Cancers of the kidney and urinary tract in patients on dialysis for end-stage renal disease: analysis of data from the United States, Europe, and Australia and New Zealand

The Incidences and Characteristics of Various Cancers in Patients on Dialysis: a Korean Nationwide Study

BACKGROUND

The numbers of patients on dialysis and their life expectancies are increasing. Reduced renal function is associated with an increased risk of cancer, but the cancer incidence and sites in dialysis patients compared with those of the general population require further investigation. We investigated the incidences of various cancers in dialysis patients in Korea and used national health insurance data to identify cancers that should be screened in dialysis clinics.

METHODS

We accessed the Korean National Health Insurance Database and excerpted data using the International Classification of Disease codes for dialysis and malignancies. We included all patients who commenced dialysis between 2004 and 2013 and selected the same number of controls via propensity score matching.

RESULTS

A total of 48,315 dialysis patients and controls were evaluated; of these, 2,504 (5.2%) dialysis patients and 2,201 (4.6%) controls developed cancer. The overall cancer risk was 1.54-fold higher in dialysis patients than in controls (adjusted hazard ratio, 1.71; 95% confidence interval, 1.61-1.81). The cancer incidence rate (incidence rate ratio [IRR], 3.27) was especially high in younger dialysis patients (aged 0-29 years). The most common malignancy of end-stage renal disease patients and controls was colorectal cancer. The major primary cancer sites in dialysis patients were liver and stomach, followed by the lung, kidney, and urinary tract. Kidney cancer exhibited the highest IRR (6.75), followed by upper urinary tract (4.00) and skin cancer (3.38). The rates of prostate cancer (0.54) and oropharyngeal cancer (0.72) were lower than those in the general population.

CONCLUSION

Dialysis patients exhibited a higher incidence of malignancy than controls. Dialysis patients should be screened in terms of colorectal, liver, lung, kidney and urinary tract malignancies in dialysis clinics.

Association between urologic malignancies and end-stage renal disease: A meta-analysis

AIM

Previous studies have suggested a higher incidence of urologic malignancies in end-stage renal disease (ESRD) patients. However, incidence trends of urologic malignancies in ESRD patients remain unclear. The aims of the present study were: (i) to investigate the pooled incidence/incidence trends; and (ii) to assess the risk of urologic malignancies in ESRD patients.

METHODS

A literature search was conducted using MEDLINE, EMBASE and Cochrane Database from inception through April 2017. Studies that reported incidence or odds ratios of urologic malignancies among ESRD patients were included. Pooled odds ratios (OR) and 95%CI were calculated using a random-effect model. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42017067687).

RESULTS

Nineteen observational studies with 1 931 073 ESRD patients were enrolled. The pooled estimated incidence of kidney cancer and urothelial cancers (carcinomas of the bladder, ureters, and renal pelvis) in ESRD patients were 0.3% (95%CI: 0.2-0.5%) and 0.5% (95%CI: 0.3-0.8%), respectively. Meta-regression showed significant positive correlation between incidence of urologic malignancies in ESRD patients and year of study (slopes = +0.05 and +0.07, P < 0.001 for kidney cancer and urothelial cancers, respectively). Compared to non-ESRD status, ESRD was significantly associated with both kidney cancer (pooled OR 6.04; 95% CI 4.70-7.77) and urothelial cancers (pooled OR 4.37; 95% CI 2.40-7.96).

CONCLUSION

Our study demonstrates a significant association between ESRD and urologic malignancies. The overall estimated incidence rates of kidney cancer and urothelial cancers are 0.4% and 0.5%, respectively. There is a significant positive correlation between the incidence of urologic malignancies and year of study.

Chronic kidney disease and positive surgical margins as prognosticators for upper urinary tract urothelial carcinoma patients undergoing radical nephroureterectomy

Chronic kidney disease (CKD) is a common condition among elderly patients and has been reported to be a biomarker for the presence of malignant disease. In addition, unfavorable outcomes for patients with upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy can be due to independent clinical factors. Therefore, the present study analyzed the clinicopathological data of patients with UTUC, who underwent radical nephroureterectomy at our institution, to clarify whether preoperative CKD and other factors are independent predictors of the shorter disease-specific and/or recurrence-free survival time of these patients. A retrospective review of 187 patients who underwent radical nephroureterectomy was conducted, and patients were followed for at least 3 months postoperatively. The clinicopathological factors that are thought to have potentially significant roles in the progression and metastasis of malignant tumors and for disease-specific and recurrence-free survival were evaluated. Positive surgical margins and an estimation of the glomerular filtration rate (eGFR) of <60 were independent factors for the shorter disease-specific survival time in multivariate analysis with Cox's proportional hazards model [hazard ratio (HR), 2.401: 95% confidence interval (CI), 1.044-5.255; and HR, 2.371: 95% CI, 1.024-5.898, respectively]. Another multivariate analysis also revealed that positive surgical margins (HR, 4.477; 95% CI, 2.042-9.469), and preoperative eGFR <60 (HR, 2.362; 95% CI, 1.067-5.592) were independent factors for the worse recurrence-free survival rate in all patients. Patients with UTUC who had eGFR <60 as well as positive surgical margins had significantly shorter time to disease-specific mortality and extraurothelial recurrence. The present study demonstrated that patients with UTUC undergoing radical nephroureterectomy who have CKD as well as positive surgical margins should be carefully followed up postoperatively.

Development and validation of a nomogram for urothelial cancer in patients with chronic kidney disease

Urothelial cancer (UC) is a common kidney cancer in Taiwan and patients with chronic kidney disease (CKD) are more at risk for UC than the general population. The diagnostic value of urine analysis and urine cytology is limited, especially in CKD patients. The aim of the study is to develop a nomogram to predict the risk of UC in CKD patients. We enrolled 169 UC patients and 1383 CKD patients from 9 hospitals in Taiwan between 2012 and 2015. CA125, HE4, clinical characteristics, and medical history were analyzed using multivariable logistic regression for its association with UC. A nomogram was developed to predict the risk of UC and was validated using Bootstrap. CA125 was associated with UC in CKD patients (OR: 5.91, 95% CI: 3.24–10.77) but HE4 was not (OR: 1.29, 95% CI: 0.67–2.35). A nomogram based on patients’ age, estimated glomerular filtration rate, CA125 (log transformed), smoking, exposure of environmental toxin, use of nonsteroid anti-inflammatory drugs, and use of traditional Chinese medicine was conducted. The AUC of the nomogram was 0.90 (95% CI: 0.86–0.92, p < 0.01). Serum CA125 may identify UC patients from CKD patients but has limited diagnostic value due to low sensitivity. The diagnostic value of serum CA125 level can be improved by the combination with clinical characteristics including age, renal function, and medical history.

Kidney stones and the risk of renal cell carcinoma and upper tract urothelial carcinoma: the Netherlands Cohort Study

Background

We examined the association between kidney stones and renal cell carcinoma (RCC) and upper tract urothelial carcinoma (UTUC) risk in the Netherlands Cohort Study on diet and cancer.

Methods

In total, 120,852 participants aged 55–69 completed a self-administered questionnaire on diet, medical conditions and other risk factors for cancer at baseline (1986). After 20.3 years of cancer follow-up 4352 subcohort members, 544 RCC cases and 140 UTUC cases were eligible for case-cohort analysis. Hazard ratios (HR) and 95% confidence intervals (CIs) were estimated by multivariable-adjusted proportional hazards models.

Results

Kidney stones were associated with an increased RCC risk (HR: 1.39, 95% CI 1.05–1.84), vs. no kidney stones. Kidney stones were associated with an increased risk of papillary RCC (HR: 3.08, 95% CI 1.55–6.11), but not clear-cell RCC (HR: 1.14, 95% CI 0.79–1.65). UTUC risk was increased for participants with kidney stones (HR: 1.66, 95% CI 1.03–2.68). No heterogeneity of associations was found for UTUC in the ureter and renal pelvis. An early kidney stone diagnosis (≤40 years) was associated with an increased RCC and UTUC risk, compared to later diagnosis.

