Bottom Line
Part of the Maintenance Hemodialysis mastery module. This page condenses sections 5, 6, and 7 of the full white paper, Screening and Health Maintenance in Maintenance Hemodialysis.
- Cancer screening on dialysis is individualized. The ASN Choosing Wisely recommendation is not to perform routine cancer screening in dialysis patients with limited life expectancy and no signs or symptoms. Transplant candidates should receive age-appropriate screening.1
- Life expectancy sets the frame. Five-year survival after starting dialysis is approximately 40%, and most cancer screening needs 5–10 years of lead time to reduce mortality.1,2,3
- Test performance changes on dialysis. Prefer fecal immunochemical testing to guaiac-based testing; PSA and mammography lose specificity.4
- Acquired cystic kidney disease is the underrecognized screening opportunity. It develops in more than 90% of patients on dialysis longer than 10 years and carries up to a 50-fold increase in renal cell carcinoma risk. Begin renal ultrasound at 3 years on dialysis, repeat annually once cystic disease is established, and use CT for suspicious findings.5,6,7
- Thyroid: hypothyroidism affects 11–20% of patients with ESKD, and its symptoms overlap with uremia. Check TSH at dialysis initiation and annually, confirm an abnormal TSH with free T4, and do not check free T3 routinely.8,9
1. Cancer Screening: The Life-Expectancy Problem
Why the general-population rules do not transfer
Cancer screening guidelines were developed for people with decades of remaining life expectancy. Median survival of incident hemodialysis patients in the United States is approximately 3–5 years, with five-year survival of approximately 40%, and it varies widely with age, diabetes, comorbidity, and functional status.2 A screening test only helps if the lead time from detection to mortality reduction fits inside the patient's expected survival. For most cancers that window is 5–10 years.1,3
The ASN Choosing Wisely campaign makes the point explicitly: "Don't perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms."1 A 2024 CJASN review of cancer screening in kidney failure requiring hemodialysis describes a field in which general-population guidelines are not directing care, and in which nephrologists increasingly own preventive-care decisions for a population those guidelines were never designed for.10
An individualized framework
| Factor | Implication |
|---|---|
| Expected survival > 5–10 years | May benefit from standard screening |
| Transplant candidacy | Age-appropriate screening per general-population guidelines |
| Patient goals and values | Shared decision-making is essential: weigh burden against benefit |
| Functional status | Patients with good functional status on dialysis may have better-than-average survival |
| Not transplant-eligible, expected survival < 5 years | Screening likely causes net harm (false positives, procedures, anxiety) |
2. Cancer-Specific Considerations
Colorectal cancer
- It is screened often. In Medicare data, 11.6% of dialysis patients aged 50 or older had a colorectal screening test over a median of 1.5 years. In that USRDS cohort of 469,574 patients, screening was appropriately targeted toward lower-risk patients, but absolute rates suggested overscreening in some groups.3
- Choose the test with dialysis in mind. Screening-test performance differs on dialysis.4 Guaiac-based fecal occult blood testing is prone to false positives from uremic platelet dysfunction and heparin exposure, so fecal immunochemical testing (FIT) is preferred.
- Colonoscopy preparation carries dialysis-specific risk: electrolyte disturbances, dehydration, and hemodynamic instability.
