details of the PSM process are provided in Supplementary Table\u0026nbsp;2.\u003c/p\u003e \u003cp\u003ePropensity scores for individual subjects were generated using logistic regression analysis based on the specified covariates. Matching was performed with a greedy nearest-neighbor algorithm, applying a caliper width of 0.1 pooled standard deviations, which was determined to be optimal. To minimize potential bias, TriNetX randomized the row order before matching. Following PSM, outcome risks were calculated and expressed as odds ratios (OR) with 95% confidence intervals (CIs). Statistical significance was defined as a two-sided p-value of less than 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient baseline characteristics\u003c/h2\u003e \u003cp\u003eInitially, we identified 7,804 patients in the CKD cohort and 54,758 patients in the control cohort who underwent colorectal EMR during the study period. The CKD cohort was older (69\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7 vs. 62.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and had a higher proportion of male patients (53.4% vs. 45.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Black or African American race (15.5% vs. 7.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), type 2 diabetes mellitus (45.7% vs. 13.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), hypertension (79.4% vs. 38.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), cirrhosis (5.9% vs. 2.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), obesity (31.7% vs. 14.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and thrombocytopenia (10.3% vs. 2.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to the control cohort. Additionally, a greater proportion of patients in the CKD cohort were on antiplatelets: aspirin (51.7% vs. 23.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and clopidogrel (16.7% vs. 4.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), ticagrelor (2.3% vs. 0.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and prasugrel (0.8% vs. 0.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and on anticoagulants: warfarin (11.5% vs. 2.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), apixaban (11.8% vs. 3.5%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), rivaroxaban (25.9% vs. 2.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and dabigatran (1% vs. 0.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Supplementary Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eAfter PSM for age, sex, race, ethnicity, comorbidities (hypertension, diabetes, obesity, and cirrhosis), thrombocytopenia, and medications (anticoagulants and antiplatelets), each cohort included 7,460 patients. Patients in the control cohort had a higher proportion of patients with hypertension (80% vs. 78.5%, p\u0026thinsp;=\u0026thinsp;0.03) compared to the CKD cohort. In contrast, a greater proportion of patients in the CKD cohort were on Rivaroxaban (5.6% vs. 4.6%, p\u0026thinsp;=\u0026thinsp;0.01). The remaining variables were balanced between the two groups after PSM. The details of PSM are shown in Supplementary Table\u0026nbsp;2.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePost-polypectomy outcomes after colorectal EMR in CKD\u003c/h3\u003e\n\u003cp\u003eAfter PSM, a total of 410 (5.5%) patients in the CKD cohort had PPB after colorectal EMR compared to 301 (4%) patients in the control cohort. The risk of PPB after colorectal EMR was higher in the CKD cohort compared to the control cohort (OR 1.38, 95% CI 1.19\u0026ndash;1.61, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Furthermore, the endoscopic reinterventions for hemostasis (1.5% vs. 1%, OR 1.50, 95% CI 1.11\u0026ndash;2.03, p\u0026thinsp;=\u0026thinsp;0.01), blood transfusion (0.8% vs. 0.4%, OR 2.04, 95% CI 1.30\u0026ndash;3.20, p\u0026thinsp;=\u0026thinsp;0.002), and ICU admission (1.3% vs. 0.6%, OR 2.29, 95% CI 1.57\u0026ndash;3.34, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were higher in the CKD cohort compared to the control cohort (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical outcomes within 30 days of colorectal EMR in CKD compared to matched control group.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCohort\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEvents/Total (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePost-polypectomy bleeding after colorectal EMR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e410/7,460 (5.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.19\u0026ndash;1.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e301/7,460 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEndoscopic reintervention for hemostasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108/7,163 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.11\u0026ndash;2.