|Year : 2014 | Volume
| Issue : 6 | Page : 3-8
Incidence, risk factors, and prognosis of acute kidney injury following transarterial chemoembolization in patients with hepatocellular carcinoma: A prospective cohort study
JF Hao1, LW Zhang2, JX Bai1, YJ Li1, JN Liu1, XL Zhang1, JM Han1, X Li1, H Jiang2, N Cao1
1 Department of Blood Purification, General Hospital of Shenyang Military Area Command, Shenyang 110000, China
2 Department of Interventional Radiology, General Hospital of Shenyang Military Area Command, Shenyang 110000, China
|Date of Web Publication||24-Feb-2015|
Department of Interventional Radiology, General Hospital of Shenyang Military Area Command, Shenyang 110000
Department of Blood Purification, General Hospital of Shenyang Military Area Command, Shenyang 110000
Source of Support: None, Conflict of Interest: None
Background: Transcatheter arterial chemoembolization (TACE) is an effective first-line therapy for intermediate stage hepatocellular carcinoma (HCC). Acute renal injury may be induced after transarterial chemoembolization because of iodinated radiocontrast medium, but its incidence, risk factors, and prognosis remain unclear. Patients and Methods: This prospective study enrolled 166 HCC patients with a total of 316 TACE treatments. The incidence, risk factors, and prognosis of acute kidney injury (AKI) were examined. Results: The incidence of post-TACE AKI was 21.84% (69/316) according to Barrett and Parfrey criteria, whereas 7.59% (24/316) according to acute kidney injury network (AKIN) criteria. Multivariate logistic regression analysis showed that serum total bilirubin (TB) (>13.5 μmol/L; odds ratio [OR]: 1.871 95% confidence interval [CI]: 1.044-3.352; P = 0.035) and hemoglobin (HGB) level (<120 g/L; OR: 1.823, 95% CI: 1.019-3.264; P = 0.043) were associated with the development of AKI after TACE procedure in accordance to Barrett and Parfrey criteria. Meanwhile, age (>55 years; OR: 3.456, 95% CI: 1.107-10.790; P = 0.033), post-TACE AKI history (OR: 7.108, 95% CI: 1.387-36.434, P = 0.019), and serum aminotransferase level (>55 U/L; OR: 4.420, 95% CI: 1.792-10.906; P = 0.001) were associated with the development of AKI after TACE procedure in accordance to AKIN criteria. Total hospitalization cost was significantly higher (P = 0.034) in the patients with AKI after TACE procedure according to Barrett and Parfrey criteria. A post-TACE AKI diagnosis was associated with mortality in any definition used (P = 0.034 and P = 0.001 for Barrett and Parfrey and AKIN criteria, respectively). Conclusion: The present study showed that the incidence of post-TACE AKI was high in HCC patients (i.e., 7.59-21.84%) depending on criteria used. HGB (<120 g/L), serum TB (>13.5), and aminotransferase level (>55 U/L), age (>55 years) and post-TACE AKI history may be predictors of post-TACE AKI in HCC patients. The development of post-TACE AKI was associated with the risk of renal replacement treatment, prolonged renal insufficiency, or mortality according to AKIN criteria.
Keywords: Acute kidney injury, contrast-induced nephropathy, hepatocellular carcinoma, prognosis, risk factor, transarterial chemoembolization
|How to cite this article:|
Hao J F, Zhang L W, Bai J X, Li Y J, Liu J N, Zhang X L, Han J M, Li X, Jiang H, Cao N. Incidence, risk factors, and prognosis of acute kidney injury following transarterial chemoembolization in patients with hepatocellular carcinoma: A prospective cohort study. Indian J Cancer 2014;51, Suppl S2:3-8
|How to cite this URL:|
Hao J F, Zhang L W, Bai J X, Li Y J, Liu J N, Zhang X L, Han J M, Li X, Jiang H, Cao N. Incidence, risk factors, and prognosis of acute kidney injury following transarterial chemoembolization in patients with hepatocellular carcinoma: A prospective cohort study. Indian J Cancer [serial online] 2014 [cited 2021 Jul 26];51, Suppl S2:3-8. Available from: https://www.indianjcancer.com/text.asp?2014/51/6/3/151984
FNx01Hao JF, Zhang LW and Bai JX contributed equally to the study
| » Introduction|| |
Hepatocellular carcinoma (HCC) is the sixth most common malignant cancer, affecting over 600,000 people/year worldwide.  The increasing incidence of HCC is mainly contributed by the chronic viral hepatitis, chronic alcoholism, and metabolic disorders.  Surgical resection may be applied during the early stages of HCC. About 70% of patients were considered unresectable upon diagnosis due to advanced stages.  Transcatheter arterial chemoembolization (TACE) is a highly selective treatment procedure for patients with intermediate-stage HCC.  Its use as treatment to HCC began in the early 1980s.  Classical TACE delivered a chemotherapeutic agent (using an oily medium as drug carrier) intra-arterially to liver tumors, combined with the effect of targeted chemotherapy with ischemic necrosis caused by arterial embolization for maximum effect. 
