Percutaneous radiofrequency ablation of hepatocellular carcinoma in 14 patients undergoing regular hemodialysis for end-stage renal disease. AJR Am J Roentgenol. 2009;193:964-969. [PMID: 19770317 DOI: 10.2214/ajr.08.2236]

Outcomes of radiofrequency ablation for liver tumors in patients on hemodialysis: Results from the US Nationwide Inpatient Sample 2005-2020

OBJECTIVE

Few studies have examined the outcomes of radiofrequency ablation (RFA) for liver tumors in patients on hemodialysis. This study aimed to investigate short-term outcomes following RFA for liver tumors in patients on hemodialysis.

METHODS

Data of patients ≥ 20 years old diagnosed with liver tumors who underwent RFA were extracted from the Nationwide Inpatient Sample (NIS) database 2005-2020. The study population was divided into two groups: patients on hemodialysis and those not on hemodialysis. Propensity score matching (PSM) was employed to address baseline differences. Associations between hemodialysis and in-hospital outcomes, including prolonged length of stay (LOS), in-hospital mortality, unfavorable discharge, and complications were determined using logistic regression analyses.

RESULTS

After applying the inclusion and exclusion criteria, a total of 12,749 patients constituted the study population, with 550 remaining after 1:4 PSM (110 on hemodialysis and 440 without hemodialysis). After adjustment in the multivariable analyses, patients on maintenance hemodialysis showed significantly higher risks of prolonged LOS (adjusted odds ratio [aOR] = 2.88, 95 % confidence interval [CI]: 1.78-4.65), in-hospital mortality (aOR=31.90, 95 % CI: 17.68-57.58), unfavorable discharge (aOR=3.79, 95 % CI: 2.05-7.01), at least one complications (aOR=3.68, 95 % CI: 2.49-5.44), and greater total hospital costs (adjusted Beta [aBeta] = 126.75, 95 % CI: 113.68-139.82).

CONCLUSIONS

Patients on hemodialysis undergoing RFA for liver tumors have greater risks of adverse short-term outcomes including in-hospital mortality, prolonged LOS, complications, and unfavorable discharge. Careful consideration and close monitoring are warranted for patients on hemodialysis when planning for RFA.3.

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.

Hepatocellular carcinoma in patients with chronic renal disease: Challenges of interventional treatment

Hepatocellular carcinoma (HCC) is a common malignancy worldwide, recognized as the fourth most common cause of cancer related death. Many risk factors, leading to liver cirrhosis and associated HCC, have been recognized, among them viral hepatitis infections play an important role worldwide. Patients suffering from chronic kidney disease (CKD), especially those on maintenance dialysis, show a higher prevalence of viral hepatitis than the general population what increases the risk of HCC onset. In addition, renal dysfunction may have a negative prognostic impact on both immediate and long-term outcomes after malignancy treatment. Several interventional procedures for the treatment of HCC are currently available: thermal ablation, transcatheter arterial chemoembolization, liver surgery or even liver transplantation. The Barcelona Clinic Liver Cancer system provides an evidence-based treatment algorithm to address different categories of patients to the most-effective treatment in consideration of the extension of disease, liver function and performance status. Liver resection and transplantation are usually reserved to patients with early stage HCC and acceptable performance status, while the other treatments are more indicated in case of impaired liver function or locally advanced or unresectable tumors. However, there is no validated treatment algorithm for HCC in CKD patients, mainly due to the rarity of reports in this cohort of patients. Hereby we discuss the available evidences on interventional HCC treatments in CKD patients, and briefly report up-to-date pharmacological therapy for HCC patients affected by viral hepatitis.

Percutaneous Ablation for Hepatocellular Carcinoma and Peritoneal Dialysis

Hepatocellular carcinoma (HCC) is the second leading cause of death by cancer worldwide. Resection and liver transplantation are the gold standards, but only a minority of people are eligible. Percutaneous ablation therapies, such as microwave ablation (MWA), have consequently been developed. There is a lack of guidelines regarding the treatment of HCCs in end-stage renal disease (ESRD) patients. Here, we report the case of a 67-year-old patient who was undergoing peritoneal dialysis (PD) for chronic congestive heart failure and who presented with an HCC while undergoing PD. The tumor size was 48 mm. Due to the patient's comorbidities, MWA was chosen as a first-line treatment. Peritoneal dialysis was stopped 1 day before the MWA, which was performed by an interventional radiology department. There were no complications from the procedure. The treated area completely covered the tumoral lesion. Peritoneal dialysis was resumed 3 weeks after the MWA without any complications. The computed tomography (CT) scan performed 3 months later showed that the tumor mass had completely regressed; a year and a half after the MWA, no recurrence has been observed. This report shows that an MWA of an HCC in PD patients is a feasible and safe procedure.

