Epidemiology of post-transplant malignancy in Asian renal transplant recipients: a population-based study

Relative carcinogenicity of tacrolimus vs mycophenolate after solid organ transplantation and its implications for liver transplant care

BACKGROUND

De novo malignancy is a leading cause of late morbidity and mortality in liver transplant recipients. Cumulative immunosuppression has been shown to contribute to post-transplant malignancy (PTM) risk. There is emerging evidence on the differential carcinogenic risk profile of individual immunosuppressive drugs, independent of the net effect of immunosuppression. Calcineurin inhibitors such as tacrolimus may promote tumourigenesis, whereas mycophenolic acid (MPA), the active metabolite of mycophenolate mofetil, may limit tumour progression. Liver transplantation (LT) is relatively unique among solid organ transplantation in that immunosuppression monotherapy with either tacrolimus or MPA is often achievable, which makes careful consideration of the risk-benefit profile of these immunosuppression agents particularly relevant for this cohort. However, there is limited clinical data on this subject in both LT and other solid organ transplant recipients.

AIM

To investigate the relative carcinogenicity of tacrolimus and MPA in solid organ transplantation.

METHODS

A literature search was conducted using MEDLINE and Embase databases using the key terms "solid organ transplantation", "tacrolimus", "mycophenolic acid", and "carcinogenicity", in order to identify relevant articles published in English between 1st January 2002 to 11th August 2022. Related terms, synonyms and explosion of MeSH terms, Boolean operators and truncations were also utilised in the search. Reference lists of retrieved articles were also reviewed to identify any additional articles. Excluding duplicates, abstracts from 1230 records were screened by a single reviewer, whereby 31 records were reviewed in detail. Full-text articles were assessed for eligibility based on pre-specified inclusion and exclusion criteria.

RESULTS

A total of 6 studies were included in this review. All studies were large population registries or cohort studies, which varied in transplant era, type of organ transplanted and immunosuppression protocol used. Overall, there was no clear difference demonstrated between tacrolimus and MPA in de novo PTM risk following solid organ transplantation. Furthermore, no study provided a direct comparison of carcinogenic risk between tacrolimus and MPA monotherapy in solid organ transplantation recipients.

CONCLUSION

The contrasting carcinogenic risk profiles of tacrolimus and MPA demonstrated in previous experimental studies, and its application in solid organ transplantation, is yet to be confirmed in clinical studies. Thus, the optimal choice of immunosuppression drug to use as maintenance monotherapy in LT recipients is not supported by a strong evidence base and remains unclear.

Native Kidney Hydronephrosis Is Associated with Upper Urinary Tract Urothelial Carcinoma in Post-Kidney Transplantation Patients

Background: Upper urinary tract urothelial carcinoma (UTUC) is the most common malignancy occurring after kidney transplantation (KT) in Taiwan. The aim of this study was to investigate the association between native kidney hydronephrosis and UTUC in post-KT patients. Methods: From 2003 to 2018, we conducted a retrospective cohort study that enrolled 1005 post-KT patients, 67 of whom were subsequently diagnosed with UTUC. We divided patients into two groups based on whether or not they had UTUC. Multivariate analysis and Kaplan-Meier plot were used to evaluate if native kidney hydronephrosis was associated with post-KT UTUC. Results: The total cohort consisted of 612 men (60.9%) and 393 women (39.1%) with a mean age of 48.2 ± 12.0 at KT. The mean follow-up time was 118.6 ± 70.2 months, and mean time from KT to UTUC was 7.53 years. There was a significant gender difference with a female predominance among the UTUC patients (73.1% versus 26.9%, p < 0.001). Native kidney hydronephrosis occurred more frequently in the UTUC group (68.7% versus 4.8%, p < 0.001). Multivariate analysis showed that native kidney hydronephrosis and female gender were significantly associated with UTUC with odds ratios of 35.32 (95% CI, 17.99–69.36; p < 0.001) and 3.37 (95% CI, 1.55–7.29; p = 0.002), respectively. UTUC in the post-KT patients also showed aggressive pathological characteristics and a tendency toward bilateral lesions (41.8%). Conclusions: Native kidney hydronephrosis is significantly associated with post-KT UTUC patients in Taiwan. Native kidney hydronephrosis may be a deciding factor for standard nephroureterectomy and bladder cuff excision in selected patients. Nevertheless, almost half of the patients with kidney hydronephrosis do not present with UTUC at the end of our study.