Conclusion

Kidney stones were associated with increased papillary RCC risk, but not clear-cell RCC risk. No heterogeneity was found for UTUC subtypes.

Oncology in nephrology comes of age: A focus on chronic dialysis patients

Dialysis is the commonest modality of renal replacement therapy for patients suffering from end-stage kidney disease. Different registry studies showed that the risks of overall cancer occurrence were significantly higher in chronic dialysis patients than in the age-matched general population. However, the frequency and pattern of different cancers may vary among different geographical areas. Since chronic dialysis patients tend to have multiple comorbidities and a shorter life expectancy, routine cancer screening in all dialysis patients may not be cost-effective; rather screening should be personalized according to the patient's expected survival, candidacy for kidney transplant together with patient preferences.

Time trends in the prevalence of cancer and non-cancer diseases among older U.S. adults: Medicare-based analysis

Longer lifespan is accompanied by a larger number of chronic diseases among older adults. Because of a growing proportion of older adults in the U.S., this brings the problem of age-related morbidity to the forefront as a major contributor to rising medical expenditures. We evaluated 15-year time trends (from 1998 to 2013) in the prevalence of 48 acute and chronic non-cancer diseases and cancers in older U.S. adults aged 65+ and estimated the annual percentage changes of these prevalence trends using SEER-Medicare and HRS-Medicare data. We found that age-adjusted prevalence of cancers of kidney, pancreas, and melanoma, as well as diabetes, renal disease, limb fracture, depression, anemia, weight deficiency, dementia/Alzheimer's disease, drug/medications abuse and several other diseases/conditions increased over time. Conversely, prevalence of myocardial infarction, heart failure, cardiomyopathy, pneumonia/influenza, peptic ulcer, and gastrointestinal bleeding, among others, decreased over time. There are also diseases whose prevalence did not change substantially over time, e.g., a group of fast progressing cancers and rheumatoid arthritis. Analysis of trends of multiple diseases performed simultaneously within one study design with focus on the same time interval and the same population for all diseases allowed us to provide insight into the epidemiology of these conditions and identify the most alarming and/or unexpected trends and trade-offs. The obtained results can be used for health expenditures planning for growing sector of older adults in the U.S.

Posttransplant Malignancies in Adult Renal and Hepatic Transplant Patients

OBJECTIVES

The risk of some cancer types increases after organ transplant compared with that shown in the general population; this has been well documented in clinical studies. With patients having longer survival and with the higher number of transplant procedures, cancer is an increasing health concern at high-volume transplant centers. Malignancy has an important effect on short- and long-term graft and patient survival. In this study, we evaluated cancer frequency during transplant patient follow-up.

MATERIALS AND METHODS

This single-center retrospective study included patients who underwent solid-organ transplant at the Baskent University Medical Faculty Hospital from 1997 to 2017. Renal and hepatic transplant patients older than 16 years at the time of transplant and diagnosed with cancer after transplant were included the study. In total, 1176 of 2018 renal transplant recipients and 274 of 548 hepatic transplant recipients met the inclusion criteria.

RESULTS

We determined that 52 of 1176 renal transplant (4.5%) and 9 of 274 hepatic transplant patients (3.3%) developed posttransplant cancer during follow-up. Of 61 total patients with cancer posttransplant, 44 were males (72.1%) and 17 were females (27.9%), with median age at transplant of 39.2 years. Overall, the incidence of cancer in transplant recipients was 4.2%. The most frequent cancers were basal and squamous skin cancers, which were seen in 18 patients (29%), and Kaposi sarcoma, which was seen in 11 patients (18%). Of the 61 patients who developed cancer, 43 (70%) were still alive at the time of this study.

CONCLUSIONS

Despite recent positive developments in the use of immunosuppressive drugs, posttransplant malignancy is still a health problem. Fortunately, most cancers in this patient group have good prognosis and can be cured by surgical resection. Transplant physicians should aim for early detection of these diseases.

Dialysis physicians' referral behaviors for hemodialysis patients suspected of having cancer: A vignette-based questionnaire study

BACKGROUND

Although cancer management in dialysis patients has become a commonly encountered issue, known as "onco-nephrology", few evidence-based clinical recommendations have been proposed. Here, we examined the variation in referral behaviors adopted by dialysis physicians on encountering dialysis patients with signs/symptoms suggestive of cancer.

METHODS

We conducted a vignette-based study in August 2015. We sent a 14-page questionnaire to 191 dialysis physicians, including the representative dialysis facilities participating in a Japanese dialysis cohort (the Japan Dialysis Outcomes and Practice Patterns Study). Using vignette scenarios for respiratory, digestive, and urological areas, we assessed the referral behaviors (expert referral or not) adopted by dialysis physicians on encountering dialysis patients with symptoms suggestive of cancer. Each scenario contained three patient functional factors: age (60 or 75 years), performance status (PS 0 or 1), and cognitive dysfunction (absence or presence). We examined the association between physician factors, patient factors, and referral behaviors.

RESULTS

We obtained 94 replies (response rate: 49.2%). For the respiratory scenarios, 38.3% and 51.9% of physicians reported watchful waiting when encountering bilateral and unilateral pleural effusion, respectively. In digestive and urologic scenarios, most physicians (>85%) selected expert referral. We detected differences in referral behaviors between scenarios with different cancer biological factors. However, we found consistency in referral behaviors within the same scenario, even with different patient functional factors (intra-class correlation coefficients within each scenario all >0.7).

CONCLUSIONS

Physicians' referral behaviors for dialysis patients suspected of having cancer vary for different cancer biological factors (probability of having cancer). However, the referral behaviors are similar for different patient functional factors (age, PS, and cognitive dysfunction).

Risk factors associated with post-kidney transplant malignancies: an article from the Cancer-Kidney International Network

In kidney transplant recipients, cancer is one of the leading causes of death with a functioning graft beyond the first year of kidney transplantation, and malignancies account for 8-10% of all deaths in the USA (2.6 deaths/1000 patient-years) and exceed 30% of deaths in Australia (5/1000 patient-years) in kidney transplant recipients. Patient-, transplant- and medication-related factors contribute to the increased cancer risk following kidney transplantation. While it is well established that the overall immunosuppressive dose is associated with an increased risk for cancer following transplantation, the contributive effect of different immunosuppressive agents is not well established. In this review we will discuss the different risk factors for malignancies after kidney transplantation.

Risks of female genital tract related cancers (gynecological cancers) or breast cancer in women with and without chronic kidney disease: A population-based cohort study in Taiwan

This article aims to test the hypothesis that the risk of female genital tract related cancer (gynecological cancer: GC) or breast cancer (BC) of women with chronic kidney disease (CKD) might be different from that of those women without CKD.A nationwide 17-year historic cohort study using the National Health Insurance Research Database (NHIRD) of Taiwan and the Registry for Catastrophic Illness Patients was conducted. A total of 3045 women with a diagnosis of CKD from 1996 to 2013 and 3045 multivariable-matched controls (1:1) were selected. We used Cox regression, and computed hazard ratios (HRs) with 95% confidence intervals (95% CIs) to determine the risk of GC or BC in women.The GC incidence rates (IRs, per 10,000 person-years) of the CKD and non-CKD women were 11.02 and 19.09, respectively, contributing to a significantly decreased risk of GCs (crude HR 0.57, 95% CI 0.39-0.81; adjusted HR 0.44, 95% CI 0.30-0.65) in the CKD women. The GC IR was relatively constant in the CKD women among the different age categories (IR ranged from 8.10 to 12.29). On contrast, the non-CKD women had a progressive and continuous increase of GC IR in the advanced age, which was more apparent at age ≥50 years (IR 17.16 for 50-59; IR 23.05 for 60-69; and IR 31.62 for ≥70, respectively), contributing to the lower risk of GC in the CKD women than that in the non-CKD women. There was no difference of BC incidence between women with and without CKD.The findings of the lower risk of GCs in the CKD women in Taiwan are worthy of further evaluation.

