Advanced CKD Increases Risk of ERCP Complications But Not PEP

A recent study published in Surgical Endoscopy is providing clinicians with an overview of endoscopic retrograde cholangiopancreatography (ERCP)-related complications for those with advanced chronic kidney disease (aCKD) as compared to the general population undergoing ERCP1.

Findings from the analysis of deidentified electronic healthcare records from the US Collaborative Network in the TriNetX platform suggest that patients with aCKD have higher rates of ERCP adverse events. While previous studies had reported that patients with end-stage renal disease face an increased risk of post-ERCP pancreatitis (PEP), new data suggests that aCKD patients are not at a greater risk for post-ERCP pancreatitis.2

“This is the largest study to our knowledge investigating ERCP-related adverse events in patients with CKD4, CKD5 and ESRD patients on hemodialysis—collectively referred to as aCKD,” Itegbemie Obaitan, MD, MPH, an assistant professor of clinical medicine in the division of gastroenterology and hepatology at Indiana University School of Medicine, and colleagues wrote.1

The population-based retrospective study included 8900 patients and utilized propensity score matching based on patient demographics, comorbidities, and relevant medications to break the group into 2 cohorts. The aCKD group included 4450 adults ≥18 years of age with CKD stage 4 or 5 or ESRD on dialysis who underwent ERCP. The control group included 4450 adults ≥18 years of age undergoing ERCP without CKD. Investigators noted propensity score matching was successful for all measures except age, with aCKD patients being younger than the control group (64.0 ± 15.0 vs 65.2 ± 14.7; P <.001).

The primary outcomes of interest were the 7-day post-procedure odds of ERCP-related adverse events such as PEP, post-procedural bleeding and intraprocedural perforation, and post-procedural cholangitis.

Upon analysis, investigators found that aCKD patients were at an increased risk for ERCP-related complications such as post-ERCP bleeding (2.9% vs 1.4%) and cholangitis (7.2% vs 4.5%). Perforation was statistically insignificant (0.3% vs 0.2%). Furthermore, aCKD did not indicate a greater risk for previous post-ERCP pancreatitis (4.7% vs 4.4%), contrary to previously recorded data suggesting such a relationship.

Investigators pointed out patients with aCKD recorded increased odds for:

• Bleeding after ERCP (Odds Ratio [OR], 2.1; P <.001)
• Cholangitis (OR, 1.6; P <.001)
• ICU admissions (OR, 2.2; P <.001)
• Intubation within 48 hours (OR, 3.0; P<.001)
• 30-day mortality (OR, 1.8; P <.001)

However, no significance difference was observed for PEP (OR, 1.1; P = .542) or perforation (OR, 1.3; P = .528).

Further analysis revealed the aCKD cohort had significantly greater odds of 7-day all-cause ICU admissions (OR, 2.2; 95% CI, 1.8–2.7; P <.001), intubations within 48 hours of the procedure (OR, 3.0; 95% CI, 1.7–5.3; P <.001), and 30 day all-cause mortality (OR, 1.8; 95% CI, 1.5–2.2; P <.001) following ERCP compared to the matched cohort control.

“In conclusion, aCKD is associated with higher odds of ERCP related adverse events with the notable exception of PEP, which had similar odds to the control cohort, a finding that may change the previous widespread perception of increased PEP risk in this population,” Investigators concluded.1 “Further prospective research is needed to validate our findings.”

References

1. Baydoun H, Beran A, Ramai D, et al. Advanced chronic kidney disease increases the odds of ERCP adverse events but not post-ERCP pancreatitis: a propensity-matched analysis of the US Collaborative Network. Surg Endosc (2025). https://doi.org/10.1007/s00464-025-12323-x

2. Dumonceau JM, Kapral C, Aabakken L, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020. https://doi.org/10.1055/a-1075-4080