The effect of subsequent immunosuppressant use in organ-transplanted patients on prostate cancer incidence: a retrospective analysis using the Korean National Health Insurance Database

Backgrounds

Prostate cancer (PC) is the most common solid organ cancer. However, there is still no definite consensus before and after organ transplantation (TPL). We aimed to analyze whether PC incidence increased in TPL patients with subsequent use of immunosuppressants using the Korean National Health Insurance Database.

Methods

TPL patients between 2003 and 2015(N = 12,970) were age- and year-matched to non-TPL patients (N = 38,910) in a 1:3 ratio. Multivariate Cox regression analysis adjusted for significant prognostic clinicopathological parameters, including the duration of immunosuppressant agent use (0–300 or > 300 days), and Kaplan–Meier analysis with log-rank test were used to evaluate the association of TPL with PC incidence between the groups.

Results

Median overall survival was 4.86 years; overall mortality rate was 3.4% (n = 1761). Regardless of differences in baseline characteristics between the groups, multivariate analysis for PC incidence showed that age, immunosuppressant use, and TPL organ subtypes were significant factors for the overall population, whereas only age was significant in the TPL group (p < 0.05). After adjusting for age, underlying disease, and prescribed medication (aspirin, statin), multiple subgroup analysis models for PC incidence were evaluated. PC incidence was increased in the TPL group (hazard ratio [HR] 1.965, p < 0.001); however, PC incidence in the TPL group became insignificant after adjusting for immunosuppressant use (p = 0.194). Kaplan–Meier curves also showed that PC incidence was significantly different according to age and TPL with the use of immunosuppressants between the TPL and non-TPL groups.

Conclusions

PC incidence was higher in the TPL group using immunosuppressants than in the non-TPL group.

Trial registration: The study was retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-021-00883-8.

Sex differences in cancer risk and outcomes after kidney transplantation

Kidney transplant recipients (KTRs) experience a two- to four-fold increased risk of developing and dying from cancer compared with the general population. High cancer risk results from the interaction of both modifiable and non-modifiable factors. This mapping review explores the impact of sex disparity on cancer's increased incidence and mortality after kidney transplantation (KT). In terms of age, population-based studies indicate that younger recipients of both sexes experience a higher risk of cancer, but this is more pronounced in young women. On the contrary, older men are more likely to be diagnosed with cancer, although their increased risk is not statistically significant compared with the general population. Regarding cancer type, studies show an increased risk of Kaposi sarcoma, gynecologic and lung cancer in women, and bladder and kidney cancer in men. Immune-related cancers such as pos-transplant lymphoproliferative disorders and melanoma are increased in both sexes. Mortality also shows differences between sexes. Although cancer is the second cause of death in both male and female KTRs, studies show higher overall mortality in men and elderly recipients. However, the relative risk of cancer mortality compared with the general population is higher at a younger age, with disparate results regarding sex. Female KTRs appear to die at a younger age than males when compared with the general population. Differences in cancer rates by sex after renal transplantation need further studies. A better understanding of sex-specific differences in cancer epidemiology after KT could help nephrologists to better address pre-transplant counseling, to establish early surveillance programs, and to plan modifiable risk factors such as immunosuppression.

Antitumor pharmacotherapy of colorectal cancer in kidney transplant recipients

Renal transplantation has become the sole most preferred therapy modality for end-stage renal disease patients. The growing tendency for renal transplants, and prolonged survival of renal recipients, have resulted in a certain number of post-transplant colorectal cancer patients. Antitumor pharmacotherapy in these patients is a dilemma. Substantial impediments such as carcinogenesis of immunosuppressive drugs (ISDs), drug interaction between ISDs and anticancer drugs, and toxicity of anticancer drugs exist. However, experience of antitumor pharmacotherapy in these patients is limited, and the potential risks and benefits have not been reviewed systematically. This review evaluates the potential impediments, summarizes current experience, and provides potential antitumor strategies, including adjuvant, palliative, and subsequent regimens. Moreover, special pharmaceutical care, such as ISDs therapeutic drug monitoring, metabolic enzymes genotype, and drug interaction, are also highlighted.

