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Jin BC, Kim DH, Seo GS, Kim SW, Oh HH, Song HY, Kim SJ, Joo YE, Lee J, Kim HS. The Outcomes of Colorectal Endoscopic Submucosal Dissection in Patients with Chronic Kidney Disease: A Honam Association for the Study of Intestinal Disease (HASID) Multicenter Study. Diagnostics (Basel) 2024; 14:1459. [PMID: 39001348 PMCID: PMC11240901 DOI: 10.3390/diagnostics14131459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/01/2024] [Accepted: 07/01/2024] [Indexed: 07/16/2024] Open
Abstract
Colorectal neoplasms are prevalent in patients with chronic kidney disease (CKD); however, the safety and efficacy of colorectal endoscopic submucosal dissection (ESD) are not well understood. This retrospective analysis included ESD procedures performed in 1266 patients with CKD across five tertiary medical institutions from January 2015 to December 2020. Patients were categorized based on their estimated glomerular filtration rate (eGFR), which ranged from CKD1 to CKD5 (including those on dialysis). We found that en bloc resection rates remained high across all CKD stages, affirming the procedural efficacy of ESD. Notably, the prevalence of cardiovascular comorbidities, such as ischemic heart disease and diabetes mellitus, significantly increased with an advancing CKD stage, with a corresponding increase in the Charlson Comorbidity Index, highlighting the complexity of managing these patients. Despite these challenges, the complete resection rate was lower in the CKD5 group (50%) than in the CKD1 group (83.4%); however, procedural complications, such as perforation and bleeding, did not significantly differ among the groups. The predictive models for complete resection and major complications showed no significant changes with a decreasing eGFR. These findings underscore that ESD is a feasible and safe treatment for colorectal neoplasms in patients with CKD, successfully balancing the inherent procedural risks with clinical benefits.
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Affiliation(s)
- Byung Chul Jin
- Department of Internal Medicine, Research Institute of Clinical Medicine, Biomedical Research Institute, Jeonbuk National University Medical School, Jeonbuk National University, Jeonju 54907, Republic of Korea;
| | - Dong Hyun Kim
- Department of Internal Medicine, Medical School, Chonnam National University, Gwangju 61469, Republic of Korea; (D.H.K.); (H.-H.O.); (Y.-E.J.); (H.-S.K.)
| | - Geom-Seog Seo
- Department of Internal Medicine, Digestive Diseases Research Institute, School of Medicine, Wonkwang University, Iksan 54538, Republic of Korea;
| | - Sang-Wook Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine, Biomedical Research Institute, Jeonbuk National University Medical School, Jeonbuk National University, Jeonju 54907, Republic of Korea;
| | - Hyung-Hoon Oh
- Department of Internal Medicine, Medical School, Chonnam National University, Gwangju 61469, Republic of Korea; (D.H.K.); (H.-H.O.); (Y.-E.J.); (H.-S.K.)
| | - Hyo-Yeop Song
- Department of Internal Medicine, Digestive Diseases Research Institute, School of Medicine, Wonkwang University, Iksan 54538, Republic of Korea;
| | - Seong-Jung Kim
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju 61452, Republic of Korea; (S.-J.K.); (J.L.)
| | - Young-Eun Joo
- Department of Internal Medicine, Medical School, Chonnam National University, Gwangju 61469, Republic of Korea; (D.H.K.); (H.-H.O.); (Y.-E.J.); (H.-S.K.)
| | - Jun Lee
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju 61452, Republic of Korea; (S.-J.K.); (J.L.)
| | - Hyun-Soo Kim
- Department of Internal Medicine, Medical School, Chonnam National University, Gwangju 61469, Republic of Korea; (D.H.K.); (H.-H.O.); (Y.-E.J.); (H.-S.K.)
