Hepatocellular carcinoma in hemodialysis patients

Prevalence of Hepatitis B Virus, Hepatitis C Virus, and HIV Infections in Hemodialysis Patients at Kano Kidney Center

Background Hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections are more prevalent in hemodialysis patients compared to the general population. The objective of this study was to evaluate the prevalence of HBV, HCV, and HIV infections in hemodialysis patients dialyzing regularly at Kano Kidney Center (KKC) in the Eastern Health Cluster of Saudi Arabia in 2022. Methods This retrospective study included all hemodialysis patients who were dialyzed regularly at KKC during 2022. Their electronic medical records were reviewed for the results of HBV, HCV, and HIV along with the patient's demographics, comorbid conditions, and dialysis history. The study was approved and monitored by the Institutional Review Board of Dammam Medical Complex. Results A total of 239 regular hemodialysis patients were included, consisting of 142 males and 97 females (59.41% and 40.59%, respectively), with a mean age of 52.71±15.83 years. Most of the patients were Saudis (156 patients, 65.27%) with the non-Saudi patients being composed mostly of Arabian patients. Nine patients (3.77%) tested positive for hepatitis B surface antigen (HBsAg), the serologic hallmark of HBV infection. Two patients (0.84%) had resolved HBV infections as evidenced by positive hepatitis B core antibody (anti-HBc) and hepatitis B surface antibody (anti-HBs). However, the majority (226 patients, 94.56%) were never tested for anti-HBc. Anti-HBs, which can imply long-term immunity against HBV from prior immunizations or infections, were positive in 165 patients (69.04%). A protective anti-HBs level of ≥ 10 IU/L was detected in 158 patients (66.11%) including 104 patients (43.51%) having ≥ 100 IU/L. Eighteen patients (7.53%) had reactive HCV antibodies. Four patients (1.67%) had chronic HCV infection as they had detectable HCV RNA. The remaining 14 patients (5.86%) cleared HCV either spontaneously (seven patients, 2.93%) or by medications (seven patients, 2.93%). HIV screening tests were negative in all 239 patients (100%). HBsAg-positive patients did not have any statistically significant differences from HBsAg-negative patients. On the other hand, the patients who were positive for HCV antibodies were older than the patients who were negative for HCV antibodies (60.66 vs 52.05 years on average, p-value <0.05). They also contained a statistically larger proportion of non-Saudi patients than the patients with no evidence of prior infections (61.11% vs 32.13%, p-value <0.05). Conclusions The study found that the prevalence of HBV and HCV infections among hemodialysis patients in KKC at 3.77% and 1.67%, respectively, is higher than that reported in the general population in Saudi Arabia, with non-Saudis having a higher prevalence rate of HCV infection than Saudis. However, the current prevalence rate is lower compared to the previous studies that were conducted in Saudi Arabia in the first decade of the 21st century, and there were no cases of HIV infections. Nevertheless, a significant proportion of patients had unprotective or negative anti-HBs antibody titers, indicating the need for strict vaccination protocols and monitoring of antibody titers to ensure optimal protection.

Nomogram to Predict the Long-Term Overall Survival of Early-Stage Hepatocellular Carcinoma after Radiofrequency Ablation

Our objective was to develop a predictive nomogram that could estimate the long-term survival of patients with very early/early-stage hepatocellular carcinoma (HCC) undergoing radiofrequency ablation (RFA). For this retrospective study, we enrolled 950 patients who initially received curative RFA for HCC at Barcelona Clinic Liver Cancer (BCLC) stages 0 and A between 2002 and 2016. Factors predicting poor survival after RFA were investigated through a Cox proportional hazard model. The nomogram was constructed using the investigated variables influencing overall survival (OS). After a median follow-up time of 6.25 years, 400 patients had died, and 17 patients had received liver transplantation. The 1-,3-,5-,7-, and 10-year OS rates were 94.5%, 73.5%, 57.9%, 45.7%, and 35.8%, respectively. Multivariate analysis showed that age greater than 65 years, albumin-bilirubin (ALBI) grades 2 and 3, AST-to-platelet ratio index (APRI) greater than 1, tumor size larger than 3 cm, diabetes mellitus, end-stage renal disease, and tumor number greater than 1 were significantly associated with poor OS. The nomogram was constructed using these seven variables. The validation results showed a good concordance index of 0.683. When comparing discriminative ability to tumor, node, and metastasis (TNM), BCLC, and Cancer of the Liver Italian Program (CLIP) staging systems, our nomogram had the highest C-index for predicting mortality. This nomogram provides useful information on prognosis post-RFA as a primary treatment and aids physicians in decision-making.