- The expected gain is small without a transplant. A modeling analysis estimated that colorectal screening adds only 2.6 days of life for dialysis patients who are not waitlisted, versus 12 days for transplant recipients.11
Prostate, breast, and cervical cancer
| Cancer | Dialysis-specific issue | Approach |
|---|---|---|
| Prostate | PSA is frequently elevated on dialysis independent of malignancy, which reduces specificity4 | No dialysis-specific PSA guideline exists; individualize by transplant candidacy and expected survival |
| Breast | Vascular and metastatic soft-tissue calcifications can complicate mammographic interpretation4 | Standard screening for transplant candidates with adequate expected survival; no dialysis-specific modification |
| Cervical | Limited data on ESKD-specific risk | Standard screening for transplant candidates |
A false-positive result leads to invasive procedures in a patient with uremic platelet dysfunction and a vascular access that limits venipuncture sites. Bowel preparation destabilizes electrolytes and volume status. And patients carry anxiety about findings that would never have become clinically significant in their remaining lifespan.1,3,10
3. Acquired Cystic Kidney Disease and Renal Cell Carcinoma
Epidemiology
Acquired cystic kidney disease (ACKD) is defined as three or more cysts in each kidney in a patient with CKD and no history of hereditary cystic disease. Its prevalence climbs with time on dialysis.5,12
| Time on dialysis | ACKD prevalence |
|---|---|
| < 3 years | 10–20% |
| 3–5 years | 40–60% |
| > 10 years | > 90% |
Source: Truong et al.5 A 2025 systematic review and meta-analysis found a standardized incidence ratio of 4.7 for kidney and renal pelvis cancer in dialysis patients compared with the general population.6 The risk is measurable and rises with dialysis duration.
The cancer risk
- Renal cell carcinoma risk is up to 50-fold higher than in the general population.5
- ACKD-associated RCC occurs in 3–7% of ESKD native kidneys overall.5,6,12,13
- ACKD-associated RCC is the most common RCC subtype in both ACKD (40%) and ESKD (30%), and the 2022 WHO Classification of Renal Tumors recognizes it as a distinct entity.5,6,12,13
- Tumors are frequently multifocal (approximately 50%) and bilateral (approximately 9%).5
- They occur approximately 20 years earlier than sporadic RCC and predominantly affect men (3:1).5,6,12,13
- Approximately 86% are asymptomatic. When symptoms occur, they include hematuria, flank pain, or an abrupt, unexplained change in hematocrit.5
Pathogenesis and pathology
ACKD-associated RCC arises in a chronic, multifactorial milieu: uremic toxin exposure and impaired cellular immunity, oxidative stress, oxalate crystal-induced chronic tubular injury, growth-factor-driven compensatory tubular epithelial proliferation, and possible proto-oncogene activation in the setting of chronic cellular turnover.5,14 Progression follows a stepwise pathway: damaged tubule, simple cyst, cyst with atypical epithelial lining, adenoma, and carcinoma. That sequence is the rationale for surveillance, because there is a detectable premalignant phase.5
Histologically, the tumors are predominantly eosinophilic with granular cytoplasm and variable cribriform, solid, and papillary architecture. Intratumoral oxalate crystals are characteristic but not required. The tumors are CAIX negative (clear cell RCC is positive) and usually CK7 negative (papillary RCC is positive). Behavior is generally indolent, although 10–15% present with recurrence or distant metastases.14
Screening recommendations
No universal guideline covers RCC screening in dialysis patients. The KDIGO 2020 guideline on kidney transplant candidates recommends ultrasonographic screening for renal cell carcinoma in candidates at increased risk, including those with 3 or more years on dialysis, a family history of renal cancer, ACKD, or analgesic nephropathy.7 For dialysis patients who are not transplant candidates, the approach is individualized. The white paper suggests the following surveillance approach.