Is there different risk of cancer among end-stage renal disease patients undergoing hemodialysis and peritoneal dialysis?

Cancer is a global issue in recent decade. Despite this alarming increase in the incidence of cancer, to date, whether the risk of developing cancer differs among peritoneal dialysis (PD) and hemodialysis (HD) patients is still uncertain. In this retrospective cohort study, data were obtained from the National Health Insurance Research Database of Taiwan, which provides coverage to almost 99% of the nation's population. After matching, a total of 4491 (or 3369) incident PD patients and 8982 (or 6738) incident HD patients between 2000 and 2009 were enrolled from the database. In addition, 22,455 (or 16,845) nondialysis patients were selected as a control group. The patients were monitored for the occurrence of cancer until 2010, and their data were analyzed using several different models. In general, the results showed that the risks of hepatocellular, kidney, bladder, extra kidney/bladder urinary tract, and thyroid cancers were higher in dialysis patients. We also compared the risk of cancer between two dialysis groups by using the HD patients as the reference group. The result showed that there is no significant different for each cancer risk between two dialysis groups. In conclusion, dialysis patients had a higher risk of certain types of cancer than those in the nonuremia group. However, there was no significant difference in the cancer risk between the two dialysis groups when compared directly.

Characteristics of Upper Urothelial Carcinoma in an Area of Balkan Endemic Nephropathy in South Serbia. A fifty-year Retrospective Study

Aims and background

Upper urinary tract transitional cell carcinoma, a relatively rare tumor, is up to 100 times more frequent in regions with Balkan endemic nephropathy. Characteristics of transitional cell carcinoma in the endemic South Morava Region in Serbia in the previous 50 years were evaluated.

Patients

We analyzed 477 cases with pathologically confirmed transitional cell carcinoma who underwent surgery from 1957 to 2006: 91 from endemic, 106 from adjacent and 280 from control settlements. Cases in the study came from 10 endemic villages, 46 adjacent villages, 51 control villages and the city of Nis.

Results

The increase in number of transitional cell carcinoma from 1957 was followed by a peak between 1967 and 1978 (yearly incidence 21.9 per 100,000) and a slow decrease thereafter to 7.4 (1997–2006). In the control settlements, the increase was steady. Reduced kidney function at surgery was found in 58% of patients from endemic and in 20% from control settlements. Age at surgery has significantly increased from 52.3 and 51.5 (1957–1966) to 70.9 and 66.1 (1997–2006) for endemic and control settlements, respectively. The female sex was predominant in endemic and adjacent settlements and the male sex in control settlements. Transitional cell carcinoma from endemic settlements was of a lower grade in the period from 1957–1986, but in the period from 1987–2006 they were predominantly high grade. Low tumor stage (pTa-pT1) predominated in transitional cell carcinoma from the endemic and adjacent but not the control settlements in the period from 1957 to 1986. However, in the last 20 years, upper urinary tract transitional cell carcinoma stage increased, the highest in the period from 1997 to 2006 in all settlements studied. Conservative surgery was advocated for transitional cell carcinoma in Balkan endemic nephropathy areas up to 1996. Transitional cell carcinoma are now more malignant and more advanced than before, and a less aggressive approach is used only for absolute indications.

Conclusions

An increased number of transitional cell carcinoma in endemic settlements was observed, markedly decreasing in the last decade. An increasing age and a shorter survival were recorded in patients both from Balkan endemic nephropathy and control settlements. Sporadic cases upper urinary tract transitional cell carcinoma in settlements adjacent to endemic settlements were demonstrated. Free full text available at www.tumorionline.it

Association of erythropoiesis-stimulating agents and the incidence risk of cancer diagnosis among chronic dialysis patients: a nested case-control study

Background

Erythropoiesis-stimulating agents (ESAs) are the cornerstone of the treatment for anemia in end-stage renal disease (ESRD) patients. Although a correlation has been established between ESAs and increased tumor growth among patients with cancer-related anemia, an association with a higher incidence of cancer among chronic dialysis patients remains relatively unclear.

Methods

We completed a nested case-control study in a cohort of 4574 patients who began chronic dialysis treatment between 1 January 2001 and 31 December 2007 in Quebec, Canada, utilizing dialysis registry and administrative databases exclusively to extract our data. We excluded patients with a prior diagnosis of cancer. Eligible cases were identified by the time of initial cancer diagnosis obtained from either the hospital's discharge or physician billing form. We then randomly selected up to 10 controls for each case. ESA exposure was evaluated between 6 and 9 months prior to the initial cancer diagnosis. The mean weekly exposure was used to categorize ESA usage as either a low dose (<30 µg/week), moderate dose (30-70 µg/week) or high dose (>70 µg/week). We estimated the association between ESAs and the risk of developing cancer using a multivariable conditional logistic regression.

Results

We identified 419 cases of cancer and 3895 matched controls during the study period. The use of ESAs was associated with a higher risk of cancer {odds ratio [OR] 1.04 [95% confidence interval (CI) 1.02-1.07]}. Specifically, patients in the high exposure group (>70 µg/week) had an increased risk of developing cancer [OR 1.77 (95% CI 1.18-2.66)] compared with patients in the unexposed group.

Conclusion

High-dose ESA was associated with an increased incidence risk of new cancer diagnosis among chronic dialysis patients.

Acquired cystic kidney disease: an under-recognized condition in children with end-stage renal disease

Acquired cystic kidney disease (ACKD) is a condition that occurs predominantly in patients with end-stage renal disease (ESRD). In contrast to hereditary cystic kidney disease, ACKD is characterized by the presence of multiple small cysts in bilaterally small kidneys. Limited pediatric data suggest a high incidence (21.6-45.8%) of ACKD in children on dialysis, comparable to that in adults, with an increased frequency associated with a longer duration of dialysis. Recent research has shed light on the pathogenesis of ACKD, such as activation of proto-oncogenes. Although most patients with ACKD are asymptomatic, the condition can be complicated by renal cell carcinoma. Routine surveillance should therefore be considered in at-risk populations.

Assessment of Kidney Function in Patients With Cancer

Cancer patients are living longer. The sequelae of cancer treatment and the role of comorbid conditions present before the diagnosis, such as CKD, have been increasingly recognized. The interface between CKD and cancer is multifaceted. CKD is frequently observed in patients with cancer, and cancer treatment contributes to CKD development and progression. In addition, CKD has been recognized as an important risk factor for cancer development and reduced specific cancer survival. In this context, an accurate evaluation of the glomerular filtration rate (GFR) during oncologic treatment is pivotal and is used to define surgery strategies, program prophylactic management of contrasted examinations, make decisions on cisplatin eligibility, and adjust drug prescriptions, particularly chemotherapy agents. Although the most commonly used equations to estimate GFR based on serum creatinine levels in clinical practice (Cockcroft-Gault, Modification of Diet in Renal Disease Study, and CKD Epidemiology Collaboration equations) have not been validated in patients with cancer in large prospective studies, there is increasingly evidence supporting the use of CKD Epidemiology Collaboration equation to assess the GFR in patients with cancer, including for the use of chemotherapy prescriptions. Many patients with cancer may have changes in nutrition status and clearance measurements such as exogenous filtration markers might be extremely useful when clinical decisions differ depending on the GFR level. Future perspectives include the advent of new serum GFR biomarkers such as cystatin C, beta-trace protein, and beta-2 microglobulin as well as the GFR assessment by measuring total kidney parenchymal volume through image examinations.

