The Influence of End-Stage Renal Disease on Crohn's Disease Hospitalizations: A Comparative Analysis in the United States

Introduction: End-stage renal disease (ESRD), the final stage of chronic kidney disease (CKD) necessitating renal replacement therapy, is a growing public health problem placing major socio-economic burden on the health system. The incidence of ESRD in patients with Crohn’s disease (CD) is reported to be roughly 5 times higher than controls. This is attributed to systemic inflammation, autoimmune susceptibility, and metabolic and nutritional disorders due to chronic intestinal inflammation. We aim to look at outcomes of ESRD in patients with CD hospitalized in the US. Methods: The National Inpatient Sample was used to identify all adult hospitalizations for patients with CD in the US between 2016-2020. The study population was divided into 2 groups based on the presence or absence of ESRD to compare hospitalization characteristics and outcomes. P-values < 0.05 were statistically significant. Results: There were 696,445 hospitalizations for CD between 2016-2020, of which 2,965 had ESRD (0.42%). Three-quarters of the hospitalizations were at urban teaching centers. CD hospitalizations with ESRD had a higher mean age (61.3 vs 47.6 years, P< 0.001). This subgroup also had a significantly higher proportion of Blacks (25.7% vs 12.8%, P< 0.001). They had higher utilization of Medicare (75.9% vs 32.8%, P< 0.001), longer length of stay [LOS] (5.39 vs 4.34 days, P< 0.001), and higher mean total healthcare charges (THC) ($74,110 vs $44,776, P< 0.001). The ESRD subgroup had significantly higher mortality (1.7% vs 0.2%, P< 0.001), with significantly higher rates of comorbidities such as hypertension, COPD, diabetes mellitus, and coronary artery disease. Furthermore, this subgroup had higher rates of blood transfusion (9.1% vs 3.3%, P< 0.001) and shock (3.5% vs 1.9%, P=0.03). Hospitalizations in patients with CD and ESRD had lower intestinal adhesion rates than those without ESRD (4% vs 1.9%, P=0.027). On adjusting for age, sex, payer, race, hospital bed size and teaching status, prolonged LOS, and above-mentioned comorbidities, CD hospitalizations with ESRD had higher mortality than those without ESRD (OR 5.42, 95% CI 2.23-9.17) (Figure 1, Table 1). Conclusion: Hospitalized patients with CD and ESRD had higher rates of co-morbidities, mortality, LOS, and THC than those without ESRD. This subgroup also tended to have higher mean age and proportion of Blacks. Though there was no significant difference in the rates of intestinal obstruction between the 2 groups, CD hospitalizations with ESRD had higher odds of mortality.Figure 1.: Racial distribution for hospitalizations with Crohn’s disease, with and without end-stage renal disease in the United States from 2016-2020. Table 1. - Comparative analysis of hospitalization characteristics and clinical outcomes for hospitalizations with Crohn’s disease, with and without end-stage renal disease, in the United States between 2016-2020 Variable Hospitalizations for Crohn’s disease with ESRD Hospitalizations for Crohn’s disease without ESRD P-value Total hospitalizations 2,965 696,445 Mean Age (years) 63.3 47.6 < 0.001 Female 52.3% 57.1% 0.052 Race Black 25.7% 12.8% < 0.001 White 65.3% 77.8% 0.02 Medicare 75.9% 32.8% < 0.001 Urban teaching hospital 75.9% 73.6% 0.627 Mean length of stay (days) 5.4 (95% CI 4.76-6.02) 4.34 (95% CI 4.31-4.38) < 0.001 Mean total hospital charges (USD) 74,110 (95% CI 61,926-86,293) 44,776 (95% CI 44094-45,458) < 0.001 Hypertension 75.4% 73.6% < 0.001 COPD 14% 8.4% < 0.001 Diabetes mellitus 31.2% 11.9% < 0.001 Coronary artery disease 25.3% 9% < 0.001 Ano-rectal abscess 0.8% 1.9% 0.4 Rectal hemorrhage 0.2% 0.5% 0.17 Intestinal obstruction 3% 5% 0.083 Sepsis 5.2% 4.7% 0.619 Shock 3.5% 1.9 0.030 PE 2.2% 1.8% 0.72 Blood transfusion 9.1% 3.3% < 0.001 Malnutrition 6.6% 5.1% 0.03 Diverting colectomy 0.2% 0.7% 0.441 Total colectomy 0.5% 0.9% 0.728 Intestinal fistula 0.2% 0.7% 0.614 Intestinal adhesions 1.9% 4% 0.027