High incidence of hepatocellular carcinoma in ESRD patients: caused by high hepatitis rate or 'uremia'? a population-based study.

OBJECTIVE: A high incidence of hepatocellular carcinoma has been reported in end-stage renal disease patients. This study was undertaken to evaluate whether this was caused by a high rate hepatitis or 'uremia' per se.
METHODS: We used claims data of the Bureau of National Health Insurance of Taiwan for analysis. All patients diagnosed with end-stage renal disease having received their first dialysis between 1 January 2003 and 31 December 2007 (n = 38 714) were enrolled for the study. A database of 1 million randomly selected subjects matched for age, gender, hepatitis B and C infection, and liver cirrhosis for the same period was used as control (n = 38 714). The longest observation period was up to 31 December 2008.
RESULTS: There was no significant difference in the incidence of hepatocellular carcinoma between end-stage renal disease patients and their non-end-stage renal disease counterparts (2.03 per 1000 person-years vs. 2.10 per 1000 person-years, rate ratio = 0.947; 95% confidence interval: 0.792-1.132). End-stage renal disease patients with hepatocellular carcinoma had higher percentages of diabetes mellitus, hypertension, heart failure and gout (all P < 0.001), and they presented with a worse cumulative survival rate than the non-end-stage renal disease group (P < 0.001). End-stage renal disease patients developing hepatocellular carcinoma were younger, and had more comorbidities than their non-end-stage renal disease counterparts. End-stage renal disease (hazard ratio = 1.61) and diabetes mellitus (hazard ratio = 1.55) were found to be independent factors for mortality in hepatocellular carcinoma patients.
CONCLUSIONS: After matching for hepatitis and liver cirrhosis, end-stage renal disease is not associated with a higher incidence of hepatocellular carcinoma than the general population. The high incidence of hepatocellular carcinoma in end-stage renal disease patients was caused by a high viral hepatitis rate rather than 'uremia' per se. Owing to increased comorbidity, end-stage renal disease patients developing hepatocellular carcinoma had worse long-term survival than non-end-stage renal disease patients.