Transcatheter arterial chemoembolization procedure could be administered repeatedly and has been demonstrated to improve the overall survival in patients with hypervascular HCC. , Iodinated radiocontrast medium used in angiographic procedure such as TACE may induce acute kidney injury (AKI), specifically in high-risk patients. 
The definition of confidence interval (CI)-AKI proposed by Barrett and Parfrey is commonly used in non-Intensive Care Unit (ICU) patients. 
Acute kidney injury network (AKIN) criteria using both serum creatinine value and urine output criteria are validated for AKI diagnosis in ICU patients.  AKIN criteria have also been widely used for CI-AKI diagnosis in non-ICU patients. , To date, no study has been reported to evaluate the effect of the different criteria in the diagnosis of AKI in HCC patients receiving TACE procedure.
Several risk factors such as preoperative serum albumin and uric acid level, proteinuria level, coexisting hypertension and diabetes, grade of cirrhosis, treatment session, and the amount and types of radiocontrast agent are reported to be associated with the development of post-TACE AKI. ,,, However, no study has been reported to investigate the cost-effectiveness of HCC patients developing post-TACE AKI. The long-term outcome in HCC patients developing post-TACE AKI also remains unclear.
This study aims to evaluate post-TACE AKI incidence, characteristics, and prognosis in HCC patients undergoing TACE procedure and to compare Barrett and Parfrey criteria and AKIN definition for diagnosis.
| » Patients and Methods|| |
This prospective observational study was conducted in our intervention therapy center for 30 months from June 2012 to October 2014. The Human Studies and the Research and Development committees of the General Hospital of Shenyang Military Area Command approved this study, and the individual consent requirement was waived.
The patient inclusion criteria were as follows: (1) Diagnosed with HCC; (2) receive TACE treatment; and (3) provision of a signed informed consent form. Exclusion criteria were the following: (1) Patients with incomplete laboratory data; (2) patients with chronic or acute renal replacement therapy (RRT); and (3) patients with other etiologies for AKI such as new shock, cardiac arrest, or surgical procedures after TACE procedure.
Demographic data, main admission diagnosis, HOD, cost, and mortality were recorded. Laboratory data (pre-TACE and post-TACE serum creatinine [Cr]; pre-TACE Cystatin C [CysC], blood urea nitrogen [BUN]; serum albumin, total bilirubin [TB], direct bilirubin [DB], aspartate aminotransferase level [AST]; prothrombin time [PT], activated partial thromboplastin time [APTT], hemoglobin [HGB], white blood cell [WBC] corpuscle count, and platelet [PLT] count level) were also recorded.
Baseline Scr was defined as the closest measurement to TACE within a timeframe of 48 h before and the time of TACE. Change in Scr between baseline and its maximal value within the 72 h following TACE was calculated. The development of AKI after TACE is defined by two different definitions: (1) Increase in serum creatinine at least 25% from the baseline hours after TACE using Barrett and Parfrey criteria; and (2) Absolute increase of 26.4 μmol/l (0.3 mg/dl) or a relative increase of 50% in SCr level from the baseline within 72 h after operation or requirement of postoperative hemodialysis according to the AKIN. ,
Transcatheter arterial chemoembolization treatment
The TACE was performed according to the modified Seldinger method of arterial embolization. Femoral artery was punctured with a 4-French catheter (Terumo, Tokyo, Japan). Hepatic arteriography was performed to localize tumor nodules and evaluate the vascularity of the tumor by injecting radiocontrast agent (Ousu iohexol, 15 g/50 ml, Yangtze River Pharmaceutical Co., Jiangsu or Visipaque iodixanol, 15 g/50 ml, GE Shanghai) using a power injector. The arteries supplying the tumor were catheterized superselectively. Under fluoroscopic control, an infusion of a mixture of 10 mg epirubicin (Pfizer, USA), 250 mg fluorouracil injection (Jinyao, Tianjin) and 10 ml Lipiodol (Laboratoire Guerbet, France) was performed. The amounts of emulsion delivered to the tumor were calculated according to the size and vascularization of the tumors.