Urologic malignancies in kidney transplantation

With advances in immunosuppression, graft and patient outcomes after kidney transplantation have improved considerably. As a result, long-term complications of transplantation, such as urologic malignancies, have become increasingly important. Kidney transplant recipients, for example, have a 7-fold risk of renal cell carcinoma (RCC) and 3-fold risk of urothelial carcinoma (UC) compared with the general population. While extrapolation of data from the general population suggest that routine cancer screening in transplant recipients would allow for earlier diagnosis and management of these potentially lethal malignancies, currently there is no consensus for posttransplantation RCC or UC screening as supporting data are limited. Further understanding of risk factors, presentation, optimal management of, and screening for urologic malignancies in kidney transplant patients is warranted, and as such, this review will focus on the incidence, surveillance, and treatment of urologic malignancies in kidney transplant recipients.

[Is cancer incidence different between type 2 diabetes patients compared to non-diabetics in hemodialysis? A study from the REIN registry]

BACKGROUND AND OBJECTIVES

In France, diabetes mellitus is now the second cause of end stage renal disease. In a large previous French national study, we observed that dialyzed diabetics have a significant lower risk of death by cancer. This first study was focused on cancer death but did not investigate cancer incidence. In this context, the aim of this second study was to compare the incidence of cancer in diabetic dialyzed patients compared to non-diabetic dialyzed patients in a French region.

METHODS

This epidemiologic multicentric study included 588 diabetic and non-diabetic patients starting hemodialysis between 2002 and 2007 in Bretagne. Data were issued from REIN registry and cancer incidence were individually collected from medical records. Diabetics and non-diabetics were matched one by one on age, sex and year of dialysis initiation.

RESULTS

During the follow-up, we observed 28 cancers (9.4%) in diabetic patients and 26 cancers (8.9%) in non-diabetics patients. The cumulative incidence to develop a cancer 2 years after the dialysis start was approximately 6% in both diabetics and non-diabetics patients. In univariate Fine and Gray analysis, BMI, hemoglobin, statin use had P-value<0.2. However, in the adjusted model, these variables were not significantly associated with cancer incidence.

CONCLUSION

This study lead on a little number of dialyzed patients did not show any significant difference on cancer incidence between diabetic and non-diabetic patients after hemodialysis start.

Perioperative Complications and Mortality in Patients with Urothelial Carcinoma and End-Stage Renal Disease Undergoing One-Stage Complete Urinary Tract Extirpation

BACKGROUND

Complete urinary tract extirpation (CUTE) is a complex procedure with substantial risk for perioperative complications. The association between clinical characteristics and the risk of major postoperative complications has not been systematically investigated.

OBJECTIVE

The aim of this study was to analyze the incidence and risks for major perioperative complications after CUTE.

METHODS

Respective chart review of 81 patients with urothelial carcinoma (UC) who were treated with one-stage CUTE between January 2004 and December 2015. Fisher's exact test with Chi square and two-tailed t test were used in categorical and continuous variables, respectively. Univariable and multivariable logistic regression models were used to evaluate the probability of major complications.

RESULTS

In this population, 53 (65.4%) patients had Clavien grade 0-2 complications ('no major complications') and 28 (34.6%) patients had Clavien grade 3-5 complications ('major complications'). Compared with the major complications group, patients in the no major complications group were younger, had lower Charlson Comorbidity Index (CCI), higher preoperative serum albumin, and shorter duration of hospitalization (p < 0.05 for all). Major complications were more common in low-volume surgeons (p = 0.002). On multivariate logistic regression analyses, CCI ≥ 5 (odds ratio [OR] 6.25, 95% confidence interval [CI] 1.42-27.47; p = 0.015) and surgery by a provider who performed three or fewer cases during the study interval (OR 13.4, 95% CI 2.20-80.89; p = 0.005) were independent predictors for major complications.

CONCLUSIONS

High CCI should alert providers to increased probability of major complications, and warrant vigilant management after CUTE. Surgeon volume was inversely related to major postoperative complications.

Nephroureterectomy increase 5 year survival in patients on dialysis with upper urinary tract urothelial carcinoma

Background

There is a high incidence rate of upper tract urothelial carcinoma (UTUC) in patients on dialysis. However, the studies about nephroureterectomy (NU) in this high surgical risk group are limited. The aim of this study is to investigate the outcomes of NU in this population.

Results

There were total 931 patients enrolled and 218, 582, 131 patients were non-NU, unilateral and one-stage bilateral NU, respectively. NU provided better 5-year overall survival (66% versus 51% in non-NU, P = 0.001). 19.7% of patients with unilateral NU had successive contralateral NU with a mean interval period of 695 days. Even for the elderly, there were no significant difference in duration of hospitalization, 30- and 90-day mortality between unilateral and bilateral NU.

Materials and Methods

Patients on dialysis with UTUC between January 1998 and December 2012 were assessed from the nationwide cohort of Taiwan National Health Insurance Research Database. We classified these patients into non-NU and NU groups. In NU group, we analyzed clinical outcomes of patient groups between different NU types and surgical methods.

Conclusions

Although the high surgical risk in patients on dialysis with UTUC, NU provided better 5-year overall survival. One-stage bilateral NU both provides comparable safety profile and avoids 19.7% of successive contralateral NU in less than two years. Even in the elderly, one-stage bilateral NU is safe and feasible.

Incidence and mortality of kidney cancer and its relationship with HDI (Human Development Index) in the world in 2012

Background and aims

Kidney cancer is among the cancers that have the highest growth rate in all age and racial groups in the world and is as the most deadly type of urinary tract cancer. Since awareness about this cancer incidence status and mortality is essential for better planning, this study aimed to investigate the incidence and mortality rate of kidney cancer and its relationship with the development index in the world in 2012.

Method

This study was an ecological study conducted based on GLOBOCAN project of the World Health Organization (WHO) for the countries in the world. The correlation between Standardized Incidence Rates (SIRs) and Standardized Mortality Rates (SMRs) of kidney cancer with HDI and its components was assessed using SPSS18.

Results

In total, 337,860 incidence cases (213,924 were men and 123,936 women) and 143,406 deaths (90,802 cases in men and 52,604 in women) of kidney cancer were recorded in 2012. A positive correlation of 0.731 was seen between SIR of kidney cancer and HDI (p≤0.001). Also, a negative correlation of 0.627 was seen between SMR of kidney cancer and HDI (p≤0.001).

Conclusion

The incidence and mortality rate of kidney cancer is higher in developed countries. A significant positive correlation has been seen between the standardized incidence and mortality rate of kidney cancer with the Human Development Index and its components. We need more studies to examine variation in incidence and mortality of kidney cancer and its related factors in the world.

Cancer in Korean patients with end-stage renal disease: A 7-year follow-up

BACKGROUND

The effectiveness of dialysis on the incidence of cancer in patients with end-stage renal disease (ESRD) remains to be clarified. In this study, we evaluated the incidence rate and type of cancer among patients with ESRD, compared to the general population, through a prospective 7-year follow-up. We also calculated the cumulative incidence rate of cancer associated with ESRD, with stratification to control for the competing risk of death.

METHODS

This prospective observational cohort study was conducted using data from a nationwide study on patients with ESRD in Korea. A total of 5,235 patients, ≥18 years old, with ESRD were identified from the national registry as being treated by dialysis between August 2008 and December 2014. The standardized incidence ratio (SIR) and cumulative incidence rate of specific cancers were evaluated and compared to the general population.

RESULTS

A total of 5,235 participants were included. During the 7 year observation period, 116 (2.2%) participants had been diagnosed as cancer. The SIR of overall cancer was 0.94 [95% confidence interval (CI), 0.72-1.19] and was comparable to the rate for the general population. Although the digestive organs were the most frequent site of a primary site cancer (N = 39, 33.6%), the SIR was highest for urinary tract cancer [4.7, 95% CI, 2.42-8.19]. The five year standardized cumulative incidence of cancer was higher for females than for males, and for non-diabetic compared to diabetic causes of ESRD. We estimated that the five year standardized cumulative incidence was highest [8.4, 95% CI, 5.07-13.75] in patients with ESRD, caused by glomerulonephritis.

CONCLUSION

A screening program should be necessary for urinary tract cancer in Korean patients with ESRD. Cancer screening programs for patients with ESRD in Korea should be emphasized on female patients and patients with non-diabetic ESRD.

