Secondary iron overload in end-stage renal disease patients being evaluated for kidney transplantation may mimic cirrhosis by CT scan: a radio-pathologic correlation study

Objectives: This study aimed to investigate whether secondary iron overload in the liver mimics cirrhosis on abdominal CT scans, particularly in patients with end-stage renal disease (ESRD), and to develop a diagnostic algorithm to differentiate these conditions. Methods: We conducted a radio-pathologic correlation study involving 4 patient groups: (1) patients with nodular regenerative hyperplasia (NRH) and no hepatic iron deposition, (2) ESRD patients with CT scans suggesting cirrhosis, (3) patients with biopsy-proven cirrhosis and hepatic iron overload, and (4) patients with biopsy-proven cirrhosis without hepatic iron overload. Two board-certified radiologists reviewed all cases in a blinded manner, and liver-related laboratory tests, along with features of portal hypertension, were assessed. Results: CT scans of ESRD patients with secondary hepatic iron overload showed irregular liver contours resembling cirrhosis. However, these patients lacked thrombocytopenia, oesophageal varices, and other clinical markers of portal hypertension, which were consistently present in true cirrhosis cases. These findings suggest that imaging alone cannot reliably diagnose cirrhosis in ESRD patients. Conclusions: Secondary hepatic iron deposition in ESRD patients can create CT features that mimic cirrhosis. A comprehensive evaluation of clinical, laboratory, and imaging data is crucial for accurate diagnosis and to prevent unnecessary liver biopsies. Advances in knowledge: This study emphasizes the importance of a multidisciplinary diagnostic approach for ESRD patients with suspected cirrhosis. The proposed algorithm helps differentiate true cirrhosis from secondary iron overload, reducing unnecessary invasive procedures, optimizing pre-transplant evaluations, and enhancing patient care.