Mortality and hemorrhagic complications associated with radiofrequency ablation for treatment of hepatocellular carcinoma in patients on hemodialysis for end-stage renal disease: A nationwide survey

BACKGROUND AND AIM

Because of the rarity of invasive treatment for hepatocellular carcinoma (HCC) in patients on hemodialysis (HD) for end-stage renal disease (ESRD), the risks associated with radiofrequency ablation (RFA) in such patients remain uncertain. We used a nationwide database to investigate in-hospital mortality and hemorrhagic complications following RFA in patients on HD for ESRD.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we enrolled patients on HD for ESRD who underwent RFA for HCC. For each patient, we randomly selected up to four non-dialyzed patients using a matched-pair sampling method based on patient age, sex, treatment hospital, and treatment year. In-hospital mortality and hemorrhagic complications were compared between dialyzed and non-dialyzed patients following RFA.

RESULTS

We compared matched-pair samples of 437 dialyzed and 1345 non-dialyzed patients. In patients on HD for ESRD, mortality was significantly lower in those aged ≤70 years than in older patients (P = 0.02). In-hospital mortality was significantly higher in dialyzed ESRD patients than in non-dialyzed patients (1.1% vs 0.15%, respectively; odds ratio = 7.77, P < 0.001). Hemorrhagic complications differed significantly between dialyzed ESRD patients and non-dialyzed patients (3.4% vs 0.87%, respectively; odds ratio = 4.75, P < 0.001).

CONCLUSIONS

In-hospital mortality following RFA was higher in dialyzed ESRD patients than in non-dialyzed patients. The indications for RFA in dialysis-dependent patients should be considered carefully. Patient age may be a useful indicator when considering RFA for HCC in patients on HD for ESRD.

Characteristics and Prognosis of Hepatocellular Carcinoma in Japanese Patients Undergoing Dialysis

Patients with end-stage renal disease who are undergoing dialysis may be at high risk of developing hepatocellular carcinoma (HCC). We investigated the characteristics and prognosis of HCC in patients undergoing dialysis in Japan. Patients characteristics, progression of HCC at diagnosis, and survival rates after diagnosis were compared between 108 HCC patients undergoing dialysis and 526 non-dialysis patients followed up at liver center. The comparisons were also performed after adjusting for patient age, gender, platelet count, and etiology using propensity-score matching. HCC was more advanced in patients undergoing dialysis than in non-dialysis controls. The 3- and 5-year survival rates of patients undergoing dialysis were 56.3% and 38.3%, respectively, which were lower than those of non-dialysis controls (66.5% and 52.7%, respectively, P = 0.0026). The results were the same after propensity score matching (P = 0.0014). In Japan, HCC was more advanced at diagnosis in patients undergoing dialysis in comparison to HCC in patients at liver centers, resulting in a lower survival rate after diagnosis.

Hepatocellular carcinoma in hemodialysis patients

We investigated the rates and predictors of mortality in hepatocellular carcinoma (HCC) patients who were or were not undergoing long-term hemodialysis. The participants in this retrospective observational study were 1298 HCC patients (60.0 ± 12.1 years old, 72% male), of whom 172 were undergoing hemodialysis and 1126 were not. HCC patients on hemodialysis exhibited a higher hepatitis C virus carrier rate (49.4% versus 39.3%, P = 0.012), lower hepatitis B virus carrier rate (37.2% versus 58.3%, P < 0.001) and lower hepatitis B or C virus carrier rate (77.9% versus 89.3%, P < 0.001) than those not on hemodialysis. Serum alkaline phosphatase levels were higher in the hemodialysis than non-hemodialysis group (162.8 ± 141.1 u/l versus 124.6 ± 102.5 u/l, P < 0.001). By the end of the analysis, 32.0% of HCC patients on hemodialysis and 28.0% of those not on hemodialysis had died. Kaplan-Meier analysis confirmed that cumulative survival was poorer in HCC patients on hemodialysis (P = 0.004). In a multivariate Cox regression model, hemodialysis (P < 0.001), older age (P < 0.001) and advanced tumor stages (P < 0.001) were found to be risk factors for mortality. HCC patients on hemodialysis had a 2.036-fold greater chance of death than HCC patients not on hemodialysis. Prospective studies with longer follow-ups and larger samples are warranted.