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73/7,236 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56/6,827 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.30\u0026ndash;3.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29/7,183 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eICU admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85/6,365 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.57\u0026ndash;3.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40/6,803 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eAbbreviations\u003c/b\u003e: CKD: chronic kidney disease, CI: confidence interval, EMR: endoscopic mucosal resection, ICU: intensive care unit, OR: odds ratio.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003ePost-polypectomy outcomes after colorectal EMR in non-advanced CKD\u003c/h3\u003e\n\u003cp\u003eThe non-advanced CKD cohort had higher rates of PPB (4.7% vs. 3.9%, OR 1.21, 95% CI 1.001\u0026ndash;1.46, p\u0026thinsp;=\u0026thinsp;0.049), endoscopic reintervention for hemostasis (1.4% vs. 0.9%, OR 1.47, 95% CI 1.02\u0026ndash;2.11, p\u0026thinsp;=\u0026thinsp;0.04), blood transfusion (1% vs. 0.5%, OR 1.94, 95% CI 1.21\u0026ndash;3.09, p\u0026thinsp;=\u0026thinsp;0.01), and ICU admission (1.7% vs. 0.9%, OR 1.91, 95% CI 1.34\u0026ndash;2.72, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) following colorectal EMR compared to the matched control cohort (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical outcomes within 30 days of colorectal EMR in advanced and non-advanced CKD compared to matched control group.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCohort\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEvents/Total (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eAdvanced CKD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePPB after colorectal EMR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvanced CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e187/2,316 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.43\u0026ndash;2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106/2,316 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEndoscopic reintervention for hemostasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvanced CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48/2,183 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.11\u0026ndash;2.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28/2,247 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvanced CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26/1,977 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.08\u0026ndash;3.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14/2,195 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eICU admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvanced CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32/1,773 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.42-5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14/2,040 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eNon-advanced CKD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePPB after colorectal EMR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-advanced CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e247/5,270 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.001\u0026ndash;1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.049\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e206/5,270 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEndoscopic reintervention for hemostasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-advanced CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73/5,270 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.02\u0026ndash;2.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50/5,270 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-advanced CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52/5,270 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.21\u0026ndash;3.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27/5,270 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eICU admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-advanced CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89/5,270 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.34\u0026ndash;2.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47/5,270 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eAbbreviations\u003c/b\u003e: CKD: chronic kidney disease CI: confidence interval, EMR: endoscopic mucosal resection, ICU: intensive care unit, OR: odds ratio, PPB: post-polypectomy bleeding.