title: Hepatocellular carcinoma in patients with chronic kidney disease.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  HCC patients with stages 4 and 5 CKD had inferior survival than stages 1 and 2 CKD. This warrants further studies.
authors.affiliation: College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
authors.forename: Chern-Horng
authors.initials: CH
authors.lastname: Lee
authors.forename: Sen-Yung
authors.initials: SY
authors.lastname: Hsieh
authors.forename: Ja-Liang
authors.initials: JL
authors.lastname: Lin
authors.forename: Maw-Sen
authors.initials: MS
authors.lastname: Liu
authors.forename: Tzung-Hai
authors.initials: TH
authors.lastname: Yen
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality; D016009:Chi-Square Distribution; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D053208:Kaplan-Meier Estimate; D016014:Linear Models; D008113:Liver Neoplasms / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D016017:Odds Ratio; D011379:Prognosis; D016016:Proportional Hazards Models; D012042:Registries; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000503:physiopathology; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013624:Taiwan / Q000453:epidemiology; D013997:Time Factors
keywords: Chronic kidney disease; End-stage renal disease; Hepatitis B virus; Hepatitis C virus; Hepatocellular carcinoma