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2
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Brown RB. Spontaneous Tumor Regression and Reversion: Insights and Associations with Reduced Dietary Phosphate. Cancers (Basel) 2024; 16:2126. [PMID: 38893245 PMCID: PMC11172109 DOI: 10.3390/cancers16112126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/21/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
Tumors that spontaneously shrink from unknown causes in tumor regression, and that return to normal cells in tumor reversion, are phenomena with the potential to contribute new knowledge and novel therapies for cancer patient survival. Tumorigenesis is associated with dysregulated phosphate metabolism and an increased transport of phosphate into tumor cells, potentially mediated by phosphate overload from excessive dietary phosphate intake, a significant problem in Western societies. This paper proposes that reduced dietary phosphate overload and reregulated phosphate metabolism may reverse an imbalance of kinases and phosphatases in cell signaling and cellular proliferation, thereby activating autophagy in tumor regression and reversion. Dietary phosphate can also be reduced by sickness-associated anorexia, fasting-mimicking diets, and other diets low in phosphate, all of which have been associated with tumor regression. Tumor reversion has also been demonstrated by transplanting cancer cells into a healthy microenvironment, plausibly associated with normal cellular phosphate concentrations. Evidence also suggests that the sequestration and containment of excessive phosphate within encapsulated tumors is protective in cancer patients, preventing the release of potentially lethal amounts of phosphate into the general circulation. Reducing dietary phosphate overload has the potential to provide a novel, safe, and effective reversion therapy for cancer patients, and further research is warranted.
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Affiliation(s)
- Ronald B Brown
- School of Public Health Sciences, University of Waterloo, Waterloo, ON N2L 3G1, Canada
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3
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Cirillo L, Innocenti S, Becherucci F. Global epidemiology of kidney cancer. Nephrol Dial Transplant 2024; 39:920-928. [PMID: 38341277 DOI: 10.1093/ndt/gfae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Indexed: 02/12/2024] Open
Abstract
Kidney cancer (KC) is a disease with a rising worldwide incidence estimated at 400 000 new cases annually, and a worldwide mortality rate approaching 175 000 deaths per year. Current projections suggest incidence continuing to increase over the next decade, emphasizing the urgency of addressing this significant global health trend. Despite the overall increases in incidence and mortality, striking social disparities are evident. Low- and middle-income countries bear a disproportionate burden of the disease, with higher mortality rates and later-stage diagnoses, underscoring the critical role of socioeconomic factors in disease prevalence and outcomes. The major risk factors for KC, including smoking, obesity, hypertension and occupational exposure to harmful substances, must be taken into account. Importantly, these risk factors also often contribute to kidney injury, a condition that the review identifies as a significant, yet under-recognized, precursor to KC. Finally, the indispensable role of nephrologists is underscored in managing this complex disease landscape. Nephrologists are at the forefront of detecting and managing kidney injuries, and their role in mitigating the risk of KC is becoming increasingly apparent. Through this comprehensive analysis, we aim to facilitate a more nuanced understanding of KC's epidemiology and determinants providing valuable insights for researchers, clinicians and policymakers alike.