Outcomes of Geriatric Patients with Hepatocellular Carcinoma

Background: The treatment modalities and outcomes of geriatric patients with hepatocellular carcinoma (HCC) remain controversial. This retrospective observational cohort study compared the outcomes of HCC between geriatric and younger patients. Methods: The medical records of patients with HCC managed between January 2001 and December 2017 were retrieved from the Chang Gung Memorial Hospital Research Database. Patients were stratified by age into two groups: a geriatric group (65−75 years) and a younger group (<65 years). The two groups were matched through 1:2 propensity score matching (PSM) according to sex, cardiovascular disease, cerebrovascular attack, diabetes mellitus, cirrhosis, hepatitis, and hypertension. Results: Of the 11,033 patients with HCC, 2147 patients aged 65−75 years and 4294 patients aged <65 years were identified after 1:2 PSM. The Kaplan−Meier model revealed that the HCC outcomes in patients older than 65 years were not significantly different after 3 years (p = 0.060). Consistent results were also obtained when the laboratory data associated with HCC incidence were included in the Fine−Gray competing risk model after 1:2 PSM (p = 0.1695). The major risk factors for HCC survival were systemic immune-inflammation index (SII) ≥ 610 × 109 cells/L, advanced tumor stage, and model for end-stage liver disease (MELD) score, etc. Conclusion: Age was not an independent factor for mortality in patients with HCC in the first 3 years. Geriatric patients with HCC should be as aggressively managed as younger patients.

An Update on Hepatocellular Carcinoma in Chronic Kidney Disease

Simple Summary

Chronic kidney disease is a major public health issue globally and the risk of hepatocellular cancer appears greater in patients with chronic kidney disease compared with the general population. Non-alcoholic fatty liver disease is a liver disorder ranging from simple fatty infiltration to advanced fibrosis plus inflammation; it plays a role in developing liver-related and extra liver-related diseases including HCC and CKD, respectively. Approximately 90% of HCCs are associated with a known underlying etiology; viral hepatitis is a well-known cause of HCC, particularly in CKD population. Antiviral therapy of HBV and HCV is important in the management of HCC in CKD patients. Therapy of HCC in CKD patients includes liver transplant (in selected patients), local approach (surgery or interventional radiology), and tyrosine kinase inhibitors (advanced HCC).

Abstract

Chronic kidney disease is a major public health issue globally and the risk of cancer (including HCC) is greater in patients on long-term dialysis and kidney transplant compared with the general population. According to an international study on 831,804 patients on long-term dialysis, the standardized incidence ratio for liver cancer was 1.2 (95% CI, 1.0–1.4) and 1.5 (95% CI, 1.3–1.7) in European and USA cohorts, respectively. It appears that important predictors of HCC in dialysis population are hepatotropic viruses (HBV and HCV) and cirrhosis. 1-, 3-, and 5-year survival rates are lower in HCC patients on long-term dialysis than those with HCC and intact kidneys. NAFLD is a metabolic disease with increasing prevalence worldwide and recent evidence shows that it is an important cause of liver-related and extra liver-related diseases (including HCC and CKD, respectively). Some longitudinal studies have shown that patients with chronic hepatitis B are aging and the frequency of comorbidities (such as HCC and CKD) is increasing over time in these patients; it has been suggested to connect these patients to an appropriate care earlier. Antiviral therapy of HBV and HCV plays a pivotal role in the management of HCC in CKD and some combinations of DAAs (elbasvir/grazoprevir, glecaprevir/pibrentasvir, sofosbuvir-based regimens) are now available for HCV positive patients and advanced chronic kidney disease. The interventional management of HCC includes liver resection. Some ablative techniques have been suggested for HCC in CKD patients who are not appropriate candidates to surgery. Transcatheter arterial chemoembolization has been proposed for HCC in patients who are not candidates to liver surgery due to comorbidities. The gold standard for early-stage HCC in patients with chronic liver disease and/or cirrhosis is still liver transplant.

