Renal cell carcinoma and arterial hypertension

Association of cancer with the risk of developing hypertension

BACKGROUND AND AIMS

Although the importance of hypertension in patients with cancer is widely recognized, little is known about the risk of developing hypertension in patients with a history of cancer.

METHODS AND RESULTS

This retrospective observational cohort study analysed data from the JMDC Claims Database between 2005 and 2022, including 78 162 patients with a history of cancer and 3692 654 individuals without cancer. The primary endpoint was the incidence of hypertension.During a mean follow-up period of 1208 ± 966 days, 311 197 participants developed hypertension. The incidence of hypertension was 364.6 [95% confidence interval (CI) 357.0-372.2] per 10 000 person-years among those with a history of cancer, and 247.2 (95% CI 246.3-248.1) per 10 000 person-years in those without cancer. Individuals with a history of cancer had an elevated risk of developing hypertension, according to multivariable Cox regression analyses [hazard ratio (HR) 1.17, 95% CI 1.15-1.20]. Both cancer patients requiring active antineoplastic therapy (HR 2.01, 95% CI 1.85-2.20), and those who did not require active antineoplastic therapy (HR 1.14, 95% CI 1.12-1.17) had an increased risk of hypertension. A multitude of sensitivity analyses confirmed the robustness of the relationship between cancer and incident hypertension. Patients with certain types of cancer were found to have a higher risk of developing hypertension than those without cancer, with varying risks dependent on the type of cancer.

CONCLUSION

Our analysis of a nationwide epidemiological database revealed that individuals with a history of cancer have a higher risk of developing hypertension, and this finding applies to both cancer patients who require active antineoplastic therapy and those who do not.

Stress Reactivity, Susceptibility to Hypertension, and Differential Expression of Genes in Hypertensive Compared to Normotensive Patients

Although half of hypertensive patients have hypertensive parents, known hypertension-related human loci identified by genome-wide analysis explain only 3% of hypertension heredity. Therefore, mainstream transcriptome profiling of hypertensive subjects addresses differentially expressed genes (DEGs) specific to gender, age, and comorbidities in accordance with predictive preventive personalized participatory medicine treating patients according to their symptoms, individual lifestyle, and genetic background. Within this mainstream paradigm, here, we determined whether, among the known hypertension-related DEGs that we could find, there is any genome-wide hypertension theranostic molecular marker applicable to everyone, everywhere, anytime. Therefore, we sequenced the hippocampal transcriptome of tame and aggressive rats, corresponding to low and high stress reactivity, an increase of which raises hypertensive risk; we identified stress-reactivity-related rat DEGs and compared them with their known homologous hypertension-related animal DEGs. This yielded significant correlations between stress reactivity-related and hypertension-related fold changes (log2 values) of these DEG homologs. We found principal components, PC1 and PC2, corresponding to a half-difference and half-sum of these log2 values. Using the DEGs of hypertensive versus normotensive patients (as the control), we verified the correlations and principal components. This analysis highlighted downregulation of β-protocadherins and hemoglobin as whole-genome hypertension theranostic molecular markers associated with a wide vascular inner diameter and low blood viscosity, respectively.

Incidence and Risk of Hypertension in Cancer Patients Treated With Atezolizumab and Bevacizumab: A Systematic Review and Meta-Analysis

PURPOSE

This study aims to inform previous clinical assessments to better understand the total risk of hypertension with atezolizumab and bevacizumab (hereafter referred to as "A-B") in cancer patients, and reduce future incidence of hypertension-related cardiovascular complications.

METHODS

Databases, including PubMed, Embase, Cochrane, and Web of Science were searched to identify relevant studies, which were retrieved from inception to March 6, 2021. Studies focused on cancer patients treated with A-B that provided data on hypertension were included. Statistical analyses were conducted to calculate hypertension incidence and relative risk (RR) with a random-effects or fixed-effects model, hinging on heterogeneity status.

