Trends in Outcomes and Hospitalization of Gastrointestinal Bleeding in Patients with Myeloproliferative Neoplasms- an Analysis of the National Inpatient Sample (NIS) (2016-2020)

Introduction

Patients with Myeloproliferative Neoplasms (MPN), including primary myelofibrosis (PMF), essential thrombocytosis (ET), or polycythemia vera (PV) are at increased risk of thromboembolic events. However, they can still manifest with bleeding events, usually due to disease-related complications or the administration of anti-platelet (APT) and anti-coagulation (AC) therapies. Acquired von Willebrand disease and platelet dysfunction commonly represent the underlying pathophysiological mechanisms. Gastrointestinal bleeding (GIB), postoperative bleeding, and intracranial hemorrhages are the most common sites of bleeding. There is limited data regarding mortality-associated risk factors and associated comorbidities in patients with MPN who present with GIB. This study identifies hospitalization trends and factors contributing to mortality in this population.

Methods

We conducted a retrospective study utilizing National Inpatient Sample data from 2016 to 2020. Using the International Classification of Diseases, 10th revision codes, we identified patients 18 years or older admitted with GIB and a history of MPN. The cohort was divided into patients with MPN with GIB and without GIB. The primary outcome was mortality. Baseline characteristics were identified and compared between the two groups. Analysis was performed with STATA. T-test and Chi-square test were used for categorical variables. Logistic regression was used to identify mortality-associated risk factors.

Results

Of 71130 patients who met the inclusion criteria, 11456 (15.6%) had concomitant GIB. The mean age at admission was 68 years, with a length of stay (LOS) of 5.18 days in patients with GIB vs. 7.84 days for those without GIB. Mortality among patients with MPN and GIB was 2.53%. Significant differences were observed in patients with MPN who had a GIB vs. those with MPN who did not have a concomitant GIB. They had higher rates of chronic kidney disease (CKD) (14.93% vs. 12.66%, p=0.0015) and acute kidney injury (AKI) (24.31% vs. 21.51%, p=0.0017), hypertension (40.81% vs. 36.35%; p=0.0000), CAD (22.04% vs. 18.34%; p=0.0000); and venous thromboembolism (VTE) (4.30% vs. 3.50%;p= 0.02). Patients with GIB also had a lower rate of obesity (10.21% vs. 13.01%; p=0.0001) than patients without GI bleed. Patients on Medicare (65.76% vs. 54.50%, P=0.0000) and of the White race (72% vs. 67.17%, p=0.0000) had higher rates of GI bleed.

Patients with an AKI (OR 3.22, p = 0.0000), malnutrition (OR 1.52, p < 0.05), and a median household income of 26th to 50th percentile for their zip code (OR 2.31, p = 0.02), had increased rates of mortality while patients who were obese (OR 0.15, p = 0.020) and had type 2 diabetes (OR 0.395, p < 0.033) or were black or African-American (0.090; p=0.018) had lower rates of mortality.

Conclusion

Overall, a large proportion of patients with MPN experience gastrointestinal bleeding. Patients with GIB had a higher rate of AKI, CKD, HTN, CAD, and VTE vis-à-vis the comparison group. Patients may have exhibited these higher rates of CAD and VTE, probably due to APT and AC therapies used in the treatment of these conditions, and are inherently associated with a higher risk of bleeding. Patients with comorbidities such as AKI, and malnutrition, and those with a median household income of 26th to 50th percentile showed increased mortality. African-American race and obesity were associated with lower mortality. Optimization of comorbidities, including nutritional status, can improve outcomes. Our findings, though limited to hospitalized patients with GIB and a history of MPN over 5 years, accentuate the need for further studies to evaluate bleeding risk in MPN patients on APT and AC and to understand the cause of GIB to improve outcomes in these patients.