Reduced estimated glomerular filtration rate (eGFR <60 mL/min/1.73 m2 ) at first transurethral resection of bladder tumour is a significant predictor of subsequent recurrence and progression

OBJECTIVE

To evaluate if moderate chronic kidney disease [CKD; estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² ] is associated with high rates of non-muscle-invasive bladder cancer (NMIBC) recurrence or progression.

PATIENTS AND METHODS

A multi-institutional database identified patients with serum creatinine values prior to first transurethral resection of bladder tumour (TURBT). The CKD-epidemiology collaboration formula calculated patient eGFR. Cox proportional hazards models evaluated associations with recurrence-free (RFS) and progression-free survival (PFS).

RESULTS

In all, 727 patients were identified with a median (interquartile range [IQR]) patient age of 69.8 (60.1-77.6) years. Data for eGFR were available for 632 patients. During a median (IQR) follow-up of 3.7 (1.5-6.5) years, 400 (55%) patients had recurrence and 145 (19.9%) patients had progression of tumour stage or grade. Moderate or severe CKD was identified in 183 patients according to eGFR. Multivariable analysis identified an eGFR of <60 mL/min/1.73 m² (hazard ratio [HR] 1.5, 95% confidence interval [CI]: 1.2-1.9; P = 0.002) as a predictor of tumour recurrence. The 5-year RFS rate was 46% for patients with an eGFR of ≥60 mL/min/1.73 m² and 27% for patients with an eGFR of <60 mL/min/1.73 m² (P < 0.001). Multivariable analysis showed that an eGFR of <60 mL/min/1.73 m² (HR 3.7, 95% CI: 1.75-7.94; P = 0.001) was associated with progression to muscle-invasive disease. The 5-year PFS rate was 83% for patients with an eGFR of ≥60 mL/min/1.73 m² and 71% for patients with an eGFR of <60 mL/min/1.73 m² (P = 0.01).

CONCLUSION

Moderate CKD at first TURBT is associated with reduced RFS and PFS. Patients with reduced renal function should be considered for increased surveillance.

Renal Tumor in Allogeneic Kidney Transplant Recipient

BACKGROUND

Malignancies will be a leading cause of mortality in renal transplant recipients in the next 20 years. Renal cell cancer (RCC) is the most common urologic cancer in kidney transplant recipients. The risk of RCC development in kidney transplant recipients is 15-100 times higher than in the general population. The purpose of the current retrospective study was to assess the frequency of nephrectomies performed because of renal tumors in the native kidneys in kidney transplant recipients in the Department of General and Transplantation Surgery at the Medical University of Warsaw between 2010 and 2014 year; the identification of kidney recipients diagnosed with RCC; and epidemiologic, clinical, and histopathological aspects associated with RCC.

PATIENTS AND METHODS

A total of 319 nephrectomies were performed in the Department of General and Transplantation Surgery at the Medical University of Warsaw between 2010 and 2014 year. Renal tumors were diagnosed in 25 renal transplant recipients.

RESULTS

Among malignant tumors, 13 cases of RCC and 1 case of post-transplant lymphoproliferative disorder (PTLD) were observed. There was no significant difference between age and duration of pretransplantation dialysis in patients with RCC and patients with benign tumors (P = .14 and P = .91, respectively). Body mass index was significantly higher in patients with RCC than in patients with benign tumors (P = .04).

CONCLUSIONS

Renal cell cancer is more common among male kidney recipients. There is a good Polish screening system allowing detection of kidney cancer in native kidney. We recommend performing periodic screening for kidney cancers to obtain an early diagnosis.

Is preoperative chronic kidney disease status associated with oncologic outcomes in upper urinary tract urothelial carcinoma? A multicenter propensity score-matched analysis

Purpose

The aim of this study was to determine the effect of preoperative chronic kidney disease (CKD) on the prognosis of patients with upper urinary tract urothelial carcinoma (UTUC) who had undergone radical nephroureterectomy (RNU).

Results

The median follow-up period was 31.1 months (interquartile range: 16.2-55.7 months). Among the study patients, 224 patients in the non-CKD group were selected via propensity score matching. The median recurrence-free, cancer-specific, and overall survival were significantly shorter for patients with preoperative CKD than for non-CKD patients (p = 0.001, p = 0.001, and p = 0.001, respectively). According to multivariable Cox regression analysis, preoperative CKD was related to worse recurrence-free (hazard ratio [HR]: 1.81, 95% confidence interval [CI]: 1.15-2.86, p = 0.011), cancer-specific (HR: 2.44, 95% CI: 1.44-4.14, p = 0.001), and overall survival (HR: 1.66, 95% CI: 1.15-2.40, p = 0.007).

Methods

A total of 566 patients who underwent RNU at 6 institutions from 2004 to 2014 were retrospectively reviewed. Of these patients, 342 had an estimated glomerular filtration rate (eGFR) ≥ 60 ml/min/1.73 m² (non-CKD group) and 224 patients had an eGFR <60 ml/min/1.73 m² (CKD group). To adjust for potential baseline confounders, 224 patients in the non-CKD group were selected by propensity matching. Clinicopathological variables and survival rates were compared between the 2 groups.

Conclusions

Preoperative CKD appears to be an important independent prognostic factor for oncologic outcomes in patients with UTUC.

Differences in Clinical and Pathological Features of Renal Cell Carcinoma Between Japanese Patients After Kidney Transplantation and Those on Hemodialysis

We compared the clinical features, pathological features, and prognoses of patients with renal cell carcinoma (RCC) arising in the native kidney after kidney transplantation (RCC-transplant) or on hemodialysis (RCC-HD), and analyzed predictive factors for survival at a Japanese single institution. This cohort included 42 patients in the RCC-transplant group and 467 patients in the RCC-HD group. RCC-transplant patients were younger (53 years vs. 56 years, P = 0.0358) and had less frequent symptoms (12% vs. 27%, P = 0.0344) than RCC-HD patients. Although tumor size, tumor stage, and histological subtype were not significantly different, the RCC-transplant group had less frequent multifocal occurrences and ACDK. Overall 5-year survival (RCC-transplant, 80%; RCC-hemodialysis, 76%; P = 0.3217) and 5-year cancer-specific survival (CSS; RCC-transplant, 84%; RCC-hemodialysis, 89%; P = 0.8916) were not significantly different between the two groups. Tumor stage and grade were significant predictors for CSS. Although kidney transplantation and hemodialysis were not associated with CSS, tumor stage was an independent predictor of CSS.

Long-term outcomes of complete urinary tract exenteration for dialysis patients with urothelial cancer

PURPOSE

To survey long-term outcomes of dialysis patients with urothelial cancers who have undergone complete urinary tract exenteration (bilateral nephroureterectomy and cystectomy).

METHODS

We retrospectively reviewed our patients with urinary tract urothelial cancer. Forty-two dialysis patients who underwent complete urinary tract exenteration were enrolled in our study. Seventeen patients had undergone one-stage complete urinary tract exenteration, and twenty-five patients had undergone multi-stage surgery. We reviewed the demographic, clinical, surgical, and pathological data to determine the clinical and pathologic variables that affected the survival between the two groups.

RESULTS

Baseline demographics were comparable in both groups. There was no significant difference in age, American Society of Anesthesiologists class, Charlson index, or body mass index between the two groups. Furthermore, there was no statistically significant difference in estimated blood loss (1280 vs. 1440 ml) or total hospital stay (31 vs. 21 days). Simultaneous upper and lower tract tumors were noted in one-stage CUTE group In comparison with multi-stage surgery, one-stage surgery was associated with a higher complication rate (58.8 vs. 28%). Twenty-two patients were still alive at the end of the study, and 20 had died. The median survival period after confirmation of complete urinary tract exenteration status was 27.5 months. The overall survival was the same between the two groups. The Charlson comorbidity index was a mandatory indicator to predict long-term survival outcome.