The critical role of calcineurin/NFAT (C/N) pathways and effective antitumor prospect for colorectal cancers

Transcription factors (TFs) like a nuclear factor of activated T-cells (NFAT) and its controller calcineurin are highly expressed in primary intestinal epithelial cells (IECs) due to delamination, damage by tumor-associated flora and selective activation in the intestinal tract tumor are crucial in the progression and growth of colorectal cancer (CRC). This study sought to summarize the current findings concerning the dysregulated calcineurin/NFAT (C/N) signaling involved in CRC initiation and progression. These signalings include proliferation, T-cell functions, and glycolysis with high lactate production that remodels the acidosis, which genes in tumor cells provide an evolutionary advantage, or even increased their attack phenotype. Moreover, the relationship between C/N and gut microbiome in CRC, especially role of NFAT and toll-like receptor signaling in regulating intestinal microbiota are also discussed. Furthermore, this review will discuss the proteins and genes relating to C/N induced acidosis in CRC, which includes ASIC2 regulated C/N1 and TFs associated with the glycolytic by-product that affect T-cell functions and CRC cell growth. It is revealed that calcineurin or NFAT targeting to antitumor, selective calcineurin inhibition or targets in NFAT signaling may be useful for clinical treatment of CRC. This can further aid in the identification of specific targets via cancer patient-personalized approach. Future studies should be focused on targeting to C/N or TLR signaling by the combination of therapeutic agents to regulate T-cell functions and gut microbiome for activating potent anticancer property with the prospect of potentiating the antitumor therapy for CRC.

Gender differences in cancer risk after kidney transplantation

Kidney transplant (KT) recipients are at greater risk of developing some cancers than the general population. Moreover, cancer is the only cause of death that is currently increasing after kidney transplantation. We analyzed incidence, risk factors and characteristics of post-transplant malignancies (solid organ tumors and lymphoproliferative disorders) at our center in 925 KT recipients (1979-2014). Sex differences were particularly assessed. One hundred and eight patients (11.7%) developed solid organ tumors (76.9%) or lymphoma (23.1%). Twenty-one percent of patients who reached 20 years after KT developed cancer, with a median post-KT time to diagnosis of 7.4 years. Most common solid organs affected were lung (30.1%), prostate (10.8%), bladder (9.6%), and native kidney (7.2%). When analyzing standardized incidence ratios (SIR) by gender compared to the general population, relative risk was increased in women (SIR = 1.81; 95%CI, 1.28-2.45) but not significantly increased in men (SIR = 1.22; 0.95-2.52). Regarding specific types, gynecological (SIR = 11.6; 4.2-22.7) and lung (SIR = 10.0; 4.3-18.2) in women, and bladder (SIR = 16.3; 5.9-32.1) in men were the most affected locations. Thymoglobulin, a polyclonal antibody that has been used as an immunosuppressive agent in kidney transplantation over the last decades, was a significant risk factor for developing cancer in adjusted regression analysis [IRR = 1.62, 1.02-2.57; p = 0.041], and was associated with lower patient survival. Compared with the general population, the incidence of post-KT non-skin cancer is almost two-fold higher in women but not significantly higher in men. Lung is the most common solid organ affected. Thymoglobulin induction therapy is associated with a greater risk.

Effect of mechanistic target of rapamycin inhibitors on postrenal transplantation malignancy: A nationwide cohort study

BACKGROUND

Post-transplantation malignancy influenced graft survival and overall survival in the patients receiving renal transplantation. Immunosuppressants influenced the immune surveillance, but whether immunosuppressive agents have impact for incidence of post-transplantation malignancy is still elusive in Taiwan.

