title: Renal dysfunction is an independent risk factor for bleeding after gastric ESD.
abstract: OBJECTIVE
  The number of patients with chronic kidney disease (CKD) is increasing worldwide and gastric cancer sometimes occurs with CKD. However, the safety and feasibility of endoscopic submucosal dissection (ESD) for patients with CKD are not clear. The aim of this study is to clarify the feasibility and safety of gastric ESD for patients with CKD.
  
  
  METHODS
  This was a multicenter retrospective cohort study. In total, 144 patients with CKD who underwent gastric ESD between May 2003 and October 2012 were enrolled. The patients were divided into three groups: stage 3 (estimated glomerular filtration rate [eGFR]: 30 - 59 mL/min), stage 4 (eGFR: 15 - 29 mL/min), and stage 5 (eGFR: < 15 mL/min) according to the Kidney Disease Improving Global Outcomes Guidelines. The en bloc and curative resection rates and complications were assessed as short-term outcomes. Overall survival was analyzed using Kaplan - Meier methods.
  
  
  RESULTS
  In total, 92 patients were in stage 3 CKD; 23 in stage 4; and 29 in stage 5, including 19 patients in hemodialysis. The en bloc resection rate was 95.8 %. Post-ESD bleeding was observed in four patients with stage 5 CKD (13.8 %), three with stage 4 (13.0 %), and one with stage 3 (1.1 %). All bleeding could be controlled by endoscopic hemostasis, but five patients required blood transfusion. Perforation occurred in two patients (6.9 %) with stage 5 CKD, none (0 %) with stage 4, and two (4.3 %) with stage 3. Multivariate Poisson regression analysis revealed CKD stage 4 was a critical factor related to bleeding, whereas diabetes mellitus and CKD stage 5, which largely consist of patients receiving hemodialysis, were not. The median observation period of patients who achieved curative resection was 25.9 months (range 0.8-112.7 months) and the 3-year overall survival rate was 92.5 %.
  
  
  CONCLUSIONS
  Estimated GFR is a significant independent predictive factor of post-ESD bleeding in patients with CKD.
authors.affiliation: Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Teppei
authors.initials: T
authors.lastname: Yoshioka
authors.affiliation: Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Tsutomu
authors.initials: T
authors.lastname: Nishida
authors.affiliation: Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Masahiko
authors.initials: M
authors.lastname: Tsujii
authors.affiliation: Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Motohiko
authors.initials: M
authors.lastname: Kato
authors.affiliation: Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Yoshito
authors.initials: Y
authors.lastname: Hayashi
authors.affiliation: Department of Gastroenterology, Osaka Rosai Hospital, Sakai, Japan.
authors.forename: Masato
authors.initials: M
authors.lastname: Komori
authors.affiliation: Department of Gastroenterology, Osaka Rosai Hospital, Sakai, Japan.
authors.forename: Harumasa
authors.initials: H
authors.lastname: Yoshihara
authors.affiliation: Department of Gastroenterology, Kansai Rosai Hospital, Amagasaki, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Nakamura
authors.affiliation: Department of Gastroenterology, Kansai Rosai Hospital, Amagasaki, Japan.
authors.forename: Satoshi
authors.initials: S
authors.lastname: Egawa
authors.affiliation: Department of Gastroenterology, Osaka National Hospital, National Hospital Organization, Osaka, Japan.
authors.forename: Toshiyuki
authors.initials: T
authors.lastname: Yoshio
authors.affiliation: Department of Gastroenterology, Osaka National Hospital, National Hospital Organization, Osaka, Japan.
authors.forename: Takuya
authors.initials: T
authors.lastname: Yamada
authors.affiliation: Department of Gastroenterology, Sakai City Hospital, Sakai, Japan.
authors.forename: Takamasa
authors.initials: T
authors.lastname: Yabuta
authors.affiliation: Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan.
authors.forename: Katsumi
authors.initials: K
authors.lastname: Yamamoto
authors.affiliation: Department of Gastroenterology, Sumitomo Hospital, Osaka, Japan.
authors.forename: Kazuo
authors.initials: K
authors.lastname: Kinoshita
authors.affiliation: Department of Gastroenterology, Osaka Police Hospital, Osaka, Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Kawai
authors.affiliation: Department of Gastroenterology, Itami City Hospital, Itami, Japan.
authors.forename: Hideharu
authors.initials: H
authors.lastname: Ogiyama
authors.affiliation: Department of Gastroenterology, Minoh City Hospital, Minoh, Japan.
authors.forename: Akihiro
authors.initials: A
authors.lastname: Nishihara
authors.affiliation: Department of Gastroenterology, Osaka Kosei-Nenkin Hospital, Osaka, Japan.
authors.forename: Tomoki
authors.initials: T
authors.lastname: Michida
authors.affiliation: Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Hideki
authors.initials: H
authors.lastname: Iijima
authors.affiliation: Department of Clinical Epidermiology, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Ayumi
authors.initials: A
authors.lastname: Shintani
authors.affiliation: Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.
authors.forename: Tetsuo
authors.initials: T
authors.lastname: Takehara