In addition, we recorded whether the operators were with experience of >10 years or not.
Hospital stay, total hospitalization cost, and death during hospitalization of the patients were also recorded. The potential risk factors that may be associated with post-TACE AKI including age, laboratory data, TACE history, and post-TACE AKI history were analyzed between the two groups of patients to identify their predictive values.
All statistical analyses were performed using the SPSS 11 (SPSS Inc., Chicago, IL, USA) software package. Differences in categorical variables between the two groups were determined by the Chi-square test, with the Yates' correction or the Fisher exact probability test as appropriate. Categorical data were expressed as percentages as appropriate, and continuous variables were expressed as means ± standard deviation or median (range). Differences in continuous variables between the two groups were determined by the analysis of variance (unpaired Student's t-test and Welch's t-test were used for the analysis for the presence of unequal variances between samples) or Mann-Whitney rank sum test, as applicable. We used multivariate logistic regression analysis, with stepwise backward variable selection, to test for predictors of the development of post-TACE AKI. The odds ratios (ORs) from logistic regression were also presented as measures of the strength of the associations; 95% CI was calculated. For all tests, a P value (two-tailed) of <0.05 was considered statistically significant.
| » Result|| |
A total of 166 consecutive patients was included during the study period and received a total of 316 TACE procedures. The incidence of CI-AKI was 21.84% (95% CI, 26.39-17.28%) according to Barrett and Parfrey criteria, and 7.59% (95% CI, 10.52-4.67%) with AKIN criteria.
In both definitions used, no significant difference existed between patients with or without TACE-AKI regarding sex, pre-TACE CysC, TB, DB, APTT, WBC, PLT, TACE history, HOD, and whether the TACE was operated by an expert with experience of >10 years.
According to Barrett and Parfrey criteria, PT-INR was significantly higher, but the level of serum albumin and WBC were significantly lower in the patients with AKI after TACE procedure compared with those without AKI. Meanwhile, according to AKIN criteria, age was significantly older, whereas the level of serum BUN and AST were significantly higher in the patients with AKI after TACE procedure compared with those without AKI. The ratio of patients with post-TACE AKI history was higher in the patients with AKI after TACE procedure compared with those without AKI.
Multivariate logistic regression analysis showed that TB (>13.5 μmol/L; OR: 1.871 95% CI: 1.044-3.352; P = 0.035) and HGB level (>120 g/L; OR: 1.823, 95% CI: 1.019-3.264; P = 0.043) were associated with the development of AKI after TACE procedure according to Barrett and Parfrey criteria [Figure 1] and [Table 1]; whereas, age (>55 years; OR: 3.456, 95% CI: 1.107-10.790; P = 0.033), post-TACE AKI history (OR: 7.108, 95% CI: 1.387-36.434, P = 0.019) and AST (>55 U/L; OR: 4.420, 95% CI: 1.792-10.906; P = 0.001) were associated with the development of AKI after TACE procedure according to AKIN criteria [Figure 2] and [Table 2].
|Figure 1: Predictors of post - transcatheter arterial chemoembolization acute kidney injury according to Barrett and Parfrey criteria in multivariate logistic regression analysis|
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|Figure 2: Predictors of post - transcatheter arterial chemoembolization acute kidney injury according to acute kidney injury network criteria in multivariate logistic regression analysis|
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|Table 1: Comparison of clinical characteristics, laboratory data, and prognosis in HCC patients undergoing TACE|
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|Table 2: Risk factors for the development of AKI after TACE procedure according to Barrett and Parfrey criteria and AKIN criteria|
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In any definition used, no significant difference in hospital stay existed between patients with or without TACE-AKI. Total hospitalization cost was significantly higher (P = 0.034) in the patients with AKI after TACE procedure according to Barrett and Parfrey criteria. A post-TACE AKI diagnosis was associated with mortality in any definition used (P = 0.034 and P = 0.001 for Barrett and Parfrey AKIN criteria, respectively). For AKIN criteria, 3 (12.50%) patients developed chronic renal insufficiency (P = 0.000), whereas 2 (8.33%) received continuous veno-venous hemofiltration treatment according to the physician's decision (P = 0.006).
| » Discussion|| |
In the present prospective cohort study, incidence of post-TACE, AKI was high in HCC patients, ranging between 7.59% and 21.84% depending on the criteria used. Post-TACE AKI ranged from 6.64% to 9.05% according to the AKIN criteria whereas 9.05% according to Barrett and Parfrey criteria in the previous study. TACE treatment on HCC patients may increase the risk of developing AKI due to considerable amounts of radio contrast agent used. For the general population receiving iodine contrast, induced AKI ranged from 3% to 14%,  and contrast agent is the third most common cause of hospital-acquired AKI. 