Clinical features of hemodialysis patients treated for hepatocellular carcinoma: Comparison between resection and radiofrequency ablation

There is no consensus regarding which therapeutic option is better and/or safer for treating hemodialysis (HD) patients with hepatocellular carcinoma (HCC). The present study compared surgical resection (Hx) and radiofrequency ablation (RFA) with regard to therapeutic efficacy in HD patients with HCC. Of 108 HD patients with naïve HCC treated at 15 institutions between 1988 and 2014 enrolled in the present study, 58 fulfilled the up-to-7 criteria [7 as the sum of the size of the largest tumor (cm) and the number of tumors] and were treated with Hx (n=23) or RFA (n=35); their clinical features, complications and prognosis were assessed. The frequency of hepatitis C virus was higher in the RFA group compared with that in the Hx group (P=0.002), whereas there were no differences between the groups with regard to the average time from the first HD (P=0.953), tumor-nodes-metastasis (TNM) stage (Union for International Cancer Control 7th edition) (P=0.588), TNM stage (Liver Cancer Study Group of Japan 5th edition) (P=0.095), Child-Pugh classification (P=0.094), and Japan Integrated Scoring system (P=0.489). There were no significant differences in overall survival (OS) and disease-free survival (DFS) rates between the Hx and RFA groups [1-, 3- and 5-year OS rates: 81.7, 55.6 and 43.3% vs. 89.9, 67.1 and 56.3%, respectively (P=0.454); 1-, 3- and 5-year DFS rates: 71.1, 30.5 and 18.3% vs. 63.8, 31.6 and 21.1%, respectively (P=0.911)] Complications were observed in 4 patients (11.4%) in the RFA group (2 with subcapsular hemorrhage, 1 with intraperitoneal bleeding and 1 with tardive intrahepatic hematoma) and in 4 patients (17.4%) in the Hx group (2 with postoperative infection, 1 with liver failure and 1 with pleural effusion) (P=0.700). In conclusion, Hx and RFA have a similar therapeutic efficacy in HD patients with naïve HCC who fulfilled the up-to-7 criteria.

Impact of renal insufficiency on patients with hepatocellular carcinoma undergoing radiofrequency ablation

BACKGROUND AND AIM

Renal insufficiency (RI) is commonly seen in patients with hepatocellular carcinoma (HCC). We aimed to investigate the impact of RI on the long-term survival of HCC patients undergoing radiofrequency ablation (RFA) and to determine the optimal staging strategy for these patients.

METHODS

RI was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m(2) . A total of 123 and 344 patients with and without RI undergoing RFA, respectively, were enrolled. A one-to-one propensity score matching analysis with preset caliper width was performed. The prognostic ability of four currently used staging systems was compared by the Akaike information criterion (AIC).

RESULTS

HCC patients with RI undergoing RFA were older (P < 0.001) and had significantly different baseline characteristics. Of all patients, RI was significantly associated with a decreased long-term survival (P = 0.03). After matching in the propensity model, the baseline characteristics were similar between patients with (n = 92) and without (n = 92) RI. In the propensity model, RI was not significantly associated with a shortened survival (P = 0.273). In the Cox multivariate analysis, Child-Turcotte-Pugh class B or C was identified as the only independent predictor of poor prognosis. Among patients with RI undergoing RFA, the Taipei Integrated Scoring (TIS) system provided the highest homogeneity and lowest AIC value among the currently used staging systems.

CONCLUSIONS

The long-term survival of HCC patients undergoing RFA is not affected by RI. The TIS staging system may provide a better prognostic prediction for HCC patients with RI undergoing RFA.

Hepatocellular carcinoma in patients with chronic kidney disease

AIM: To investigate outcomes of hepatocellular carcinomas (HCCs) in patients with chronic kidney disease (CKD).