| Dialysis duration | Suggested approach | Rationale |
|---|---|---|
| Years 0–3 | No routine imaging unless symptomatic | ACKD prevalence is low; risk-benefit unfavorable |
| Year 3 | Baseline renal ultrasound | ACKD prevalence reaches 40–60%5 |
| Years 3–5 | Repeat ultrasound every 1–2 years if ACKD is present | Monitor for solid lesions |
| After 5 or more years | Annual renal ultrasound once ACKD is established | Highest-risk period; prevalence exceeds 90% after 10 years5 |
| Transplant candidates | Imaging of native kidneys before transplant, with continued surveillance afterward | ACKD and RCC risk persist in native kidneys after transplantation |
Choosing the imaging test
| Modality | Role | Notes |
|---|---|---|
| Renal ultrasound | First-line screening | Detects cysts and solid masses; operator-dependent; may miss small tumors in severely cystic kidneys |
| CT with contrast | Definitive characterization | More sensitive; the white paper notes no nephrotoxicity concern in dialysis-dependent patients; use for suspicious ultrasound findings |
| MRI | Alternative to CT | The white paper treats gadolinium as acceptable in established dialysis patients with post-dialysis removal, and advises avoiding it in advanced CKD not yet on dialysis because of nephrogenic systemic fibrosis risk |
When a lesion is found
| Finding | Approach |
|---|---|
| Tumor > 3 cm | Nephrectomy recommended |
| Tumor < 3 cm with symptoms | Consider nephrectomy |
| Tumor < 3 cm, asymptomatic | Serial imaging; growth rate guides intervention |
| Native kidneys after transplant | Continue surveillance; ACKD-associated RCC risk persists |
ACKD-associated RCC accounts for approximately 2% of deaths in kidney transplant recipients.5 Native-kidney surveillance should continue after transplantation. Young patients on long-term dialysis are the highest-risk group and have the most to gain from screening.5,6,12
Tumors as large as 8 cm have been reported that no imaging modality visualized in extensively cystic kidneys. The distorted architecture makes interpretation difficult. Keep a low threshold for CT characterization of any new or changing ultrasound finding.5
4. Thyroid Screening
Prevalence and why it matters
Hypothyroidism is more common in ESKD than in the general population. Reported rates range from 11% to 20%, depending on the TSH threshold and the population studied.8,9,15,16
| Study | Population | Finding | Definition |
|---|---|---|---|
| Lo 2017, Frequent Hemodialysis Network trial9 | 226 hemodialysis patients | 11% hypothyroid | TSH ≥ 8 mIU/mL or on thyroid hormone |
| Cuna 20178 | 2,147 ESKD transplant-waitlist patients (Italy) | 20.3%, two-thirds subclinical | TSH > 3 mU/L |
| Rhee 2017 (prospective hemodialysis cohort)15 | 541 hemodialysis patients | Highest vs lowest TSH tertile: 2.2- to 2.5-fold mortality | TSH tertiles (not a prevalence study) |
| Brenta et al. (narrative review)17 | — | Subclinical hypothyroidism more common in CKD than in the general population | Variable thresholds |
A Nature Reviews Endocrinology review of kidney disease and the thyroid concluded that hypothyroidism in ESKD is not merely a laboratory curiosity.17 Higher TSH is independently associated with coronary artery calcification in hemodialysis patients16 and with mortality: the highest TSH tertile carried 2.2- to 2.5-fold mortality in a prospective hemodialysis cohort,15 and impaired sensitivity to thyroid hormone tracked all-cause and cardiovascular mortality in CKD.18 Higher TSH has also been linked to left ventricular hypertrophy and diastolic dysfunction, which add to the cardiac structural disease already common in ESKD.
Why the diagnosis has to be biochemical
The symptoms of hypothyroidism overlap almost completely with uremia: fatigue, cold intolerance, edema, constipation, dry skin, cognitive impairment, and weight gain. Clinical diagnosis alone is unreliable.
Low T3 syndrome (euthyroid sick syndrome) is common in ESKD and does not require treatment. It results from impaired peripheral conversion of T4 to T3, reduced thyroid-binding globulin, and the catabolic and inflammatory milieu of CKD. Low T3 is associated with worse outcomes in observational studies, but treatment trials have not shown benefit, and thyroid hormone supplementation carries a risk of atrial fibrillation and accelerated bone loss.17
Diagnose hypothyroidism in ESKD on a persistently elevated TSH, not on free T3 or free T4 alone. Free hormone assays are unreliable in uremia because of protein-binding abnormalities, interference from uremic toxins, and the confounding effect of non-thyroidal illness. A TSH above the upper limit of normal on two consecutive measurements, not a single value, should prompt evaluation and consideration of levothyroxine.