METHOD

We conducted a nationwide population-based study. Patients who did not have malignancy history and received kidney transplantation between 2000 and 2010 were enrolled. Specific immunosuppressive users are defined as sustained use (more than 12 months) after renal transplantation. The primary outcome is the development of cancer after kidney transplantation. A Cox proportional hazards model was used to determine the risk of cancer development.

RESULT

Among 4438 recipients, 559 of them were diagnosed with malignancy after 1 year of transplantation. A total of 742 of recipients were as user of mechanistic target of rapamycin (mTOR) inhibitors. The mTOR users had higher rate of receiving pulse therapy. The hazard ratios (HR) for mTOR inhibitor users with exposure more than 5 years for overall malignancy and urothelial malignancy were 0.68 (95% CI: 0.48-0.95, P = 0.02) and 0.60 (95% CI: 0.36-0.99, P = 0.02), respectively. For the overall mortality and reentry of dialysis, the probability of both groups was similar (overall mortality: P = 0.53; reentry of dialysis: P = 0.77).

CONCLUSION

Among the recipients of renal transplantation in Taiwan, mTOR inhibitors with exposure more than 5 years provided a protective role in reducing the risk of overall neoplasm and urothelial malignancy. The probability of reentry of dialysis and overall mortality was similar between the mTORi users and nonusers.

Prevalence and survival prognosis of prostate cancer in patients with end-stage renal disease: a retrospective study based on the Korea national database (2003-2010)

Objective

The study was aimed to evaluate the prevalence and prognosis of prostate cancer (PC) and end-stage renal disease (ESRD), determine the risk factors for overall survival (OS) and PC-specific survival (CSS), and evaluate differences in PC-related clinical therapeutic patterns between patients with and without PC-ESRD.

Methods

This observational population study, performed at the National Cancer Center and Cancer Research Institute in Korea, included patients with PC and ESRD from the nationwide Korean Health Insurance System and Korean Central Cancer Registry data. Five-year overall and cancer-specific survival. A joinpoint regression analysis was performed to predict incidence and mortality of PC. Survival was analyzed using Kaplan-Meir curves with log rank tests of patients with dialysis or transplantation.

Results

Of 3945 patients with PC-ESRD, 3.9% were on dialysis (N=152), 0.2% had kidney transplantation (N=10, D-TPL group); 3783 (95.9%) had neither dialysis nor transplantation (non-D-TPL ESRD group). There were 697 PC-specific deaths. The median respective OS, PC-specific survival, and 5-year survival rates in the non-ESRD, non-D-TPL ESRD, dialysis ESRD, and transplantation ESRD groups were significantly different (p<0.001). Presence of ESRD, age, body mass index, SEER stage, no treatment within 6 months after diagnosis, no surgery, chemotherapy, radiotherapy or hormonal therapy, non-adenocarcinoma pathology, and Charlson comorbidity index were independent risk factors for OS and CSS.

Conclusions

With a 10.1% nationwide prevalence of PC-ESRD, the presence of ESRD was a significant survival factor along with other significant clinicopathological factors.

Association of Pretransplant Skin Cancer With Posttransplant Malignancy, Graft Failure and Death in Kidney Transplant Recipients

BACKGROUND

Posttransplant malignancy (PTM) is one of the leading causes of late death in kidney recipients. Those with a cancer history may be more prone to develop a recurrent or a new cancer. We studied the association between pretransplant skin cancer, PTM, death, and graft failure.

METHODS

Primary adult kidney recipients transplanted between 2005 and 2013 were included. Malignancy information was obtained from Organ Procurement Kidney Transplant Network/United Network for Organ Sharing registration and follow-up forms. Posttransplant malignancy was classified into skin cancer, solid tumor, and posttransplant lymphoproliferative disorder (PTLD). Competing risk and survival analysis with adjustment for confounders were used to calculate risk for PTM, death and graft failure in recipients with pretransplant skin cancer compared with those without cancer. Risk was reported in hazard ratios (HR) with 95% confidence interval (CI).