Three major pathways are recognized in the pathophysiology of contrast-induced AKI: Hemodynamic effects, direct contrast media (CM) molecule tubular cell toxicity, and increase in oxygen free radicals. These three interacting pathways lead to tubular necrosis.  Approximately 100% of the CM are eliminated through glomerular filtration in 24 h after intravascular administration in patients with a normal renal function.  Intra-arterial administration of contrast shows a biphasic impact on renal hemodynamics: A transient increase in blood flow and a following durative decline of 10-25% below baseline. , PO 2 of outer medullary declines by 50-67% (9-15 mmHg) after CM administration. , Decline in medullary microcirculatory blood flow and the increased oxygen demand of renal tubular cells caused by CM administration lead to hypoxia. , Ischemia/reperfusion injury leads to increased formation of cytotoxic substance, including oxygen free radicals and reactive oxygen species (ROS). When the concentration of these molecules exceeds the cellular scavenging capacities, cellular injury occurs. Oxygen free radicals and ROS induce an imbalance between vasoconstrictive and vasodilative mediators, including an increase in angiotensin II and endothelin I and nitric oxide reduction. 
The alteration of these vasoactive mediators induces renal vasoconstriction and aggravates hypoxia. Oxidative stress of highly reactive molecules leads to intracellular imbalance between oxidants and antioxidants. This imbalance increased cell injury by affecting mitochondrial and nuclear DNA, membrane lipids, and cellular proteins, eventually increasing oxygen free radicals and ROS.  Both processes enhance each other.
Apoptosis, redistribution of membrane proteins, and DNA fragmentation of renal cell cultures induced by CM have been described in the previous study.  Apoptosis is associated with increased levels of oxygen free radicals in vitro studies. The apoptosis of renal tubular epithelial cell induced by CM has also been demonstrated in vivo studies.  Iodine is toxic to human cells,  but the degree of free iodine in contrast solutions that is responsible for tubular cell toxicity remains unknown. 
The key points of renal vascular affected by CM seem to be the afferent arterioles and descending vasa recta.  The cytotoxicity of CM induces vasoconstriction of the afferent arterioles and reduction in glomerular filtration rate.  Descending vasa recta constriction may be a consequence of endothelial damage and dysfunction.  Advanced cirrhosis is a frequent concomitant of HCC due to. Hepatic insufficiency may activate the vasoconstrictor system, induce peripheral vasodilatation, and decrease renal perfusion. , Cirrhosis may be a risk factor for the decline in the renal function.
Serum albumin constitutes 60% of the total plasma protein and contributes about 70% of the total osmotic pressure.  It maintains 80% of the oncotic pressure in the vascular system and has antioxidant properties in the body.  Serum albumin may have its effect on the prevention of contrast-induce AKI by vascular expansion and antioxidant properties.  The level of serum albumin was significantly lower in patients with AKI after TACE procedure, compared with those without AKI according to Barrett and Parfrey criteria in the present study, which seems to support that the low albumin is responsible for the development of post-TACE AKI. Further studies are mandatory to determine the role of mechanism involved in the association between post-TACE AKI and low albumin precisely.
All types of CM have negative effects on cell cultures in vitro studies. High-osmolar CM is more toxic than low-osmolar or isoosmolar ones. , Regarding the effect on descending vasa recta constriction, no significant difference exists among the high-osmolar ionic, low-osmolar ioxaglate, the low-osmolar iopromide, and the iso-osmolar iodixanol CM amidotrizoate.  The use of iodixanol versus iohexol or contrast load has very limited or no positive association with renal outcomes, compared with low-osmolar CM; high-osmolar CM induces more renal tubular cell injury due to the cytotoxicity of hyperosmolar solutions.  Compared with low-osmolar CM, iso-osmolar nonionic contrast agent is reported to have relatively high viscosity, which leads to a relatively long contact time with renal tubular cells,  decrease of oxygen supply, increase of the expression of kidney injury markers, and formation of vacuoles in the renal tubular epithelium of the proximal and distal tubules. , However, there is no difference in the risk of renal cell apoptosis between iso-osmolar and low-osmolar contrast agents,  and randomized studies show no difference in CI-AKI between the iodixanol and different low-osmolar contrast agents. ,,
Low-osmolar iohexol is reported to induce a higher risk of AKI in CKD patients.  CM isoosmolar iodixanol is also reported to reduce the risk of contrast-induced AKI in DM or CKD patients compared with low-osmolar iohexol. , Nevertheless, findings on the apparent benefit have not been consistent; no significant advantage of iohexol over iodixanol was observed in the prevention of AKI and prolonged renal insufficiency.  Operators of coronary angiography may prefer to use iodixanol for radiography in high-risk subjects, hence in this present study. In consideration of the selection bias, the comparison of the risk for post-TACE AKI between iohexol and iodixanol was not included in this study.