Thyroid nodules and cancer
Patients with ESKD have a higher reported incidence of benign and malignant thyroid nodules, although the absolute risk of thyroid cancer remains low.8 KDIGO does not issue a formal thyroid cancer screening recommendation. Clinical vigilance is reasonable: palpate the thyroid during routine examinations and obtain ultrasonography if a nodule is found.8,17
Screening recommendation
No formal guideline mandates thyroid screening on hemodialysis. The combination of high prevalence (11–20%), symptoms that make clinical diagnosis impossible, and the association with cardiovascular morbidity and mortality supports a simple approach:8,9
- TSH at hemodialysis initiation as a baseline
- TSH annually for surveillance
- Free T4 to confirm when TSH is abnormal
- No routine free T3: it is unreliable in ESKD, and low T3 syndrome is common
5. Four Conversations
These sketches apply the recommendations above. They are illustrative teaching examples, not patients.
The transplant candidate four years into dialysis
A 58-year-old on the transplant waiting list has been on dialysis for four years. Transplant candidates should receive age-appropriate cancer screening under general-population guidelines, and the KDIGO 2020 transplant-candidate guideline recommends renal ultrasound for RCC in candidates with 3 or more years on dialysis.7 Use FIT rather than guaiac testing for colorectal screening, and interpret PSA and mammography knowing that both lose specificity on dialysis.4
The frail patient who asks about a colonoscopy
An 84-year-old who is not a transplant candidate and has declining function asks whether she is due for a colonoscopy. The Choosing Wisely recommendation applies directly: routine cancer screening is not recommended with limited life expectancy and no symptoms.1 Modeling suggests colorectal screening adds only days of life for dialysis patients who are not waitlisted,11 while bowel preparation risks electrolyte and volume instability. The conversation is shared decision-making about burden and benefit, not a reminder that she is overdue.
The long-vintage patient with an unexplained hematocrit change
A 45-year-old has been on dialysis for 12 years and has an abrupt, unexplained change in hematocrit. After 10 years on dialysis, more than 90% of patients have ACKD, and RCC risk is up to 50-fold higher than in the general population. Most of these tumors are silent, and an abrupt hematocrit change is one of the few signs.5 Image the native kidneys, and keep a low threshold for CT if the ultrasound shows anything new, because cystic kidneys can hide large tumors.5
The tired patient with a high TSH
A patient reports fatigue, cold intolerance, and constipation, and the annual TSH is above the upper limit of normal. The symptoms cannot separate hypothyroidism from uremia, so the diagnosis rests on the laboratory. Repeat the TSH: two consecutive elevated values, not one, should prompt evaluation and consideration of levothyroxine, with free T4 to confirm. A low free T3 alone is likely low T3 syndrome, which does not need treatment.17
6. Evidence Gaps
- Screening guidelines were built for the general population. No dialysis-specific PSA screening guideline exists, and data on cervical cancer risk in ESKD are limited.10
- The benefit of colorectal screening in patients not waitlisted for transplant rests on modeling rather than trial data.11
- No universal guideline covers RCC surveillance in dialysis patients who are not transplant candidates. The KDIGO 2020 recommendation applies to transplant candidates, and the surveillance intervals above are a suggested approach rather than a tested one.7
- Several key ACKD figures are old. The prevalence-by-vintage estimates and the up-to-50-fold RCC risk come from a 1995 publication; the 2025 meta-analysis gives a contemporary estimate only for overall kidney cancer incidence.5,6
- No formal guideline mandates thyroid screening on hemodialysis, and treatment trials in low T3 syndrome have not shown benefit.17
7. At the Chair
- Report blood in the urine, new flank pain, or an unexplained drop or jump in hemoglobin in a patient who has been on dialysis for several years. Kidney cancers in cystic native kidneys are usually silent, and these are the signs when they appear.
- Fatigue, feeling cold, constipation, dry skin, and weight gain are common on dialysis and can also mean an underactive thyroid. The annual TSH is how it is found.
- When a patient asks about cancer screening tests, route the question to the nephrologist. The answer depends on transplant plans, overall health, and the patient's own goals.
Chair-side reference: Nursing card N9 — Monthly labs: what they mean and what to report.
References
Claims and references on this page are drawn from the source white paper (Screening and Health Maintenance in Maintenance Hemodialysis), whose reference list was re-verified against PubMed on 2026-09-26. References are renumbered for this page.