RESULTS

The cohort included 1671 recipients with and 102 961 without pretransplant skin malignancy. The 5-year cumulative incidence of PTM in patients with and without a pretransplant skin cancer history was 31.6% and 7.4%, respectively (P < 0.001). Recipients with pretransplant skin cancer had increased risk of PTM (sub-HR [SHR], 2.60; 95% CI, 2.27-2.98), and posttransplant skin cancer (SHR, 2.92; 95% CI, 2.52-3.39), PTLD (SHR, 1.93; 95% CI, 1.01-3.66), solid tumor (SHR, 1.44; 95% CI, 1.04-1.99), death (HR, 1.20; 95% CI, 1.07-1.34), and graft failure (HR, 1.17; 95% CI, 1.05-1.30) when compared with those without pretransplant malignancy.

CONCLUSIONS

Pretransplant skin cancer was associated with an increased risk of posttransplant skin cancer, PTLD, solid organ cancer, death and graft failure.

From 'Big 4' to 'Big 5': a review and epidemiological study on the relationship between psychiatric disorders and World Health Organization preventable diseases

PURPOSE OF REVIEW

This study outlines the rationale and provides evidence in support of including psychiatric disorders in the World Health Organization's classification of preventable diseases. The methods used represent a novel approach to describe clinical pathways, highlighting the importance of considering the full range of comorbid disorders within an integrated population-based data repository.

RECENT FINDINGS

Review of literature focused on comorbidity in relation to the four preventable diseases identified by the World Health Organization. This revealed that only 29 publications over the last 5 years focus on populations and tend only to consider one or two comorbid disorders simultaneously in regard to any main preventable disease class.

SUMMARY

This article draws attention to the importance of physical and psychiatric comorbidity and illustrates the complexity related to describing clinical pathways in terms of understanding the etiological and prognostic clinical profile for patients. Developing a consistent and standardized approach to describe these features of disease has the potential to dramatically shift the format of both clinical practice and medical education when taking into account the complex relationships between and among diseases, such as psychiatric and physical disease, that, hitherto, have been largely unrelated in research.

Betel quid chewing leads to the development of unique de novo malignancies in liver transplant recipients, a retrospective single center study in Taiwan

Orthotopic liver transplantation (OLT) is the choice of treatment not only for end-stage liver disease and acute liver failure but also for hepatocellular carcinoma (HCC). The development of de novo malignancies after liver transplantation plays an important role in late mortality; the incidence of late mortality has increased owing to improved survival. The incidence of de novo malignancies is 2.3% to 25%, which is 2 to 3 times that of malignancies in the general population. The most commonly reported de novo malignancies in solid organs are skin cancer, Karposi sarcoma, and colon cancer according to the frequency of exposure to a specific carcinogen. We hypothesized that exposure to different carcinogens would change the distribution of de novo malignancies among patients after OLT. In Taiwan, 10% of the population is exposed to a unique carcinogen, the betel quid, which is associated with a high incidence of head and neck cancer (HNC) among the Taiwanese population.From 2004 to 2014, we retrospectively reviewed 484 cases post-OLT at our institution and 16 patients with 17 de novo malignancies were identified. Most of the patients had HNC, which is in contrast to previous literature reports.Univariate and multivariate analyses identified betel quid chewing as the main leading factor for HNC in the Taiwanese population.Routine screening of the oral mucosa in patients with the habit of betel quid chewing is recommended in Taiwan for the early detection of HNC. Routine screening with aggressive treatment after diagnosis of HNC in patients with the habit of chewing betel quid, who underwent OLT, resulted in good patient prognosis.

Increased Calcineurin A Expression Is Associated with a Lower Relapse-Free Survival Rate after Colorectal Cancer Surgery

OBJECTIVE

Increased expression of calcineurin in colorectal cancer (CRC) has been reported. Although the oncogenic function has been suggested, the clinical relevance is still unclear. We herein studied calcineurin expression as a prognostic biomarker in patients receiving curative surgery for stages I-III CRC.

METHODS

In 121 patients with stages I-III CRC treated at Hiroshima University between 1997 and 2003, calcineurin A expression was examined using immunohistochemistry (IHC) staining of surgical specimens. Specimens were considered positive for calcineurin A if any IHC-stained cells were observed within the carcinomatous area, and clinicopathological characteristics and survival outcomes were compared between IHC-positive and -negative groups.