RESULTS

Ten studies including 2106 patients with renal cell carcinoma (RCC), hepatocellular carcinoma (HCC), ovarian cancer, anal cancer, neuroendocrine tumors (NETs), and cervical cancer were selected for this meta-analysis. For patients treated with A-B, the all-grade and high-grade (grade 3) hypertension incidence were 31.1% (95% CI: 25.5-37.3) and 14.1% (95% CI: 10.9-18.1), respectively. No significant difference was observed in all-grade hypertension incidence between RCC and a non-RCC patients (32.9% [95% CI: 25.3-42.6] v.s. 29.2% [95% CI: 19.7-39.6)]). However, the number of high-grade hypertension incidence in RCC patients (9.4% [95% CI: 4.1-21.3]) was lower than that of non-RCC patients (15.6% [95% CI: 12.8-19.1]). RCC or HCC patients who received the A-B treatment were associated with significantly increased risk of all-grade hypertension with a RR of 7.22 (95% CI: 3.3-15.7; p = 0.6) compared with patients treated with atezolizumab.

CONCLUSIONS

Cancer Patients treated with atezolizumab and bevacizumab have a significantly increased risk of hypertension. Sufficient monitoring is highly recommended to prevent the consequences of treatment-induced hypertension and other cardiovascular complications.

Open kidney cancer surgery and perioperative cardiac arrhythmias

Introduction

Although cardiac arrhythmias during anesthesia are often observed, the literature focuses mainly on cardio-thoracic surgery. We aimed to evaluate the incidence of arrhythmias appearing in the perioperative period in patients undergoing urological surgery and furthermore to define whether combining general with epidural anesthesia prevents them.

Material and methods

The study included 50 adults, without a prior cardiac or arrhythmia history, undergoing an open kidney cancer surgery, who were randomly allocated to receive either general or combined epidural/general anesthesia. A Holter monitor was applied the evening before the surgery, tracing continuously for a period of 24 hours (7PM–7PM). ClinicalTrials.gov NCT02988219

Results

There was no statistical difference in the arrhythmia occurrence between the randomization groups. Among 65.21% the following arrhythmias were observed: 27 – bradycardia, 4 – sinus pause, 6 – ventricular extrasystoles (>1000/24 hours), 3 – supraventricular extrasystoles (>200/24 hours). The patients with arrhythmia were older and often with hypertension (p <0.01). A longer surgery duration predisposed to arrhythmia appearance (122.5 vs. 99 minutes), (p <0.01). The temperature measured at the beginning and at the end of the surgery was significantly lower among the participants with arrhythmia (p = 0.02, p = 0.01). The gender, body mass index (BMI), laboratory tests and the intake of intravenous fluids did not influence the occurrence of arrhythmia.

Conclusions

Perioperative cardiac arrhythmias (usually sinus arrhythmias) are common during an open kidney surgery and occur regardless of the anesthetic technique and usually do not require any treatment. Age, hypertension, long operation time or low body temperature predispose the patient to perioperative cardiac arrhythmias during surgery.

Arterial hypertension in patients under antineoplastic therapy: a systematic review

BACKGROUND

Cardio-oncology aims to mitigate adverse cardiovascular manifestations in cancer survivors, but treatment-induced hypertension or aggravated hypertension has received less attention in these high cardiovascular risk patients.

METHODS

In this systematic review, we searched literature for contemporary data on the prevalence, pathophysiologic mechanisms, treatment implications and preventive strategies of hypertension in patients under antineoplastic therapy.

RESULTS

Several classes of antineoplastic drugs, including mainly vascular endothelial growth factor inhibitors, proteasome inhibitors, cisplatin derivatives, corticosteroids or radiation therapy were consistently associated with increased odds for new-onset hypertension or labile hypertensive status in previous controlled patients. Moreover, hypertension constitutes a major risk factor for chemotherapy-induced cardiotoxicity, which is the most serious cardiovascular adverse effect of antineoplastic therapy. Despite the heterogeneity of pooled studies, the pro-hypertensive profile of examined drug classes could be attributed to common structural and functional disorders. Importantly, certain antihypertensive drugs are considered to be more effective in the management of hypertension in this population and may partially attenuate indirect complications of cancer treatment, such as progressive development of cardiomyopathy and/or cardiovascular death. Nonpharmacological approaches to alleviate hypertension in cancer patients are also described, albeit adjudicated as less effective in general.

