Renal cell carcinoma in a patient with cystinosis and inflammatory bowel disease: a case report

Adult complications of nephropathic cystinosis: a systematic review

While nephropathic cystinosis is classically thought of as a childhood disease, with improved treatments, patients are more commonly living into adulthood. We performed a systematic review of the literature available on what complications this population faces as it ages. Nearly every organ system is affected in cystinosis, either from the disease itself or from sequelae of kidney transplantation. While cysteamine is known to delay the onset of end-stage kidney disease, its effects on other complications of cystinosis are less well determined. More common adult-onset complications include myopathy, diabetes, and hypothyroidism. Some less common complications, such as neurologic dysfunction, can still have a profound impact on those with cystinosis. Areas for further research in this area include additional study of the impact of cysteamine on the nonrenal manifestations of cystinosis, as well as possible avenues for new and novel treatments.

A systematic literature review of cysteamine bitartrate in the treatment of nephropathic cystinosis

OBJECTIVES

To summarize available clinical evidence for cysteamine bitartrate preparations in the treatment of nephropathic cystinosis as identified through a systematic literature review (SLR).

METHODS

We searched MEDLINE, MEDLINE In-Process and Embase using Ovid with a predefined search strategy through 19 January 2016. All publicly available clinical reports on the use of delayed-release (DR) cysteamine bitartrate (Procysbi ¹ ) or immediate-release (IR) cysteamine bitartrate (Cystagon ² ) in patients with cystinosis were included.

RESULTS

We identified a total of 103 publications and 10 trial records. Of these, 9 studies describe DR cysteamine bitartrate (n = 267 patients), 42 describe IR cysteamine bitartrate (n = 1,427 patients) and in 53 studies the exact preparation was not specified (n = 906 patients). The vast majority of the studies used a non-randomized study design, with randomized clinical trials (RCTs) being scarce (1 study comparing DR and IR formulation) and case reports (n = 49) being the most common study design representing 47% of the total.

CONCLUSION

A substantial evidence base for cysteamine bitartrate in the treatment of nephropathic cystinosis was identified. However, the majority of the evidence was of relatively low quality, with evidence levels of 3 or 4.

Better survival of renal cell carcinoma in patients with inflammatory bowel disease

Background

Immunosuppressive therapy may impact cancer risk in inflammatory bowel disease (IBD). Cancer specific data regarding risk and outcome are scarce and data for renal cell carcinoma (RCC) are lacking. We aimed(1) to identify risk factors for RCC development in IBD patients (2) to compare RCC characteristics, outcome and survival between IBD patients and the general population.

Methods

A PALGA (Dutch Pathology Registry) search was performed to establish a case group consisting of all IBD patients with incident RCC in The Netherlands (1991–2013). Cases were compared with two separate control groups: (A) with a population-based IBD cohort for identification of risk factors (B) with a RCC cohort from the general population to compare RCC characteristics and outcomes.

Results

180 IBD patients with RCC were identified. Pancolitis (OR 1.8–2.5), penetrating Crohn's disease (OR 2.8), IBD related surgery (OR 3.7–4.5), male gender (OR 3.2–5.0) and older age at IBD onset (OR 1.0–1.1) were identified as independent risk factors for RCC development. IBD patients had a significantly lower age at RCC diagnosis (p < 0.001), lower N-stage (p = 0.025), lower M-stage (p = 0.020) and underwent more frequently surgical treatment for RCC (p < 0.001) compared to the general population. This translated into a better survival (p = 0.026; HR 0.7) independent of immunosuppression.

Conclusions

IBD patients with a complex phenotype are at increased risk to develop RCC. They are diagnosed with RCC at a younger age and at an earlier disease stage compared to the general population. This translates into a better survival independent of immunosuppressive or anti-TNFα therapy.

An approach to renal masses in pediatrics

Renal masses in children may be discovered during routine clinical examination or incidentally during the course of diagnostic or therapeutic procedures for other causes. Renal cancers are rare in the pediatric population and include a spectrum of pathologies that may challenge the clinician in choosing the optimal treatment. Correct identification of the lesion may be difficult, and the appropriate surgical procedure is paramount for lesions suspected to be malignant. The purpose of this article is to provide a comprehensive overview regarding the spectrum of renal tumors in the pediatric population, both benign and malignant, and their surgical management.