CONCLUSIONS

In dialysis patients with urothelial cancers who have undergone complete urinary tract exenteration, one-stage complete urinary tract exenteration had a high perioperative complication rate. The Charlson comorbidity index was a mandatory indicator to predict long-term survival outcome.

Risk of Renal Cell Carcinoma Among Kidney Transplant Recipients in the United States

Renal cell carcinoma (RCC) is a common malignancy following kidney transplantation. We describe RCC risk and examine RCC risk factors among US kidney recipients (1987-2010). The Transplant Cancer Match Study links the US transplant registry with 15 cancer registries. Standardized incidence ratios (SIRs) were used to compare RCC risk (overall and for clear cell [ccRCC] and papillary subtypes) to the general population. Associations with risk factors were assessed using Cox models. We identified 683 RCCs among 116 208 kidney recipients. RCC risk was substantially elevated compared with the general population (SIR 5.68, 95% confidence interval 5.27-6.13), especially for papillary RCC (SIR 13.3 versus 3.98 for ccRCC). Among kidney recipients, RCC risk was significantly elevated for blacks compared to whites (hazard ratio [HR] 1.50) and lower in females than males (HR 0.56). RCC risk increased with prolonged dialysis preceding transplantation (p-trend < 0.0001). Risk was variably associated for RCC subtypes with some medical conditions that were indications for transplantation: ccRCC risk was reduced with polycystic kidney disease (HR 0.54), and papillary RCC was increased with hypertensive nephrosclerosis (HR 2.02) and vascular diseases (HR 1.86). In conclusion, kidney recipients experience substantially elevated risk of RCC, especially for papillary RCC, and multiple factors contribute to these cancers.

Anemia management in cancer patients with chronic kidney disease

Anemia is a common complication of cancer and chronic kidney disease (CKD) associated with decreased physical performance as well as poor prognosis for life expectancy. Renal and cancer-induced anemia share common features regarding pathogenesis and therapeutic strategies. It is typically treated with iron substitution, erythropoiesis-stimulating agents (ESA) and in refractory cases with red blood cell transfusions. However, studies of the past few years unveiled numerous setbacks in the use of ESAs. These included a higher risk of cerebrovascular events and increased mortality without the improvement of cardiovascular outcomes in patients with CKD. Moreover, particularly negative results were observed in patients with previous cancer history under ESA therapy. These unfavorable findings have forced the clinicians to reevaluate the management of renal anemia. This led to decrease of ESA usage, while iron substitution and alternative therapeutic options gained more significance. Iron supplementation is also accompanied with certain risks ranging from gastrointestinal complications to severe allergic reactions and increased rate of infections. Furthermore, the evaluation of the long-term safety of excessive iron therapy is still lacking, especially in CKD patients with cancer. In the absence of these clinical studies, this review aims to summarize the currently available therapeutic strategies in anemia management of CKD patients with concomitant cancer.

End Stage Renal Disease Predicts Increased Risk of Death in First Degree Relatives in the Norwegian Population

BACKGROUND

Increased risk of end stage renal disease (ESRD) and death in Norwegian living kidney donors has been reported, most of the donors were related to the recipient. The present study investigates risk of death in first degree relatives of ESRD patients.

METHODS

The Norwegian Population Registry, The Norwegian Cause of Death Registry and the Norwegian Renal Registry were linked. All citizens born in Norway, alive in 1960 and with at least one registered first degree relative were included; individuals who died during the first year of life were excluded. A cohort-design was used, ESRD in a first degree relative was the main exposure variable and death and causes of death were the main outcome variables. Cox regression statistics were used to investigate mortality risks.

RESULTS

5 130 600 individuals were included, 27 508 had at least one first degree relative with ESRD. 828 022 died during follow-up, of whom 4105 had a first degree relative with ESRD. Adjusted hazard ratio (aHR) for death was 1.13 (1.09-1.16) in individuals with a relative with ESRD compared to those without a relative with ESRD. Excluding known hereditary renal disease, aHR decreased to 1.12 (1.09-1.15). Cardiovascular death aHR was 1.15 (1.10-1.21), of which cerebrovascular death 1.34 (1.22-1.50). aHR for death due to non-hereditary renal/ureteric disease was 2.29 (1.81-2.91) with renal failure 1.80 (1.26-2.56) and glomerular disease 5.69 (3.88-8.34) as main contributors. Diabetes mellitus death aHR was 1.68 (1.35-2.10). Absolute mortality risks increased most for the oldest cohorts with excess mortality of 148 per 100.000 person years for the cohort born 1920-39 and 218 for the cohort born 1900-1919.

CONCLUSIONS

ESRD in first degree relatives was associated with increased hazard ratio for death. Death due to cardiovascular disease, renal disease and diabetes mellitus increased the most.

Chronic kidney disease and the risk of cancer: an individual patient data meta-analysis of 32,057 participants from six prospective studies

BACKGROUND

Chronic kidney disease (CKD) is an established risk factor for cardiovascular disease but the relevance of reduced kidney function to cancer risk is uncertain.

METHODS

Individual patient data were collected from six studies (32,057 participants); including one population-based cohort and five randomized controlled trials. Participants were grouped into one of five CKD categories (estimated glomerular filtration rate [eGFR] ≥75 mL/min/1.73 m(2); eGFR ≥60 to <75 mL/min/1.73 m(2); eGFR ≥45 to <60 mL/min/1.73 m(2); eGFR <45 mL/min/1.73 m(2); on dialysis). Stratified Cox regression was used to assess the impact of CKD category on cancer incidence and cancer death.

RESULTS

Over a follow-up period of 170,000 person-years (mean follow-up among survivors 5.6 years), 2626 participants developed cancer and 1095 participants died from cancer. Overall, there was no significant association between CKD category and cancer incidence or death. As compared with the reference group with eGFR ≥75 mL/min/1.73 m(2), adjusted hazard ratio (HR) estimates for each category of renal function, in descending order, were: 0.98 (95 % CI 0.87-1.10), 0.99 (0.88-1.13), 1.01 (0.84-1.22) and 1.24 (0.97-1.58) for cancer incidence, and 1.03 (95 % CI 0.86-1.24), 0.95 (0.78-1.16), 1.00 (0.76-1.33), and 1.58 (1.09-2.30) for cancer mortality. Among dialysis patients, there was an excess risk of cancers of the urinary tract (adjusted HR: 2.34; 95 % CI 1.10-4.98) and endocrine cancers (11.65; 95 % CI: 1.30-104.12), and an excess risk of death from digestive tract cancers (2.11; 95 % CI: 1.13-3.99), but a reduced risk of prostate cancers (0.38; 95 % CI: 0.18-0.83).

CONCLUSIONS

Whilst no association between reduced renal function and the overall risk of cancer was observed, there was evidence among dialysis patients that the risk of cancer was increased (urinary tract, endocrine and digestive tract) or decreased (prostate) at specific sites. Larger studies are needed to characterise these site-specific associations and to identify their pathogenesis.

Proteinuria is a Predictor of Renal Functional Decline in Patients with Kidney Cancer

PURPOSE

Prior studies have shown that 26% to 34% of patients with suspected renal cancers have a glomerular filtration rate less than 60 ml/minute/1.73 m(2) but limited information exists regarding proteinuria. We investigated the extent of proteinuria in patients with renal tumors to determine the impact on the classification and progression of chronic kidney disease.

MATERIALS AND METHODS

Among 1,622 patients evaluated between 1999 and 2014, 1,016 had preoperative creatinine and proteinuria measurements available. Patients were classified according to the risk of chronic kidney disease progression into low, moderately increased, high and very high risk groups according to 2012 KDIGO guidelines. Predictors of risk group and chronic kidney disease progression were analyzed using univariable and multivariate models.