METHODS: Four hundred and forty patients referred between 2000 and 2002 for management of HCCs were categorized according to their CKD stage, i.e., estimated glomerular filtration rate (eGFR) > 90 (stage 1), 60-90 (stage 2), 30-60 (stage 3), 15-30 (stage 4), and < 15 (stage 5) mL/min per 1.73 m², respectively. Demographic, clinical and laboratory data were collected and mortality rates and cause of mortality were analyzed. The mortality data were examined with Kaplan-meier method and the significance was tested using a log-rank test. An initial univariate Cox regression analysis was performed to compare the frequency of possible risk factors associated with mortality. To control for possible confounding factors, a multivariate Cox regression analysis (stepwise backward approach) was performed to analyze those factors that were significant in univariate models (P < 0.05) and met the assumptions of a proportional hazard model.

RESULTS: Most HCC patients with CKD were elderly, with mean age of diagnosis of 60.6 ± 11.9 years, and mostly male (74.8%). Hepatitis B, C and B and C co-infection virus were positive in 61.6%, 45.7% and 14.1% of the patients, respectively. It was found that patients with stages 4 and 5 CKD were not only older (P = 0.001), but also had higher hepatitis C virus carrier rate (P = 0.001), lower serum albumin level (P = 0.001), lower platelet count (P = 0.037), longer prothrombin time (P = 0.001) as well as higher proportions of advanced cirrhosis (P = 0.002) and HCCs (P = 0.001) than patients with stages 1 and 2 CKD. At the end of analysis, 162 (36.9%) patients had died. Kaplan-Meier analysis revealed that patients with stages 4 and 5 CKD suffered lower cumulative survival than stages 1 and 2 CKD (log-rank test, χ² = 11.764, P = 0.003). In a multivariate Cox-regression model, it was confirmed that CKD stage [odds ratio (OR) = 1.988, 95%CI: 1.012-3.906, P = 0.046)], liver cirrhosis stage (OR = 3.571, 95%CI: 1.590-8.000, P = 0.002) and serum albumin level (OR = 0.657, 95%CI: 0.491-0.878, P = 0.005) were significant predictors for mortality in this population.

CONCLUSION: HCC patients with stages 4 and 5 CKD had inferior survival than stages 1 and 2 CKD. This warrants further studies.

Differential prognostic impact of renal insufficiency on patients with hepatocellular carcinoma: a propensity score analysis and staging strategy

BACKGROUND AND AIM

Renal insufficiency (RI) can coexist in patients with hepatocellular carcinoma (HCC). This study analyzed the prognostic impact of RI on patients with HCC and determined the optimal staging strategy for these patients.

METHODS

RI was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m(2). A total of 502 and 1701 HCC patients with and without RI, respectively, were enrolled. One-to-one matched patient cohorts according to treatments were built by using the propensity model. The prognostic ability of the Cancer of the Liver Italian Program, Barcelona Clinic Liver Cancer, Japan Integrated Scoring, and Taipei Integrated Scoring (TIS) systems in HCC patients with RI was compared by using the Akaike information criterion (AIC).

RESULTS

For patients undergoing percutaneous ablation and transarterial chemoembolization (TACE), RI was significantly associated with decreased long-term survival (P = 0.001 and 0.004, respectively). In patients receiving resection and other treatments, there were no significant survival differences between patients with and without RI. With similar demographics generated in the propensity model, significantly decreased survival was found in patients with RI in the TACE group (P = 0.018), but not in the resection, percutaneous ablation, and other treatment groups. Among HCC patients with RI, the TIS system had the lowest AIC value.

CONCLUSIONS

RI is often present in patients with HCC and predicts a poor outcome in patients undergoing TACE. The survival of HCC patients receiving resection, percutaneous ablation, and other treatments is not affected by RI. The TIS staging system is a more feasible prognostic model for HCC patients with RI.

Cancer screening in people who have chronic disease: the example of kidney disease

Cancer screening in people with chronic illness has been the subject of considerable debate recently. Despite the increased incidence of cancer and higher risk of cancer deaths in selected populations, such as those with kidney disease, the benefits-to-harms ratio of cancer screening is uncertain and is likely to be different to people without chronic illnesses because of the expected higher competing risk of death from disease other than cancer, and a higher risk of complications associated with the screening, the diagnostic, and the treatment processes. Using kidney disease as an example, the authors reviewed the current evidence for early cancer detection through screening in people with two or more coexistent chronic diseases, discussed the accepted principles underpinning cancer screening, and the applicability of these concepts to individuals with chronic disease. This review suggests that future research that evaluates the screening test accuracy, quality of life of having cancer, and cancer treatment effectiveness, targeting those with chronic illnesses are necessary for the development of an effective, safe, and acceptable cancer screening program among people with two or more chronic diseases.