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RFA treatment for HCC patients on hemodialysis for ESRD requires caution

Patients with hepatocellular carcinoma on hemodialysis for end-stage renal disease had a higher mortality rate than non-dialyzed patients when treated with radiofrequency ablation, according to a recently published study.

“Image-guided minimally invasive techniques have been widely used for the treatment of HCC in the past decade, and radiofrequency ablation (RFA) has yielded promising clinical results, with survival rates comparable with those of hepatectomy,” Masaya Sato, MD, PhD, of the department of gastroenterology, Graduate School of Medicine, University of Tokyo, and colleagues wrote. “During the last decade, there has been growing interest in the use of RFA in patients with liver tumors considered to be unresectable because of impaired hepatic function or associated comorbidities. Improvement of surveillance programs that have reduced the number of HCC cases detected at an already advanced stage has also increased the use of RFA.”

To investigate in-hospital mortality rates and hemorrhagic complications following RFA in patients on hemodialysis (HD) for end-stage renal disease (ESRD), researchers accessed the Diagnosis Procedure Combination database of Japan. They selected 437 dialyzed patients and 1,345 non-dialyzed patients matched by broad age categories ( 60, 61-70, 71-80 and 81 years), sex and treatment year.

There were five mortalities among the dialyzed patients and two mortalities in the non-dialyzed group (OR = 7.77; P < .001). Among the dialyzed group, mortality was significantly lower in patients age 70 years or younger vs. patients age 71 years or older (P = .02).

The five dialyzed patients had at least one of the following comorbidities: diabetes, aortic valve stenosis, chronic thyroiditis or angina. Hemorrhage, liver abscess, respiratory distress syndrome, acute myocardial infarction and liver failure were recorded as probable causes of death.

Diabetes or hypertension were recorded as comorbidities in the two non-dialyzed fatal cases; congestive heart failure and generalized peritonitis were recorded as probable causes of death.

The rate of hemorrhagic complications differed significantly (P < .001) between the dialyzed group (n = 15) and the non-dialyzed group (n = 10), though neither group showed significant association between hemorrhagic complication rates and sex, age, Charlson Comorbidity Index or hospital volume.

The researchers found that use of hemostat agents (tranexamic acid, carbazochrome sodium sulfonate hydrate and vitamin K) for the prevention of hemorrhage was significantly higher in the non-dialyzed group than that in dialyzed patients (63.2% vs. 55.6%, P = .006).

“The reason for increased risk following RFA in HD-dependent is thought to be multifactorial,” the researchers wrote. “Patients with ESRD commonly have other significant comorbidities such as diabetes or cardiovascular disease. Also, patients with ESRD on HD have impaired immune function, which make them susceptible to infection or sepsis. Moreover, ESRD patients are also at increased risk for pulmonary complication possibly related to hypoxemia and hypocapnia induced by heart disease. Actually, acute myocardial infarction, liver abscess or respiratory distress syndrome was recorded as probable causes of death in HD-dependent patient in the database used for the current study. Thus, the indications for RFA in HD-dependent patients should be considered carefully in view of the therapeutic benefit and risks.” – by Talitha Bennett

Disclosure: The researchers report no relevant financial disclosures.