RESULTS

Calcineurin A was preferentially expressed in the cytoplasm of cancer cells, and a median of 8% of the cells (range: 0-80%; interquartile range: 0-22.5%) were stained within the carcinomatous areas. Of 121 cases, 81 were determined as IHC positive while 40 were determined to be negative. Positive expression of calcineurin A, as well UICC-TNM stage, was associated with low relapse-free survival (RFS) rates in multivariate analyses (hazard ratio = 2.92; 95% CI: 1.27-7.92; p = 0.010).

CONCLUSION

Increased calcineurin A expression is associated with lower RFS rates and may have clinical value in predicting recurrence.

Video-assisted thoracoscopic surgery after renal transplantation: A single-institution experience

INTRODUCTION

The number of renal transplantations performed for patients with chronic kidney disease has increased in Japan, but little is known about the outcomes in those who subsequently undergo video-assisted thoracoscopic surgery (VATS). We therefore investigated the outcomes of consecutive patients requiring VATS after renal transplantation at our institute.

METHODS

We retrospectively collected the clinical data for patients undergoing VATS after renal transplantation between January 2003 and September 2014. Specifically, we compared the serum creatinine level and estimated glomerular filtration rate preoperatively and postoperatively, and investigated the postoperative complications.

RESULTS

In total, 12 patients underwent VATS after renal transplantation during the study period. All patients received two or three immunosuppressive agents. Operative methods used included VATS wedge resection (n = 4), segmentectomy (n = 4), lobectomy (n = 2), mediastinal tumor resection (n = 1), and chest wall tumor resection (n = 1). No patients required perioperative hemodialysis. There were no intraoperative complications, but one patient developed postoperative hemorrhagic cystitis and another developed pneumonia. One patient developed pneumocystis pneumonia 2 months after left lower lobectomy and required hemodialysis. No further hemodialysis was required by any patient. Of note, no statistically significant differences were observed between the preoperative and postoperative serum creatinine level (P = 0.666) and estimated glomerular filtration rate (P = 0.388). There were no in-hospital deaths. Univariate analysis revealed no significant risk factors for postoperative complications.

CONCLUSION

This report showed favorable results for VATS after renal transplantation. However, clinicians must remain vigilant for complications because transplant recipients remain permanently immunocompromised.

Post-transplant malignancy in liver transplantation: a single center experience

We aim to determine the incidence of malignancy after liver transplantation (LT) compared to general population. The records of patients who received LTs at our center from October 1989 and November 2012 were retrospectively reviewed. The standardized incidence ratio (SIR) of cancer in the patients was compared to general population using the data from the Taiwan Cancer Registry. Survival was estimated using the Kaplan-Meier method. A total of 444 patients were included. Malignancy was found in 46 (28 de novo and 19 recurrent malignancies) patients (10.4%) with the median follow up of 4.2±4.2 years. The median time of cancer occurrence after transplant was 1.2±1.9 years (range, 0.2-9.1 years). Post-transplant lymphoproliferative disorder was the most frequent de novo malignancy (57.1% [16/28]). The cumulative incidence rates of all malignancies were 5.1%, 10.4%, 12.8%, 15.8%, and 15.8% at 1, 3, 5, 10, and 15 years, respectively. The cumulative incidence rates of de novo malignancies were 3.4%, 5.97%, 7.7%, 10.9%, and 10.9 % at 1, 3, 5, 10, and 15 years. Compared to general population, transplant recipients had significantly higher incidence of all de novo cancers (SIR: 3.26, 95% confidence interval [CI]: 2.17-4.72), hematologic (SIR: 58.4; 95% CI, 33.3-94.8), and bladder (SIR: 10.2, 95% CI: 1.1-36.7) cancers. The estimated mean survivals after transplantation in cancer-free, de novo cancer, and recurrent cancer patients were 17.7±0.5, 11.3±1.2, and 3.6±0.6 years, respectively. There is a significantly increased risk of malignancies after LT in the Taiwanese population.