CONCLUSION

A growing body of evidence suggests that multiple antineoplastic agents increase the rate of progression of hypertension. Physicians need to balance the life-saving cancer treatment and the inflated risk of adverse cardiovascular events due to suboptimal management of hypertension in order to achieve improved clinical outcomes and sustained survival for their patients.

Polycythemia with Renal Cell Carcinoma and Normal Erythropoietin Level

A 61-year-old obese Caucasian male with past medical history of smoking, hypertension, chronic obstructive pulmonary disease (COPD), and sleep apnea presented to the hematology clinic with polycythemia. Despite the newly-diagnosed polycythemia, the patient denied any significant symptoms or history of blood clots. Further evaluation with computerized tomography (CT) and ultrasound showed a large renal mass suspicious for renal cell carcinoma of the right kidney. An incidental abdominal aortic aneurysm (AAA) measuring was also appreciated on imaging. Subsequent histological sections of the tumor showed cell renal cell carcinoma. Though previously reported, the concomitant finding of an AAA with renal cell carcinoma with a normal erythropoietin levels is surprising. Given the surgical complications associated with concomitant conditions with renal cell carcinoma, further investigation into paraneoplastic syndromes secondary to renal cell carcinoma remains open to investigation.

Hypertension in Cancer Patients and Survivors: Epidemiology, Diagnosis, and Management

Cancer patients and survivors of cancer have a greater burden of cardiovascular disease compared to the general population. Much of the elevated cardiovascular risk in these individuals is likely attributable to hypertension, as individuals with cancer have a particularly high incidence of hypertension following cancer diagnosis. Treatment with chemotherapy is an independent risk factor for hypertension due to direct effects of many agents on endothelial function, sympathetic activity, and renin-angiotensin system activity as well as nephrotoxicity. Diagnosis and management of hypertension in cancer patients requires accurate blood pressure measurement and consideration of potential confounding factors, such as adjuvant treatments and acute pain, that can temporarily elevate blood pressure readings. Home blood pressure monitoring can be a useful tool to facilitate longitudinal blood pressure monitoring for titration of antihypertensive medications. Selection of antihypertensive agents in cancer patients should account for treatment-specific morbidities and target organ injury.

Physical activity and sedentary behavior in relation to mortality among renal cell cancer survivors

Background

The relations of physical activity and sedentary behavior to mortality risk among patients with renal cell cancer have not yet been evaluated.

Methods

We conducted a prospective cohort study among 667 renal cell cancer survivors aged 50–71 years of the National Institutes of Health (NIH)-AARP Diet and Health Study with a median follow-up time of 7.1 years. Post-diagnosis physical activity, TV viewing, and total sitting time were assessed using self-administered questionnaires. Hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality were estimated using Cox proportional hazards models.

Results

Increasing levels of moderate to vigorous physical activity were related to decreased risk of overall mortality [multivariable-adjusted HRs for <1 hr/wk (reference), 1 to 3 hrs/wk, ≥3 to <7 hrs/wk, and ≥7 hrs/wk = 1.0, 1.16, 0.94, and 0.60 (95% CI = 0.38–0.96; p-trend = 0.03)]. In contrast, television viewing was associated with increased risk of overall mortality in the age- and sex-adjusted model (HR for >4 hrs/d vs. 0 to 2 hrs/d = 1.52, 95% CI = 1.02–2.26; p-trend = 0.04), but the relation was attenuated following further control for other covariates (multivariable-adjusted HR = 1.44, 95% CI = 0.92–2.24; p-trend = 0.11). Total sitting time was unrelated to all-cause mortality.

Conclusion

Among renal cancer patients, moderate to vigorous physical activity is associated with decreased risk of overall mortality. Clinicians should consider discussing the potential benefits of physical activity for longevity among survivors of renal cell cancer.

The incidence of kidney cancer in Iran: a systematic review and meta-analysis

Background: The incidence of kidney cancer from different areas of Iran was reported. Nevertheless, there is no available systematic reviews in this regard. Therefore, the present systematic review carried out to estimate the incidence rate of kidney cancer among Iranian people.