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePost-polypectomy outcomes after colorectal EMR in advanced CKD\u003c/h2\u003e \u003cp\u003eThe advanced CKD cohort had significantly higher rates of PPB (8.1% vs. 4.6%, OR 1.83, 95% CI 1.43\u0026ndash;2.34, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), endoscopic reintervention for hemostasis (2.2% vs. 1.2%, OR 1.78, 95% CI 1.11\u0026ndash;2.85, p\u0026thinsp;=\u0026thinsp;0.02), blood transfusion (1.3% vs. 0.6%, OR 2.08, 95% CI 1.08\u0026ndash;3.99, p\u0026thinsp;=\u0026thinsp;0.03), and ICU admission (1.8% vs. 0.7%, OR 2.66, 95% CI 1.42-5.00, p\u0026thinsp;=\u0026thinsp;0.002) following colorectal EMR compared to the matched control cohort (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur findings suggest that patients with CKD are at an increased risk of PPB following colorectal EMR compared to those without CKD, but the absolute risk was low. This increased risk is associated with a greater need for endoscopic interventions to control bleeding, along with increased rates of blood transfusions and ICU admissions. The risk of PPB was particularly pronounced in patients with advanced CKD, whereas those with non-advanced CKD experienced a more modest increase in risk compared to the matched control group.\u003c/p\u003e \u003cp\u003eCKD, especially advanced CKD and ESRD, has been identified as an independent risk factor for bleeding in several population studies\u003csup\u003e\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. The increased risk of PPB associated with CKD is likely multifactorial including impaired platelet function\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e and presence of albuminuria\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Additionally, the uremic environment resulting from declining kidney function, along with changes in the gut microbiome observed in CKD, may contribute to this risk\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA recent retrospective study noted immediate PPB and delayed bleeding in 26.1% and 2.2% of patients with end-stage renal disease, respectively\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Data from a large retrospective cohort study examining colonoscopy with any polypectomy demonstrated that the risk of significant immediate PPB in patients with ESRD is higher than non-ESRD patients (4.94% vs. 1.36%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); however, the rate of delayed PPB was similar (0.64% vs. 0.40%, p\u0026thinsp;=\u0026thinsp;0.08)\u003csup\u003e26\u003c/sup\u003e. Similarly, patients with advanced CKD and ESRD undergoing endoscopic submucosal resection for gastric neoplasms had a higher risk of bleeding and longer hospital stay than non-CKD patients. Despite this higher risk of bleeding, patients with ESRD were observed to respond to endoscopic hemostatic interventions similarly to a control group (OR 6.1, 95% CI 2.7\u0026ndash;13.6, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003csup\u003e13\u003c/sup\u003e. A study of colorectal endoscopic submucosal dissection included 118 patients with CKD stage\u0026thinsp;\u0026ge;\u0026thinsp;3 and demonstrated lower en bloc resection rates with advancing kidney disease; however, complications including bleeding and perforation were not different between groups. Due to a small number of patients with CKD stages 4 and 5, predictive modeling was performed, which did not show changes in complications based on decreasing glomerular filtration rates\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Our study findings indicate that patients with CKD, particularly those with advanced stages, have an increased risk of PPB, aligning with previous studies\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study has some limitations. By utilizing a large, deidentified database, we were unable to identify the size of lesion for which patient underwent EMR, the use of electrocautery, and if prophylactic closure was performed. Clip closure of large polyp EMR defects removed with electrocautery proximal to the splenic flexure has been shown to reduce the risk of delayed bleeding\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. There may also be variability amongst endoscopists in clip closure\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. The technique used for EMR also influences post-polypectomy bleeding risk. Two randomized controlled trials have found that cold EMR significantly lowered post-procedure bleeding compared to hot EMR, though it increased the risk of polyp recurrence\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. In select patients with advanced CKD, cold EMR may be preferred to minimize bleeding risk, accepting a higher risk of residual or recurrent polyp\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Additionally, as a retrospective cohort design, despite one-to-one PSM, this study is subject to selection and confounding biases. A dedicated ICD-10 code for PPB after EMR is not available. We defined PPB following EMR as lower gastrointestinal