Hepatocellular carcinoma in patients with renal dysfunction: Pathophysiology, prognosis, and treatment challenges

The population of patients with hepatocellular carcinoma (HCC) overlaps to a high degree with those for chronic kidney disease (CKD) and end-stage renal disease (ESRD). The degrees of renal dysfunction vary, from the various stages of CKD to dialysis-dependent ESRD, which often affects the prognosis and treatment choice of patients with HCC. In addition, renal dysfunction makes treatment more difficult and may negatively affect treatment outcomes. This study summarized the possible causes of the high comorbidity of HCC and renal dysfunction. The possible mechanisms of CKD causing HCC involve uremia itself, long-term dialysis status, immunosuppressive agents for postrenal transplant status, and miscellaneous factors such as hormone alterations and dysbiosis. The possible mechanisms of HCC affecting renal function include direct tumor invasion and hepatorenal syndrome. Finally, we categorized the risk factors that could lead to both HCC and CKD into four categories: Environmental toxins, viral hepatitis, metabolic syndrome, and vasoactive factors. Both CKD and ESRD have been reported to negatively affect HCC prognosis, but more research is warranted to confirm this. Furthermore, ESRD status itself ought not to prevent patients receiving aggressive treatments. This study then adopted the well-known Barcelona Clinic Liver Cancer guidelines as a framework to discuss the indicators for each stage of HCC treatment, treatment-related adverse renal effects, and concerns that are specific to patients with pre-existing renal dysfunction when undergoing aggressive treatments against CKD and ESRD. Such aggressive treatments include liver resection, simultaneous liver kidney transplantation, radiofrequency ablation, and transarterial chemoembolization. Finally, focusing on patients unable to receive active treatment, this study compiled information on the latest systemic pharmacological therapies, including targeted and immunotherapeutic drugs. Based on available clinical studies and Food and Drug Administration labels, this study details the drug indications, side effects, and dose adjustments for patients with renal dysfunction. It also provides a comprehensive review of information on HCC patients with renal dysfunction from disease onset to treatment.

Short-term Outcomes of Liver Resection in Patients With Hemodialysis

BACKGROUND

The number of patients with hemodialysis is increasing increased yearly. Few reports are available on hepatobiliary and gastrointestinal surgery in these patients.

PATIENTS AND METHODS

A total of 222 patients who underwent partial liver resection or segmentectomy in our hospital between January 2015 and September 2019 were included in this study. Patients were divided into the hemodialysis group (n=9) and non-hemodialysis group (n=213).

RESULTS

No significant difference was observed in postoperative complications between the hemodialysis and non-hemodialysis group. The hemodialysis group had a significantly higher infectious complication rates than the non-hemodialysis group (33.3% vs. 8.0%, p=0.009). In logistic regression analysis, hemodialysis was only a significant risk factor for postoperative infectious complications (OR=5.61, 95% CI=1.12-28.20, p=0.036).

CONCLUSION

Liver resections, at least segmentectomy or smaller, is acceptable in patients on hemodialysis. However, these patients may have a higher risk of postoperative infectious complications than other patients.

Differences between exhausted CD8+ T cells in hepatocellular carcinoma patients with and without uremia

The purpose of this study was to explore the differences between exhausted CD8+ T cells in hepatocellular carcinoma (HCC) patients with and without uremia. We enrolled 45 uremic patients who were recently diagnosed with HCC into the HCC + uremia cohort and similar patients with HCC but without uremia into the HCC-only cohort. Lymphocytes were obtained from the two cohorts, and exhausted CD8+ T cells, comprising PD-1+CD8+, TIM-3+CD8+, and LAG-3+CD8+ T cells, were sorted and expanded in vitro. After expansion, the proportions of PD-1+CD8+, TIM-3+CD8+, and LAG-3+CD8+ T cells were significantly higher in the HCC-only cohort than in the HCC + uremia cohort. CD8+ T cells expressing PD-1, TIM-3, or LAG-3 showed increased tumor reactivity and release of interferon-γ in vitro; however, these cells demonstrated weaker anti-tumor activity in HCC + uremia patients than in HCC-only patients. Among the expanded lymphocytes, only the decreased proportion of PD-1+CD8+ T cells significantly correlated with the HCC + uremia cohort (odds ratio of 2.731, p = 0.009). We concluded that peripheral CD8+ T cells expressing PD-1, TIM-3, or LAG-3 from the HCC + uremia cohort were dysfunctional in vitro. Among these populations, PD-1+CD8+ T cells were most evident in HCC patients with uremia.