Method: This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) in September 2017. A search was concluded using Medline/ PubMed, Scopus, ScienceDirect, and Google scholar for international papers and four national databases (Scientific Information Database, MagIran, IranMedex, and IranDoc) for Persian papers. The incidence rate of kidney cancer was calculated using random effect model.

Result: An aggregate of 159 papers were retrieved in the primary search of the databases. Further screening and advanced refinement of the retrieved studies produced 15 studies totally. The age-standardized rate (ASR) of kidney cancer was 1.94, 95% CI (1.62-2.55) and 1.36, 95 % CI (1.09-1.62) in males and females, respectively.

Conclusion: In comparison to other parts of the world, the incidence of kidney cancer was lower in Iran. Afterwards, further studies are necessary to outline the exact incidence rate and the trend of kidney cancer in Iran.

Proteome profiling of clear cell renal cell carcinoma in von Hippel-Lindau patients highlights upregulation of Xaa-Pro aminopeptidase-1, an anti-proliferative and anti-migratory exoprotease

Patients of the von Hippel-Lindau (VHL) disease frequently develop clear cell renal cell carcinoma (ccRCC). Using archived, formalin-fixed, paraffin-embedded (FFPE) samples, we sought to determine global proteome alterations that distinguish ccRCC tissue from adjacent, non-malignant kidney tissue in VHL-patients. Our quantitative proteomic analysis clearly discriminated tumor and non-malignant tissue. Significantly dysregulated proteins were distinguished using the linear models for microarray data algorithm. In the ccRCC tissue, we noticed a predominant under-representation of proteins involved in the tricarboxylic acid cycle and an increase in proteins involved in glycolysis. This profile possibly represents a proteomic fingerprint of the "Warburg effect", which is a molecular hallmark of ccRCC. Furthermore, we observed an increase in proteins involved in extracellular matrix organization. We also noticed differential expression of many exoproteases in the ccRCC tissue. Of particular note were opposing alterations of Xaa-Pro Aminopeptidases-1 and -2 (XPNPEP-1 and -2): a strong decrease of XPNPEP-2 in ccRCC was accompanied by abundant presence of the related protease XPNPEP-1. In both cases, we corroborated the proteomic results by immunohistochemical analysis of ccRCC and adjacent, non-malignant kidney tissue of VHL patients. To functionally investigate the role of XPNPEP-1 in ccRCC, we performed small-hairpin RNA mediated XPNPEP-1 expression silencing in 786-O ccRCC cells harboring a mutated VHL gene. We found that XPNPEP-1 expression dampens cellular proliferation and migration. These results suggest that XPNPEP-1 is likely an anti-target in ccRCC. Methodologically, our work further validates the robustness of using FFPE material for quantitative proteomics.

Effect of hypertension on preoperative neutrophil-lymphocyte ratio evaluation of prognosis of renal cell carcinoma

OBJECTIVES

As an indicator of inflammatory reaction of immune system, the neutrophil-lymphocyte ratio (NLR) is a significantly independent prognostic factor of renal cell carcinoma (RCC). However, the NLR was not added in any well-established prognostic models. Many physiologic factors were also associated with NLR, such as hypertension. As such, we evaluated the effect of hypertension on NLR evaluation of prognosis of RCC.

MATERIALS AND METHODS

Hematological parameters and clinicopathological data during diagnosis were retrospectively recorded for 401 patients with RCC between the years 1999 and 2009. The standardized cutoff-finder algorithm was used to find the suitable NLR cutoff value for recurrence. The Log-rank test and Kaplan-Meier method were used to compare and estimate the recurrence-free survival. Univariate and multivariate Cox regression analyses were used to evaluate the association between NLR and clinicopathologic outcomes.