- Williams AW, Dwyer AC, Eddy AA, et al. Critical and honest conversations: the evidence behind the "Choosing Wisely" campaign recommendations by the American Society of Nephrology. Clin J Am Soc Nephrol. 2012;7(10):1664-1672. (ASN Choosing Wisely recommendation 1: "Don't perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms."). PMID 22977214
- Flythe JE, Watnick S. Dialysis for chronic kidney failure: a review. JAMA. 2024;332(18):1559-1573. PMID 39356511
- Carlos CA, McCulloch CE, Hsu CY, et al. Colon cancer screening among patients receiving dialysis in the United States: are we choosing wisely? J Am Soc Nephrol. 2017;28(8):2521-2528. PMID 28336719
- Rosner MH. Cancer screening in patients undergoing maintenance dialysis: who, what, and when. Am J Kidney Dis. 2020;76(4):558-566. PMID 32305205
- Truong LD, Krishnan B, Cao JT, et al. Renal neoplasm in acquired cystic kidney disease. Am J Kidney Dis. 1995;26(1):1-12. PMID 7611240
- Ye J, Ran B, Huang Y, et al. Incidence of major urological cancers in patients on dialysis: a systematic review and meta-analysis. World J Surg Oncol. 2025;23(1):118. PMID 40186281
- Chadban SJ, Ahn C, Axelrod DA, et al. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. 2020;104(4S1):S11-S103. PMID 32301874
- Cuna V, Menghi V, Comai G, et al. Functional abnormalities and thyroid nodules in patients with end-stage renal disease. In Vivo. 2017;31(6):1203-1208. PMID 29102947
- Lo JC, Beck GJ, Kaysen GA, et al. Thyroid function in end stage renal disease and effects of frequent hemodialysis. Hemodial Int. 2017;21(4):534-541. PMID 28301073
- Jayaram D, Golestaneh L. Cancer screening among patients with kidney failure requiring hemodialysis: where we are and where we are going. Clin J Am Soc Nephrol. 2024;19(12):1521-1523. PMID 39482278
- Kiberd B. Colorectal cancer screening in kidney disease patients: working backwards. Nephrol Dial Transplant. 2013;28(4):774-777. PMID 23129825
- McCarthy MR, Gupta S, Erickson LA. Acquired cystic disease-associated renal cell carcinoma. Mayo Clin Proc. 2023;98(4):637-638. PMID 37019519
- Ishikawa I, Saito Y, Shikura N, et al. Ten-year prospective study on the development of renal cell carcinoma in dialysis patients. Am J Kidney Dis. 1990;16(5):452-458. PMID 2239936
- Abdelwahed R, Tretiakova M. Acquired cystic disease associated renal cell carcinoma. PathologyOutlines.com. 2026.
- Rhee CM, You AS, Nguyen DV, et al. Thyroid status and mortality in a prospective hemodialysis cohort. J Clin Endocrinol Metab. 2017;102(5):1568-1577. PMID 28324018
- Rhee CM, Budoff M, Brent G, et al. Serum thyrotropin elevation and coronary artery calcification in hemodialysis patients. Cardiorenal Med. 2022;12(3):106-116. PMID 35551382
- Brenta G, et al. Kidney diseases and the thyroid: interactions and consequences. Nat Rev Endocrinol. 2026;22(4):228-241. PMID 41249474
- Liu C, Zhu X, Wang D, et al. Impaired sensitivity to thyroid hormones is associated with all-cause and cause-specific mortality among chronic kidney disease patients. Ren Fail. 2024;46(2):2433178. PMID 39689980
Also in this module
- Infection screening and vaccination: HBV, HCV, vaccines
- Cardiometabolic monitoring: lipids, statins, glycemic markers, and cardiovascular screening
- Adequacy, nutrition, depression and cognition, and what quality metrics miss
- Maintenance Hemodialysis module index
Full white paper
- Screening and Health Maintenance in Maintenance Hemodialysis, sections 5, 6, and 7