RESULTS

Before treatment 32% had a glomerular filtration rate less than 60 ml/minute/1.73 m(2). Preoperative proteinuria was present in 22%. Proteinuria was detected in 30% with a reduced glomerular filtration rate and 18% with a normal glomerular filtration rate. Among the 44% at increased risk for chronic kidney disease progression 24%, 12% and 8% were at moderately increased, high and very high risk, respectively. The presence of proteinuria also reclassified 25% with stage III chronic kidney disease as high or very high risk. KDIGO classification predicted renal functional decline, which occurred in 2.2%, 4.4%, 9.4% and 34.6% at 3 years in low, moderately increased, high and very high risk categories, respectively. Predictors of KDIGO group included age and tumor size (each p <0.001), and the main predictors of renal functional decline were KDIGO group, tumor size and radical nephrectomy (each p <0.0001).

CONCLUSIONS

Identification of chronic kidney disease using only glomerular filtration rate left 18% of patients undiagnosed. The assessment of glomerular filtration rate and proteinuria classified patients according to risk of chronic kidney disease progression, identifying 44% to be at increased risk. As proteinuria predicted renal functional decline, we advocate for routine evaluation before treatment.

Treatment strategy for bladder cancer in patients on hemodialysis: a clinical review of 28 cases

PURPOSE

To clarify the background, clinical symptoms, pathological characteristics, and duration of survival in patients with bladder cancer on hemodialysis and to examine the appropriate treatment strategies.

METHODS

Between April 1988 and May 2012, 28 patients in whom bladder cancer was diagnosed and treated after dialysis was initiated were included in this retrospective study. We examined the clinicopathological characteristics and survival.

RESULTS

Twenty men and 8 women were included (mean age 64.1 ± 11.9 years). The mean duration of dialysis was 80.2 ± 79.1 months. The duration of follow-up after treatment was 43.9 ± 41.2 months. Fourteen patients underwent immediate total cystectomy after the diagnosis of muscle-invasive bladder cancer or high-grade pT1 tumors. Of these, four died of cancer and two had surgery-related deaths. Fourteen patients underwent transurethral resection, and the initial diagnosis was non-muscle-invasive bladder cancer. Of these, three underwent delayed total cystectomy because the time to recurrence was short or there were multiple intravesical recurrences; none died of cancer. The duration of hemodialysis tended to be longer in patients who underwent immediate total cystectomy than in those who underwent only transurethral resection or delayed total cystectomy (107.1 ± 92.0 vs. 53.3 ± 63.9 months, p = 0.10).

CONCLUSIONS

Bladder cancer in hemodialysis patients can be treated using the same strategy as for the general population. Bladder cancer in longer-term hemodialysis patients tends to be pathologically more advanced; thus, total cystectomy, although highly invasive, is often needed. Establishing bladder cancer screening for patients on dialysis is desirable.

Death Does Matter--Cancer Risk in Patients With End-Stage Renal Disease: A Nationwide Population-Based Study With Competing Risk Analyses

Patients with end-stage renal disease (ESRD) have a high mortality rate. We hypothesized that not accounting for death as a competing risk overestimates the event rate caused by ESRD. Thus, we examined the cancer risk for patients with ESRD (ESRD) after death as a competing risk event had been adjusted for. Patients with newly diagnosed ESRD (n = 64,299) between 1999 and 2007, together with age- and sex-matched controls without ESRD (ESRD) (n = 128,592) were enrolled (1:2). In a Cox proportional hazards model that included death as a competing risk, ESRD patients in Taiwan had a lower overall incidence (subdistribution hazard ratio [sdHR] = 1.29) of cancer than did ESRD patients in a Cox model that did not include death as a competing risk (HR = 1.70). After competing mortality had been adjusted for, ESRD patients ≥70 (sdHR = 0.82) and ESRD patients on long-term dialysis (> 5 follow-up years, sdHR = 0.62), had a lower risk for developing cancer than did ESRD patients. This finding supported our hypothesis that standard survival analyses overestimate the event rate, especially when the mortality rate is high. It also showed that ESRD patients, when they grow older, were far less likely to develop cancer and far more likely to die because of underlying illnesses that might also affect the risk of death because of ESRD.

Geographic Variation of Chronic Kidney Disease Prevalence: Correlation with the Incidence of Renal Cell Carcinoma or Urothelial Carcinoma?

Background. The aim of this study is to evaluate whether geographic variations in the prevalence of late-stage chronic kidney disease (CKD) exist and are associated with incidence rates of renal cell carcinoma (RCC), upper tract urothelial carcinoma (UTUC), or lower tract urothelial carcinoma (LTUC). Methods. Prevalence rates of late-stage CKD for 366 townships (n > 30) in Taiwan were calculated for 1,518,241 and 1,645,151 subjects aged 40 years or older in years 2010 and 2009, respectively. Late-stage CKD prevalence in year 2010 was used as a training set and its age-adjusted standardized morbidity rates (ASMR) were divided into three groups as defined <1.76%, 1.76% ≤ ASMR < 2.64%, and ≥2.64%, respectively. Year 2009, defined as the validation set, was used to validate the results. Results. The ASMR of late-stage CKD in years 2010 and 2009 were 1.76%, and 2.09%, respectively. Geographic variations were observed, with notably higher rates of disease in areas of the central, southwestern mountainside, and southeastern seaboard. There were no significant differences among different combined risk groups of RCC, UTUC, and LTUC incidence. Conclusion. The substantial geographic variations in the prevalence of late-stage CKD exist, but are not correlated with RCC, UTUC, or LTUC incidence.

Bladder cancer in renal allograft recipients: risk factors and outcomes

BACKGROUND

Solid organ transplant recipients have an increased cancer risk owing to immunosuppression and oncogenic viral infections. We report on the incidence and types of bladder cancer in kidney transplant recipients in Ireland, describing possible additional risk factors and outcomes in these patients.

METHODS

We identified kidney transplant recipients diagnosed with de novo bladder cancer between January 1, 1994, and July 31, 2012, by integrating data from the Irish National Cancer Registry and National Renal Transplant Registry. We calculated the standardized incidence ratio (SIR) and examined patient and tumor characteristics and 1-year survival rate.

RESULTS

Fifteen patients were diagnosed with de novo bladder cancer during the study period, representing 0.48% of kidney transplant recipients. The SIR was 2.5 (95% CI, 1.4-4.2; P < .001). The mean interval between transplantation and diagnosis of bladder tumor was 8.6 years and mean age at time of diagnosis was 55.7 years. Sixty percent of patients were male. The tumor types were transitional cell carcinoma (9 patients), squamous cell carcinoma (3 patients), adenocarcinoma (1 patient), carcinoma in situ (1 patient), and diffuse large B-cell lymphoma (1 patient). Beside immunosuppression, risk factors associated with bladder cancer were urogenital disease (6 patients), cyclophosphamide exposure (2 patients), BK nephropathy (1 patient), analgesic nephropathy (1 patient), and extensive smoking (1 patient). Eight patients underwent radical cystectomy for invasive tumors, with resection of other pelvic organs in 7 patients. Mortality rate within the first year was 40%.

CONCLUSION

Bladder cancer occurred more commonly in kidney transplant recipients with a predominance of aggressive tumors and a high mortality. In patients with preexisting risk factors such as urologic abnormalities and cyclophosphamide exposure careful assessment before transplantation and vigilant monitoring posttransplantation with a low threshold for cystoscopy may improve outcomes.

Shorter hemodialysis duration is a risk factor for the recurrence of urothelial carcinoma of the bladder in patients on maintenance hemodialysis

PURPOSE

To investigate the association of hemodialysis duration with the recurrence of urothelial carcinoma (UC) of the bladder and overall survival in patients undergoing maintenance hemodialysis (MHD).

PATIENTS AND METHODS

52 bladder cancer patients who underwent MHD at the Xiangya Hospital of The Central South University between 2001 and 2011 were enrolled in the study. The patients were divided into three groups according to hemodialysis duration, and patient mortality and tumor recurrence rates were analyzed. The association of hemodialysis duration with occurrence and recurrence of UC of the bladder was analyzed by Cox regression analysis. Survival was evaluated by the Kaplan-Meier method.