RESULTS

In the analysis of total subjects, recurrence-free survival was significantly worse among patients with a preoperative NLR (>3.139 [21.9%] vs.≤3.139 [78.1%]; P<0.001). High NLR value was associated with high pathological TNM stage (P = 0.009, 0.018, 0.001, respectively). In the normotensive subgroup, recurrence-free survival was also significantly worse among patients with a preoperative NLR (>3.139 [22.6%] vs.≤3.139 [77.4%]; P<0.001). However, in the subgroup with hypertension, the difference of recurrence-free survival was not significant between patients with preoperative NLR (>3.139 [21.2%] vs.≤3.139 [78.8%]; P = 0.093). Moreover, multivariate analysis identified increased NLR as a poor prognosis index for recurrence-free survival in total group (hazard ratio [HR] = 2.27; 95% CI: 1.50-3.44; P<0.001) and normotensive subgroup (HR = 2.97; 95% CI: 1.74-5.07; P<0.001), but not in hypertensive subgroup (HR = 1.25; 95% CI: 0.59-2.65; P = 0.566).

CONCLUSIONS

Hypertension is a disturbance factor in the evaluation of prognosis of RCC by preoperative NLR.

Perioperative Considerations in Metastatic Renal Cell Carcinoma

Patients with metastatic renal cell carcinoma are complex, with the potential for significant complications, and require extensive pre-, peri-, and postoperative management. This article discusses, in depth, the necessary considerations in the treatment of these patients.

L-DOPA decarboxylase mRNA levels provide high diagnostic accuracy and discrimination between clear cell and non-clear cell subtypes in renal cell carcinoma

OBJECTIVES

Renal cell carcinoma (RCC) is the most frequent type of kidney cancer. RCC patients frequently present with arterial hypertension due to various causes, including intrarenal dopamine deficiency. L-DOPA decarboxylase (DDC) is the gene encoding the enzyme that catalyzes the biosynthesis of dopamine in humans. Several studies have shown that the expression levels of DDC are significantly deregulated in cancer. Thus, we herein sought to analyze the mRNA levels of DDC and evaluate their clinical significance in RCC.

DESIGN AND METHODS

DDC levels were analyzed in 58 surgically resected RCC tumors and 44 adjacent non-cancerous renal tissue specimens via real-time PCR. Relative levels of DDC were estimated by applying the 2(-ΔΔC)T method, while their diagnostic accuracy and correlation with the clinicopathological features of RCC tumors were assessed by comprehensive statistical analysis.

RESULTS

DDC mRNA levels were found to be dramatically downregulated (p<0.001) in RCC tumors, exhibiting remarkable diagnostic accuracy as assessed by ROC curve analysis (AUC: 0.910; p<0.001) and logistic regression (OR: 0.678; p=0.001). Likewise, DDC was found to be differentially expressed between clear cell RCC and the group of non-clear cell subtypes (p=0.001) consisted of papillary and chromophobe RCC specimens. Furthermore, a statistically significant inverse correlation was also observed when the mRNA levels of DDC were analyzed in relation to tumor grade (p=0.049).

CONCLUSIONS

Our data showed that DDC constitutes a highly promising molecular marker for RCC, exhibiting remarkable diagnostic accuracy and potential to discriminate between clear cell and non-clear cell histological subtypes of RCC.

Evidence for aldosterone-dependent growth of renal cell carcinoma

The aim if this study was to investigate the hypothesis that K-RAS 4A is upregulated in a mineralocorticoid-dependent manner in renal cell carcinoma and that this supports the proliferation and survival of some renal cancers. Expression of the K-RAS in renal tumour tissues and cell lines was examined by real-time PCR and Western blot and mineralocorticoid receptor, and its gatekeeper enzyme 11β-hydroxysteroid dehydrogenase-2 was examined by immunocytochemistry on a tissue microarray of 27 cases of renal cell carcinoma. Renal cancer cells lines 04A018 (RCC4 plus VHL) and 04A019 (RCC4 plus vector alone) were examined for the expression of K-RAS4A and for the effect on K-RAS expression of spironolactone blockade of the mineralocorticoid receptor. K-RAS4A was suppressed by siRNA, and the effect on cell survival, proliferation and activation of the Akt and Raf signalling pathways was investigated in vitro. K-RAS4A was expressed in RCC tissue and in the renal cancer cell lines but K-RAS was downregulated by spironolactone and upregulated by aldosterone. Spironolactone treatment and K-RAS suppression both led to a reduction in cell number in vitro. Both Akt and Raf pathways showed activation which was dependent on K-RAS expression. K-RAS expression in renal cell carcinoma is at least partially induced by aldosterone. Aldosterone supports the survival and proliferation of RCC cells by upregulation of K-RAS acting through the Akt and Raf pathways.