Sofosbuvir and Velpatasvir combination is safe and effective in treating chronic hepatitis C in end-stage renal disease on maintenance haemodialysis

BACKGROUND & AIMS

There is emerging data on the use of Sofosbuvir-based directly acting antiviral (DAA) drug regimens in chronic hepatitis C (CHC) patients with end-stage renal disease (ESRD) on maintenance haemodialysis (MHD). We evaluated the safety and efficacy of Sofosbuvir plus Velpatasvir fixed-dose combination in CHC patients with ESRD on MHD.

METHODS

Fifty-one CHC patients with ESRD on MHD were included in a real-life prospective study. All patients irrespective of genotype; presence of cirrhosis; treatment naive or experienced status were treated with full-dose Sofosbuvir (400 mg) plus Velpatasvir (100 mg) fixed-dosed combination given daily for 12 weeks. The efficacy was assessed by the sustained virological response (SVR12) with negative HCV RNA 12 weeks after the end of treatment (ETR). Side effects if any were recorded in all patients.

RESULTS

The median HCV RNA level in 51 CHC patients [Males 41 (80.4%), mean age 42.8 ± 14.6 years] was 2.0 × 10⁶ IU/mL. HCV genotype was available in 19 patients with predominant genotype 1 in 15 (79%) patients. Ten (19.6%) patients had evidence of cirrhosis (defined as LSM ≥ 12.5 kPa on Transient Elastography), and 8 (15.6%) patients were treatment experienced. Testing for ETR was done in 36 patients and all 36 (100%) patients achieved ETR, and 49 patients (96%) achieved SVR 12. All 51 patients tolerated the Sofosbuvir + Velpatasvir combination, with none of the patients reporting any serious adverse event.

CONCLUSION

Sofosbuvir plus Velpatasvir fixed-dose combination is safe and effective in treating CHC in patients with ESRD on MHD.

Predicting outcomes for recurrent hepatocellular carcinoma within Milan criteria after complete radiofrequency ablation

BACKGROUND

Intrahepatic distant recurrence (IDR) is a significant problem for patients who have undergone radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC). The objective of the study was to investigate risk factors and to predict outcomes of recurrent IDR within Milan criteria after complete RFA for primary early-stage HCC.

METHOD

This retrospective study reviewed 449 patients with intrahepatic distant recurrent HCC after complete RFA for early-stage HCC. After excluding 100 patients who were beyond Milan criteria, with incomplete lab data, or had follow-up less than three months, a total of 349 patient cases were compiled and their baseline characteristics, further treatment modalities after tumor recurrence and survival were analyzed.

RESULTS

After a median follow-up of 36.2 months, 92 patients had expired. The majority of patients were male (59.9%) with a median age of 64.3 years (range:38-88). The cumulative 5-year overall survival (OS) rates after treatment for recurrent HCC was 67.2%. On multivariate analysis, end-stage renal disease(Hazard ratio (H.R.) = 2.33, p = 0.021), m-ALBI grade 2a (H.R. = 2.86, p = 0.003) and m-ALBI grades 2b or 3 (H.R. = 2.30, p = 0.009), APRI greater than 1 (H.R. = 1.92, p = 0.036) and 2nd recurrence occurring within 1 year (H.R. = 2.69, p<0.001) were significantly associated with worse survival. The cumulative 5-year 2nd recurrence rate was 87.4%. On multivariate analysis, male gender (H.R. = 1.47, p = 0.01), age greater than 65 years (H.R. = 1.72, p<0.001), an alpha fetoprotein level greater than 20ng/ml (H.R. = 1.41, p = 0.016), surgical treatment for recurrent HCC (H.R. = 0.25, p = 0.007), tumor number greater than 1 (H.R. = 1.35, p = 0.046), and IDR developing within 2 years (H.R. = 1.67, p = 0.001) were prognostic factors for 2nd recurrence.

