Hepatocellular carcinoma after renal transplantation in the absence of cirrhosis or viral hepatitis: A case series

The occurrence of hepatocellular carcinoma (HCC) in renal transplant recipi ents has typically been associated with hepatitis B or C infection. We enco untered two cases of HCC in renal transplant recipients with negative hepat itis B and C markers and no underlying liver pathology, in whom immunosuppr ession therapy consisted of prednisone and azathioprine (AZA). Patient no. 1 is a 66-year-old man with diabetes who underwent cadaveric renal transpla ntation 13 years before presentation. An ultrasound obtained for evaluation of a prolonged prothrombin time and decreased serum albumin level showed a suspicious nodular lesion in the left lobe of the liver. A computed tomogr aphic (CT) scan confirmed a 4- x 5- x 5-cm mass that, on biopsy, was determ ined to be well-differentiated HCC. There was no evidence of metastasis, an d the results of random biopsies of the surrounding parenchyma were normal. The patient underwent a left lateral segmentectomy, did well, and an initi al alpha-fetoprotein (AFP) level of 85995 ng/mL decreased to 9 ng/mL. Appro ximately 20 months postoperatively, however, a surveillance CT scan showed three hypervascular lesions in the right lobe of the liver and the AFP leve l increased to 28,370 ng/mL. Subsequent percutaneous alcohol injections yie lded good results, and the patient is alive and well 13 months later. Patie nt no. 2 is a 57-year-old man who underwent cadaveric renal transplantation 24 years earlier. A CT scan of the abdomen obtained for evaluation of lowe r abdominal pain showed a 4- x 4- x 6.5-cm mass in the right lobe of the li ver that, on biopsy, was found to be poorly differentiated HCC. Multiple bi opsies of adjacent liver parenchyma showed no evidence of cirrhosis, AFP le vel was normal, and imaging studies showed no evidence of tumor spread. The patient underwent a right hepatic lobectomy and is doing well without evid ence of recurrence 27 months postoperatively. Our two patients had no evide nce of viral hepatitis, cirrhosis, or metabolic liver disease, yet both dev eloped HCC. The use of AZA may have had a role in the development of HCC. I n renal transplant recipients on long-term immunosuppression therapy, parti cularly AZA, it is prudent to maintain a high index of suspicion for HCC wh en liver enzyme level or function abnormalities are encountered. Copyright (C) 1999 by the American Association for the Study of Liver Diseases.