Effects of partial nephrectomy on postoperative blood pressure

Purpose

The effects of partial nephrectomy (PN) on postoperative blood pressure (BP) are not known, and PN has the potential to worsen BP. We therefore sought to determine whether PN alters postoperative BP.

Materials and Methods

Patients who underwent PN for suspected malignancy at our institution from 2002 to 2008 were included. Data on BP and medication from before and after PN were retrieved from family physicians. BP and number of antihypertensive medications were compared after surgery with preoperative values by use of paired t tests and Chi-squared analyses, respectively.

Results

Of 74 patients undergoing PN and providing consent, 48 met the inclusion and exclusion criteria, with a median follow-up of 24 months. For the early postoperative period (1 month to 1 year after surgery), the mean BPs (132.3/77.0 mmHg) were unchanged compared with preoperative values (132.4/78.0 mmHg; p=0.59 systolic BP and p=0.30 diastolic BP). For the later postoperative period (beyond 1 year after surgery), the mean postoperative systolic BP was unchanged from the mean preoperative systolic BP (131.2 mmHg vs. 132.4 mmHg, respectively; p>0.30). However, the corresponding average diastolic BP was lower in the long term (78.0 mmHg versus 76.4 mmHg respectively; p=0.01). No significant difference in the mean number of BP medications prescribed preoperatively, at one year, and beyond one year was identified (p>0.37).

Conclusions

PN does not result in initial or long-term postoperative deterioration in BP.

Hypertension and risk of renal cell carcinoma among white and black Americans

BACKGROUND

Renal cell carcinoma and hypertension (a well-established renal cancer risk factor) are both more frequent among blacks than whites in the United States. The association between hypertension and renal cell carcinoma has not been examined in black Americans. We investigated the hypertension-renal cancer association by race, and we assessed the role of hypertension in the racial disparity of renal cancer incidence.

METHODS

Participants were enrolled in a population-based case-control study in Detroit and Chicago during 2002-2007 (number of cases: 843 whites, 358 blacks; number of controls: 707 whites, 519 blacks). Participants reported their history of hypertension and antihypertensive drug use. We used unconditional logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs), adjusted for demographic characteristics, smoking, body mass index, and family history of cancer.

RESULTS

Hypertension doubled renal cancer risk (OR = 2.0 [CI = 1.7-2.5]) overall. For whites, the OR was 1.9 (CI = 1.5-2.4), whereas for blacks it was 2.8 (2.1-3.8) (P for interaction = 0.11). ORs increased with time after hypertension diagnosis (P for trend <0.001), reaching 4.1 (CI = 2.3-7.4) for blacks and 2.6 (CI = 1.7-4.1) for whites after 25 years. ORs for poorly controlled hypertension were 4.5 (CI = 2.3-8.8) for blacks and 2.1 (CI = 1.2-3.8) for whites. If these estimates correctly represent causal effects and if, hypothetically, hypertension could be prevented entirely among persons aged 50-79 years, the black/white disparity in renal cancer could be reversed among women and reduced by two-thirds among men.

CONCLUSIONS

Hypertension is a risk factor for renal cancer among both blacks and whites, and might explain a substantial portion of the racial disparity in renal cancer incidence. Preventing and controlling hypertension might reduce renal cancer incidence, adding to the known benefits of blood pressure control for heart disease and stroke reduction, particularly among blacks.

MR in hypertension

Hypertension is a common systemic disorder affecting the cardiovascular system and kidneys with important morbidity and mortality. However, hypertension is often thought of by radiologists as an "invisible" disease. The aim of this article is to first review hypertension first in terms of its diagnosis, epidemiology and clinical importance. Second, those causes of secondary hypertension that may be diagnosed with MRI techniques are described along with the effects of hypertension on the cardiovascular system and kidneys that are demonstrable with MRI with particular emphasis on renovascular disease. Lastly the use of integrated MRI protocols to evaluate the hypertensive patient and areas for future research are considered.