RESULTS

Out of 6266 chronic hemodialysis patients, 52 patients had UC of the bladder after the initiation of hemodialysis for 6 months. The mean age at hemodialysis onset was 55 years (IQR 36, 71). The major complaints were painless gross hematuria and urethral bloody discharge. Tumors were generally large and multifocal. The standardized incidence ratio of UC of the bladder was 43.9 compared with general population, and it was higher in women (76.7) and in the age group 61-65 years (186.6). The mean hemodialysis duration before the diagnosis of bladder cancer was 32 months. 30 (57.7 %) patients received hemodialysis no more than 3 years, 10 (19.2 %) patients received hemodialysis between 3 and 6 years, and 12 (23.1 %) patients received hemodialysis for more than 6 years.

CONCLUSION

Preoperative shorter hemodialysis duration is a risk factor for the occurrence and recurrence of UC of the bladder in patients undergoing MHD.

Renal cancer in kidney transplanted patients

Renal cancer occurs more frequently in renal transplanted patients than in the general population, affecting native kidneys in 90% of cases and the graft in 10 %. In addition to general risk factors, malignancy susceptibility may be influenced by immunosuppressive therapy, the use of calcineurin inhibitors (CNI) as compared with mammalian target of rapamycin inhibitors, and the length of dialysis treatment. Acquired cystic kidney disease may increase the risk for renal cancer after transplantation, while autosomal dominant polycystic kidney disease does not seem to predispose to cancer development. Annual ultrasound evaluation seems appropriate in patients with congenital or acquired cystic disease or even a single cyst in native kidneys, and every 2 years in patients older than 60 years if they were on dialysis for more than 5 years before transplantation. Immunosuppression should be lowered in patients who develop renal cancer, by reduction or withdrawal of CNI. Although more evidence is still needed, it seems reasonable to shift patients from CNI to everolimus or sirolimus if not already treated with one of these drugs, with due caution in subjects with chronic allograft nephropathy.

Chronic kidney disease and risk of renal cell carcinoma: differences by race

BACKGROUND

The incidence of renal cell carcinoma in the United States differs by race/ethnicity. To better understand these disparities, we conducted a nested case-control study investigating renal cell carcinoma risk factors across racial/ethnic groups within the Kaiser Permanente Northern California health care network.

METHODS

Our study included 3136 renal cell carcinoma cases (2152 whites, 293 blacks, 425 Hispanics, and 255 Asians) diagnosed between 1998 and 2008 and 31031 individually matched controls (21478 whites, 2836 blacks, 4147 Hispanics, and 2484 Asians). Risk of renal cell carcinoma was assessed in relation to smoking status, body mass index (BMI), hypertension, and chronic kidney disease. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using conditional logistic regression, and population attributable risk (PAR) to estimate by race the proportion of cases attributable to hypertension and chronic kidney disease.

RESULTS

The association between chronic kidney disease and renal cell carcinoma differed markedly by race (Pinteraction < 0.001), with associations observed among blacks (OR = 10.4 [95% CI = 6.0-17.9]), Asians (5.1 [2.2-11.7]), and Hispanics (2.3 [1.1-4.6]) but not whites (1.1 [0.6-1.9]). Hypertension, high BMI, and smoking were associated with renal cell carcinoma, but findings generally did not differ by race. Relative to other racial/ethnic groups, blacks had the highest proportion of renal cell carcinoma incidence attributable to hypertension and chronic kidney disease (combined, PAR = 37%; hypertension only, PAR = 27%; chronic kidney disease, PAR = 10%).

CONCLUSIONS

Our findings suggest that hypertension and chronic kidney disease likely have contributed to the observed excess in renal cell carcinoma incidence among blacks compared with whites.

Type 1 and type 2 diabetes and cancer mortality in the 2002-2009 cohort of 39,811 French dialyzed patients

End-stage renal disease is a chronic and progressive pathology associated with several comorbidities, particularly diabetes. Indeed, diabetes is the first cause of end-stage renal disease and, in France, 42% of incident patients had diabetes in 2012. In the general population, diabetes is associated with increased cancer risk. The aim of this study was to examine the association between risk of cancer death and diabetes in a large French cohort of patients with end-stage renal disease. Data on all patients with end-stage renal disease who initiated dialysis in France between 2002 and 2009 were extracted from the Renal Epidemiology Information Network registry. The risk of dying by cancer was studied using the Fine and Gray model to take into account the competing risk of death by other causes. We analyzed 39,811 patients with end-stage renal disease. Their mean age was 67.7±15 years, 39.4% had diabetes and 55.3% at least one cardiovascular disease. Compared with the non-diabetic group, patients with diabetes were older and had more cardiovascular and respiratory comorbidities when they started dialysis. Conversely, fewer diabetic patients had also a tumor at the beginning of the renal replacement therapy. Cancer was indicated as the cause of death for 6.7% of diabetic and 13.4% of non-diabetic patients. The Fine and Gray multivariate analyses indicated that diabetes (HR=0.72 95% CI: [0.68-0.95], p<0.001) and also female gender, peritoneal dialysis, cardio-vascular disease and kidney transplantation were associated with decreased risk of death by cancer. In this French cohort of patients with end-stage renal disease, diabetes was not associated with a significant increased risk of dying from cancer. Studies on the incidence of cancer in patients with ESRD are now needed to evaluate the potential association between diabetes and specific malignancies in this population.

Association of dialysis with the risks of cancers

Background

To increase the survival span after dialysis in patients with end-stage renal disease (ESRD), identifying specific cancer risks is crucial in the cancer screening of these patients. The aim of this study was to investigate the risks of various cancers in an incident dialysis group in comparison with a non-dialysis group.

Method

We conducted a nationwide cohort study by using data from the Taiwan National Health Insurance Research Database. Patients who initially received long-term dialysis between January 1997 and December 2004, were selected and defined as the dialysis group and were matched with the non-dialysis patients (control group) according to age, sex, and index year. Competing risk analysis was used to estimate cumulative incidence and subdistribution hazard ratios (SHRs) of the first cancer occurrence.

Results

After consideration for the competing risk of mortality, the dialysis group showed a significantly higher 7-year cancer incidence rate than did the control group (6.4%; 95% confidence interval [CI], 6.0%-6.7% vs 1.7%; 95% CI, 1.4%-2.1%; P <0.001).The modified Cox proportional hazard model revealed that the dialysis group had significantly association with increased risks for all cancers (SHR, 3.43; 95% CI, 3.02-3.88). The risk of cancers was dominated in younger and female patients. Specific cancer risks were significantly higher in the dialysis group particularly in the development of oral, colorectal, liver, blood, breast, renal, upper urinary tract, and bladder cancer than in the control group. Multivariable stratified analyses confirmed the association between long-term dialysis and cancer in all subgroups of patients.

Conclusions

Dialysis is associated with a higher risk of cancer in patients with ESRD. However, cancer screening in ESRD population should be a selective approach, based on individual patient health condition and life expectancy.

Shoulder pad sign and asymptomatic hypercalcemia in a patient with end-stage kidney disease

Interpreting an abnormal serum calcium level in subjects with chronic kidney disease (CKD) requires the simultaneous evaluation of various clinical and laboratory parameters. An excessive intake of calcium salts and vitamin D overdosing may be the most common etiologies of hypercalcemia in individuals with advanced CKD. Nevertheless, it should be noted that such patients are susceptible to all diseases that may cause hypercalcemia in subjects without renal disease. In this report, we describe the case of a male chronic hemodialysis patient who developed asymptomatic hypercalcemia associated with polyarticular swelling. On the basis of the findings of systemic workup, he was finally diagnosed as having multiple myeloma. The so-called shoulder pad sign, which is pathognomonic for light chain amyloidosis, although its detection remains a challenge for physicians, was a clue leading to the prompt diagnosis of the disease in the current case. The impact of articular manifestations on the diagnostic strategy for assessing multiple myeloma is also discussed.