bleeding recorded with ICD-10 codes occurring within 30 days of colorectal EMR, but this bleeding may not always be attributable to EMR. We also could not capture the timing of anticoagulant and antiplatelet discontinuation before the procedure or their resumption afterward, which could influence PPB risk following EMR. However, we assume that most patients adhered to standard guidelines for discontinuing these medications, given that EMR is an elective procedure\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. As with any database study, there are inherent concerns regarding potential misdiagnosis, underreporting of certain variables, and inaccuracies in diagnosis entry. There may be under-reporting of complications if patients received care outside any of the health networks participating in the TriNetX, particularly for post-procedure complications.\u003c/p\u003e \u003cp\u003eDespite its limitations, our study has several notable strengths. It is a large-scale, multicenter, U.S.-based population study involving a diverse cohort, which improves the generalizability of our findings. To our knowledge, this is the first study to provide a comparative analysis of PPB risk in patients with CKD undergoing colorectal EMR in comparison to a matched control group. We employed rigorous one-to-one PSM, carefully balancing relevant comorbidities, demographic factors, and the use of anticoagulants and antiplatelet agents between the cohorts. These efforts enhance the robustness of our findings, which provide valuable insights to inform clinical decision-making and serve as a foundation for future research on the safety of EMR in patients with CKD.\u003c/p\u003e \u003cp\u003eIn conclusion, patients with CKD exhibited an increased risk of post-polypectomy bleeding following colorectal EMR compared to controls, although the absolute risk remained low. The risk was notably increased in patients with advanced CKD. Optimizing patients with CKD, especially advanced CKD, prior to colorectal EMR and monitoring for post-procedure bleeding remains important. Further prospective studies are needed to confirm these findings, explore the benefits of prophylactic lesion closure, and assess the potential use of cold resection in this select population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFNP:\u003c/strong\u003e Travel Support - Boston Scientific\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDKR:\u003c/strong\u003e Consultant- Olympus Corporation, Boston Scientific, Braintree Laboratories, Norgine, Medtronic, Acacia Pharmaceuticals; Research Support - Olympus Corporation, Medivators, Erbe USA Inc, Braintree Laboratories; Shareholder - Satisfai Health\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJJG:\u003c/strong\u003e Travel Support - Boston Scientific Corporation, Olympus Corporation, Ovesco Endoscopy AG\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOther authors:\u003c/strong\u003e no disclosures\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions: Conceptualization and design:\u003c/strong\u003e AB, JJG. \u003cstrong\u003eManuscript drafting:\u003c/strong\u003e AB, KE, FP, DR, KS, and JJG. \u003cstrong\u003eData collection:\u003c/strong\u003e AB, KE, and IB. \u003cstrong\u003eStatistical analysis:\u003c/strong\u003e AB and KE. \u003cstrong\u003eTables:\u003c/strong\u003e DR, AC, and AB. \u003cstrong\u003eCritical revision of manuscript:\u003c/strong\u003e ST, KS, DS, DKR, IB, and JJG\u003cstrong\u003e. Guarantor of article:\u003c/strong\u003e JG. \u003cstrong\u003eFinal review and approval of the manuscript:\u003c/strong\u003e All authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSiegel RL, Wagle NS, Cercek A, Smith RA, Jemal A. Colorectal cancer statistics, 2023. \u003cem\u003eCA Cancer J Clin\u003c/em\u003e. May-Jun 2023;73(3):233-254. doi:10.3322/caac.21772\u003c/li\u003e\n\u003cli\u003eBrenner H, Stock C, Hoffmeister M. Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies. \u003cem\u003eBmj\u003c/em\u003e. Apr 9 2014;348:g2467. doi:10.1136/bmj.g2467\u003c/li\u003e\n\u003cli\u003eZauber AG, Winawer SJ, O\u0026apos;Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. \u003cem\u003eN Engl J Med\u003c/em\u003e. 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Oct 2020;35(10):1704-1711. doi:10.1111/jgh.14969\u003c/li\u003e\n\u003cli\u003ePohl H, Grimm IS, Moyer MT, et al. Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial. \u003cem\u003eGastroenterology\u003c/em\u003e. Oct 2019;157(4):977-984.e3. doi:10.1053/j.gastro.2019.03.019\u003c/li\u003e\n\u003cli\u003eStark EM, Lahr RE, Shultz J, Vemulapalli KC, Guardiola J, Rex DK. Audit of hemostatic clip use after colorectal polyp resection in an academic endoscopy unit. \u003cem\u003eeio\u003c/em\u003e. // (AAM)doi:10.1055/a-2284-9739\u003c/li\u003e\n\u003cli\u003eSteinbr\u0026uuml;ck I, Ebigbo A, Kuellmer A, et al. Cold versus Hot Snare Endoscopic Resection of Large Non-Pedunculated Colorectal Polyps (Randomized-controlled German CHRONICLE-trial). \u003cem\u003eGastroenterology\u003c/em\u003e. May 23 2024;doi:10.1053/j.gastro.2024.05.013\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Sullivan T, Cronin O, van Hattem WA, et al. Cold versus hot snare endoscopic mucosal resection for large (\u0026ge;15 mm) flat non-pedunculated colorectal polyps: a randomised controlled trial. \u003cem\u003eGut\u003c/em\u003e. Jul 4 2024;doi:10.1136/gutjnl-2024-332807\u003c/li\u003e\n\u003cli\u003eGuardiola JJ, Anderson JC, Kaltenbach T, Pohl H, Rex DK. Cold Snare Resection in the Colorectum: When to Choose it, When to Avoid it, and How to Do it. \u003cem\u003eClin Gastroenterol Hepatol\u003c/em\u003e. Sep 23 2024;doi:10.1016/j.cgh.2024.08.030\u003c/li\u003e\n\u003cli\u003eAbraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. \u003cem\u003eAm J Gastroenterol\u003c/em\u003e. Apr 1 2022;117(4):542-558. doi:10.14309/ajg.0000000000001627\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6398416/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6398416/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eStudies evaluating the risk of post-polypectomy bleeding (PPB) after colorectal endoscopic mucosal resection (EMR) in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) are limited.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study utilized the U.S. Collaborative Network to assess the risk of PPB after colorectal EMR in patients with CKD compared to controls. Using one-to-one propensity score matching (PSM), the primary outcome measured was PPB within 30 days after colorectal EMR. The PPB risk was further stratified by CKD severity: non-advanced CKD and advanced CKD.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAfter PSM, each cohort included 7,460 patients. Overall, CKD was associated with increased risk of PPB following colorectal EMR (5.5% vs. 4%, odds ratio [OR] 1.38, 95% confidence interval [CI] 1.19\u0026ndash;1.61, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The PPB risk was significantly higher in patients with advanced CKD (8.1% vs, 4.6%, OR 1.83, 95% CI 1.43\u0026ndash;2.34, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while those with non-advanced CKD showed modest increase in risk of PPB (4.7% vs. 3.9%, OR 1.21, 95% CI 1.001\u0026ndash;1.46, p\u0026thinsp;=\u0026thinsp;0.049).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePatients with CKD had higher risk of PPB than patients without CKD, but absolute risk remained low. The PPB risk was notably increased in patients with advanced CKD. Optimizing patients with CKD, especially advanced CKD, before colorectal EMR and monitoring for post-procedure bleeding remains important.\u003c/p\u003e","manuscriptTitle":"Risk of Post-Polypectomy Bleeding After Colorectal Endoscopic Mucosal Resection in Patients with Chronic Kidney Disease: A Propensity-Matched Analysis of the US Collaborative Network","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-25 06:55:45","doi":"10.21203/rs.3.rs-6398416/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-29T03:12:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-28T17:28:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-27T14:00:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-27T09:30:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82349268644584771175200852454397919093","date":"2025-04-19T08:10:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133730334578822772598373768127016690436","date":"2025-04-18T14:33:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210028923556982349399047186576772118058","date":"2025-04-18T09:34:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-18T03:21:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-16T03:59:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-09T09:44:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Digestive Diseases and Sciences","date":"2025-04-08T02:29:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"987ca56e-4a82-45ea-a177-d4c76764d64d","owner":[],"postedDate":"April 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-02T15:58:10+00:00","versionOfRecord":{"articleIdentity":"rs-6398416","link":"https://doi.org/10.1007/s10620-025-09122-8","journal":{"identity":"digestive-diseases-and-sciences","isVorOnly":false,"title":"Digestive Diseases and Sciences"},"publishedOn":"2025-06-01 15:56:53","publishedOnDateReadable":"June 1st, 2025"},"versionCreatedAt":"2025-04-25 06:55:45","video":"","vorDoi":"10.1007/s10620-025-09122-8","vorDoiUrl":"https://doi.org/10.1007/s10620-025-09122-8","workflowStages":[]},"version":"v1","identity":"rs-6398416","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6398416","identity":"rs-6398416","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}