Apart from contrast osmolarity, other mechanisms such as the clinical comorbidities and hemodynamic condition may attribute to AKI pathogenesis.  Older age, cardiac or liver failure, diabetic nephropathy, and preexisting chronic kidney disease were identified as risk factors for the contrast-induced nephropathy in the general population.  Several risk factors for post-TACE AKI in HCC patients were also found in previous studies. Preoperative serum albumin and uric acid level, proteinuria level, coexisting hypertension and diabetes, grade of cirrhosis, treatment session, and the amount and types of radiocontrast agent are important predisposing factors. ,,, In the present study, serum TB (>13.5 μmol/L) and HGB level (<120 g/L) were independent risk factors of post-TACE AKI according to Barrett and Parfrey criteria, whereas age (>55 years), post-TACE AKI history, and serum aminotransferase level (>55 U/L) were independent risk factors of post-TACE AKI according to AKIN criteria on multivariate logistic regression analysis.
Inpatient hospital mortality, renal replacement treatment, and hospital length of stay are increased in patients developing contrast-induced AKI. ,,
Statistically significant associations were found between post-TACE AKI and inpatient hospital mortality, in both definitions used in our study. For AKIN criteria, 3 (12.50%) patients developed chronic renal insufficiency (P = 0.000), whereas 2 (8.33%) received continuous veno-venous hemofiltration treatment according to the physician's decision (P = 0.006).
No statistically significant difference in the development of post-TACE AKI existed between TACE operated by an expert with intervention experience of >10 years and those operated by doctor with intervention experience of <10 years, in both definitions used, which can be caused by the selective operation of the TACE procedures on patients with critical or complex concomitant diseases by expert.
The increase of creatinine values are associated with adverse renal outcomes, hence the AKIN definition for AKI based on smaller variations in serum creatinine level. 
Increase of serum creatinine level in iodine CIN patient occurs in 48 h after angiography, reaches a maximum between days 4 and 7, and then decreases during days 7-21. 
The baseline creatinine value is not necessary for Barrett and Parfrey and the AKIN definition. AKIN was reported to be correlated with RRT and mortality in critically ill patients. 
Using the AKIN criteria, the ratio of RRT and mortality was more frequent in patients with post-TACE AKI. Post-TACE AKI was associated with chronic renal insufficiency and renal replacement treatment according to the AKIN criteria used. Hence, AKIN criteria appear to be more relevant in defining the post-TACE AKI in our study. Further studies are mandatory to determine the role of AKIN criteria and Barrett and Parfrey criteria for post-TACE AKI in HCC patients precisely.
Most of the post-TACE AKI were transient and reversible, usually not needing of any special treatment. However, in the present study, post-TACE AKI history (OR: 7.108, 95% CI: 1.387-36.434, P = 0.019) were associated with the development of AKI after TACE procedure according to AKIN criteria. To the best of our knowledge, the impact of post-TACE AKI history on the development of post-TACE AKI in HCC patients has not been investigated in previous studies. We suppose that aside from the three main pathways and CM acting on renal, susceptibility may take effect on the development of post-TACE AKI. Nevertheless, the factors and mechanism remain unclear. Clinical and experimental studies should be conducted for further investigation.
The present study has few limitations. First, it focused on the data from a single center and was limited by the small sample size. Second, the role of other etiologies of AKI may not be ruled out completely, despite the exclusion criteria that were used. Third, this study did not include long-term follow-up data to assess the long-term prognosis.
| » Conclusion|| |
The present study showed that the incidence of post-TACE AKI was high in HCC patients, ranging between 7.59% and 21.84%, depending on the criteria used. The serum aminotransferase level (>55 U/L), age (>55 years), and post-TACE AKI history may be predictors of post-TACE AKI in HCC patients. The development of post-TACE AKI was associated with the risk of renal replacement treatment, prolonged renal insufficiency or mortality according to AKIN criteria. Further studies are mandatory to investigate the prevention of post-TACE AKI in HCC patients.
| » Acknowledgment|| |
We acknowledge Dr. Xue-Ting Wei, Bing Shao, Zhuo Ren, Qian Wang, Chen Zhao, and Hui Li for the help they provided in the data collection.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]