Chronic pouch inflammation and risk for new-onset extraintestinal cancers in patients with restorative proctocolectomy for ulcerative colitis

OBJECTIVES

To date, there have been no studies on extraintestinal cancer in patients after ileal pouch-anal anastomosis (IPAA) for inflammatory bowel disease (IBD). The aim of this study was to evaluate the frequency and natural history of extraintestinal cancer and their risk factors in patients after IPAA for IBD.

METHODS

All patients after IPAA with underlying IBD and extraintestinal neoplasia were identified from a prospectively maintained 932-case Pouchitis Registry from 2002 to 2010. The study group consisted of patients with de novo extraintestinal cancer, which developed after IPAA. Controls were those without extraintestinal cancer, who were randomly selected from the registry with a case to control ratio of 1 to 4. Thirty-one demographic and clinical data were compared between the study and control groups.

RESULTS

Twenty-eight patients with de novo extraintestinal cancer after IPAA were identified, with a mean duration of pouch construction of 8.2 ± 9.7 years. The cumulative frequency of de novo extraintestinal cancer in patients after IPAA for IBD was 3%, consisting of cancer of the breast (18%), kidney (14%), prostate (11%), thyroid (11%), and bladder (7%); melanoma (11%); and other cancers (28%). The mean age of the study group was 57.6 ± 10.1 years, with 16 (57%) being men; 8 (29%) were consuming tobacco, and 3 (11%) having preoperative and/or postoperative biologic use. Patient age, left-sided colitis, and duration of IBD before IPAA were significantly greater in patients in the study group than in controls (P < 0.05) in univariate analysis. Preoperative or postoperative use of biologics and a preoperative diagnosis of colonic neoplasia were not shown to be associated with extraintestinal cancer. The prevalence seemed to be increased in patients with renal cancer with the standardized prevalence ratio of 4.8 (95% confidence interval [CI], 1.6-12.2). In the logistic regression model, older age (odds ratio [OR] = 1.5; 95% CI, 1.2-1.8), left-sided colitis (OR = 12.3; 95% CI, 2.2-67.8), and chronic pouch inflammation (OR = 4.4; 95% CI, 1.5-12.9) were associated with the risk for extraintestinal cancer. The 1-year and 2-year mortality rates after cancer diagnosis were 7.1% and 10.7%, respectively. There was no difference in pouch failure rate between the 2 groups (4% versus 5%; P = 1.00).

CONCLUSION

The observed number of cases of renal cancer in patients after IPAA appeared to be greater than the expected number of cases in the general population. Older age and chronic pouch inflammation may be associated with an increased risk for extraintestinal cancer in this cohort. Biologic use is not associated with extraintestinal cancer in our population.

Long-term outcome of nephropathic cystinosis: a 20-year single-center experience

Nephropathic cystinosis (NC) is a severe disease that is complicated by early-onset chronic renal failure (CRF) and other complications related to cystine deposition in tissue. Since the 1980s, the prognosis of NC has dramatically improved after the introduction of cysteamine treatment. Limited data are available documenting improvement in prognosis. We reviewed our long-term data (follow-up 6.3-27.8 years) on 23 patients followed in the past 26 years. Overall, stage III CRF was reached at 10 years of age in >90% of patients, whereas >80% reached end-stage renal disease before the age of 14 years. Three patients died during the follow-up. Our analysis shows a clear improvement in renal outcome (p = 0.001) and linear growth (p = 0.04) in patients treated more recently. Improvement in the evolution of renal function was significantly associated with early initiation of cysteamine (p = 0.006), with the dose of cysteamine (p = 0.04), and with the use of angiotensin-converting enzyme inhibitors (p = 0.01). Nonrenal long-term complications are similar to previously reported data. Of note, 3/23 patients developed rare forms of primary tumors that were successfully treated. In conclusion, our experience shows a significant improvement in the renal and nonrenal complications of cystinosis over the past decades and highlights the importance of early diagnosis in order to initiate cysteamine as soon as possible.