CONCLUSION

Our study suggested that presence of end-stage renal disease, m-ALBI grades 2 and 3, APRI >1 and time to 2nd HCC recurrence were all associated with overall survival while the 2nd HCC recurrence was associated with male gender, age ≥65 years, α-fetoprotein level >20 ng/mL, non-surgical therapy, time to IDR, and tumor number> 1.

Association between Ambient Particulate Matter 2.5 Exposure and Mortality in Patients with Hepatocellular Carcinoma

Air pollution is a severe public health problem in Taiwan. Moreover, Taiwan is an endemic area for hepatocellular carcinoma (HCC). This study examined the effect of particulate matter 2.5 (PM_2.5) exposure on mortality in this population. A total of 1003 patients with HCC treated at Chang Gung Memorial Hospital between 2000 and 2009 were included in this study. At the end of the analysis, 288 (28.7%) patients had died. Patients with HCC living in environments with PM_2.5 concentrations of ≥36 µg/m³ had a higher mortality rate than patients living in environments with PM_2.5 concentrations of <36 µg/m³ (36.8% versus 27.5%, p = 0.034). The multivariate Cox regression analysis confirmed that PM_2.5 ≥ 36 µg/m³ was a significant risk factor for mortality (1.584 (1.162–2.160), p = 0.004). A nonlinear relationship was observed between the odds ratio and PM_2.5. The odds ratio was 1.137 (1.015–1.264) for each increment of 5 µg/m³ in PM_2.5 or 1.292 (1.030–1.598) for each increment of 10 µg/m³ in PM_2.5. Therefore, patients with HCC exposed to ambient PM_2.5 concentrations of ≥36 µg/m³ had a 1.584-fold higher risk of death than those exposed to PM_2.5 concentrations of <36 µg/m³. Further studies are warranted.

Pretreatment Inflammation-Based Markers Predict Survival Outcomes in Patients with Early Stage Hepatocellular Carcinoma After Radiofrequency Ablation

The prognostic significance of various systemic inflammation‐based markers has been explored in different cancers after surgery. This study aimed to investigate whether these markers could predict outcomes in patients with early-stage hepatocellular carcinoma (HCC) undergoing radiofrequency ablation (RFA). One hundred eighteen patients with newly diagnosed HCC within the Milan criteria receiving RFA as initial therapy were retrospectively enrolled. Pretreatment inflammation-based markers including the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) and prognostic nutritional index (PNI), together with other clinicopathologic parameters were collected. Cumulative overall survival (OS) and recurrence-free survival (RFS) were estimated by the Kaplan-Meier method and by multivariate analysis using Cox proportional hazard model. The 1-, 3-, and 5-year OS rates of patients were 90%, 67%, and 52%, respectively. Kaplan-Meier curves showed that baseline high NLR ≥ 2.5 (p = 0.006), low PNI < 40 (p = 0.005), history of end-stage renal disease (ESRD) (p = 0.005), non-Child-Pugh class A (p = 0.001) and elevated alpha-fetoprotein (AFP) ≥ 200 ng/mL (p = 0.005) significantly associated with the poor OS, whereas high PLR ≥ 100 did not. By multivariate analysis, high NLR ≥ 2.5 (hazard ratio (HR) 1.94; 95% confidence interval (CI), 1.05–3.59; p = 0.034), low PNI < 40 (HR 0.38; 95% CI, 0.20–0.72; p = 0.003), ESRD history (HR 3.60; 95% CI, 1.48–8.76; p = 0.005) and elevated AFP ≥ 200 ng/mL (HR 4.61; 95% CI, 1.75–12.13; p = 0.002) were independent factors. An elevated AFP level of ≥200 ng/mL was the significant factor associated with intrahepatic new RFS by univariate and multivariate analyses. In conclusion, pretreatment NLR and PNI are simple and useful predictors for OS in patients with early-stage HCC after RFA.