Radioiodine Ablation Therapy Feasible in Hemodialysis-Dependent ESKD Patients with Low-Risk Thyroid Cancer: Case Series

Australia: In a recently published case series in BMC Nephrology, researchers from the University of Sydney, led by Dr. Raymond Lin, have demonstrated that with tailored protocols and safety precautions, radioiodine (I-131) therapy can be safely administered to patients with end-stage kidney disease (ESKD) on haemodialysis (HD) who are being treated for thyroid cancer.    

Radioiodine therapy is a well-established adjuvant treatment for differentiated thyroid cancer (DTC), particularly following thyroidectomy. However, its use in patients with impaired renal function poses a significant challenge. In those with ESKD, the clearance of I-131 is severely reduced, increasing the risk of prolonged radiation exposure and myelotoxicity. Currently, there is no universally accepted protocol for administering radioiodine in patients on dialysis, making treatment planning complex.

To address this, Dr. Lin and colleagues reported on two ESKD patients undergoing chronic haemodialysis who received I-131 therapy for low-risk thyroid cancer. The team adapted its institutional approach by implementing modifications to infrastructure, scheduling, and radiation safety protocols. This included pre-treatment patient training, altered dialysis timing, and close monitoring of serum radioactivity to ensure patient and staff safety.

Patient 1, who had undergone bilateral nephrectomy, was trained to self-cannulate in preparation for therapy, while Patient 2 had several comorbidities, including morbid obesity and a colostomy. Both patients underwent haemodialysis at 24, 72, and 144 hours post-I-131 administration. This schedule helped achieve radiation retention profiles comparable to those seen in individuals with normal kidney function.
Radiation exposure to the bone marrow—a primary concern in patients with impaired clearance—remained within acceptable safety margins (<0.3 Gy in both cases). The majority of radiation exposure to bone marrow occurred before the initial dialysis session, accounting for 60% in Patient 1 and 47% in Patient 2. Additionally, cumulative radiation exposure to dialysis staff remained well below the local annual safety threshold, measuring only 7 and 23 μSv, respectively.
At 24 months of follow-up, both patients showed undetectable thyroglobulin levels, indicating effective disease control. There were no significant complications during or after therapy.
The findings from this case series reinforce that radioiodine therapy can be administered safely in dialysis-dependent patients with proper planning. The study highlights the importance of adapting existing treatment pathways and monitoring protocols to address the unique risks posed by renal impairment.
While the small number of cases limits generalizability, the authors stress the value of sharing such clinical experiences. As standardization remains lacking in this area, collaborative efforts and pooled data from multiple centers could support the development of practical, flexible guidelines for managing radioiodine therapy in ESKD patients.
Reference:
Lin, R., Malaroda, A., Ryder, W. et al. Management of radioiodine ablation therapy in haemodialysis patients with thyroid cancer: a case series of two patients. BMC Nephrol 26, 420 (2025). https://doi.org/10.1186/s12882-025-04348-0

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