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Affiliation(s)
- Luigi Cirillo
- Nephrology and Dialysis Department, Meyer Children's Hospital IRCCS, Florence 50139, Italy
| | - Samantha Innocenti
- Nephrology and Dialysis Department, Meyer Children's Hospital IRCCS, Florence 50139, Italy
| | - Francesca Becherucci
- Nephrology and Dialysis Department, Meyer Children's Hospital IRCCS, Florence 50139, Italy
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
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4
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Hu YW, Yeh CM, Liu CJ, Chen TJ, Huang N, Chou YJ. Severity of Complications and Duration of Type 2 Diabetes and the Risk of Cancer: A Population-Based Study. Cancer Epidemiol Biomarkers Prev 2024; 33:739-748. [PMID: 38412010 DOI: 10.1158/1055-9965.epi-23-1600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/08/2024] [Accepted: 02/23/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND The literature on the association between diabetes severity and cancer risk is limited and inconclusive. The study aimed to evaluate the association between the adapted Diabetes Complications Severity Index (aDCSI) and the duration of type 2 diabetes and cancer risk. METHODS Patients ages 20 years or older with newly diagnosed type 2 diabetes between January 1, 2007, and December 31, 2011, were identified from Taiwan National Health Insurance claims data. Standardized incidence ratios (SIR) were calculated to compare cancer incidence in people with diabetes with that in the general population. Poisson regression was used to examine whether SIRs differed by age, sex, aDSCI, and duration of diabetes. RESULTS A total of 756,547 patients were included, with a median follow-up of 8.8 years. Excluding the first year after diagnosis, the SIR for overall cancer was 1.18 [95% confidence interval (CI) 1.17-1.19]. Higher aDCSI was associated with increased SIRs for overall [SIR ratio 1.03 (1.02-1.03) per point increase], head and neck (1.03; 1.01-1.04), liver (1.04; 1.03-1.05), pancreas (1.03; 1.00-1.05), kidney (1.13; 1.10-1.15), and leukemia (1.09; 1.06-1.13). There was no association between aDCSI and colorectal, extrahepatic biliary tract, uterus and thyroid cancer, and a negative association with breast cancer (0.97; 0.95-0.98). Type 2 diabetes duration was associated with increased SIRs for overall [1.01 (1.00-1.02) per year increase], head and neck (1.03; 1.01-1.05), and liver cancer (1.04; 1.02-1.05). CONCLUSIONS The heterogeneity in the association between diabetes severity and diabetes-related cancers suggests diverse underlying connections. IMPACT Adopting distinct approaches in further research and prevention strategies for different kinds of diabetes-related cancers is important.
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Affiliation(s)
- Yu-Wen Hu
- Department of Heavy Particles and Radiation Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chiu-Mei Yeh
- Institute of Public Health, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Jen Liu
- Institute of Public Health, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Family Medicine, Taipei Veterans General Hospital, Hsinchu Branch, Taipei, Taiwan
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yiing-Jenq Chou
- Institute of Public Health, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Office of the Deputy Superintendent, National Yang Ming Chiao Tung University Hospital, Yilan, Taiwan
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Kollerits B, Gruber S, Steinbrenner I, Schwaiger JP, Weissensteiner H, Schönherr S, Forer L, Kotsis F, Schultheiss UT, Meiselbach H, Wanner C, Eckardt KU, Kronenberg F. Apolipoprotein A-IV concentrations and cancer in a large cohort of chronic kidney disease patients: results from the GCKD study. BMC Cancer 2024; 24:320. [PMID: 38454416 PMCID: PMC10921727 DOI: 10.1186/s12885-024-12053-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 02/26/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is highly connected to inflammation and oxidative stress. Both favour the development of cancer in CKD patients. Serum apolipoprotein A-IV (apoA-IV) concentrations are influenced by kidney function and are an early marker of kidney impairment. Besides others, it has antioxidant and anti-inflammatory properties. Proteomic studies and small case-control studies identified low apoA-IV as a biomarker for various forms of cancer; however, prospective studies are lacking. We therefore investigated whether serum apoA-IV is associated with cancer in the German Chronic Kidney Disease (GCKD) study. METHODS These analyses include 5039 Caucasian patients from the prospective GCKD cohort study followed for 6.5 years. Main inclusion criteria were an eGFR of 30-60 mL/min/1.73m2 or an eGFR > 60 mL/min/1.73m2 in the presence of overt proteinuria. RESULTS Mean apoA-IV concentrations of the entire cohort were 28.9 ± 9.8 mg/dL (median 27.6 mg/dL). 615 patients had a history of cancer before the enrolment into the study. ApoA-IV concentrations above the median were associated with a lower odds for a history of cancer (OR = 0.79, p = 0.02 when adjusted age, sex, smoking, diabetes, BMI, albuminuria, statin intake, and eGFRcreatinine). During follow-up 368 patients developed an incident cancer event and those with apoA-IV above the median had a lower risk (HR = 0.72, 95%CI 0.57-0.90, P = 0.004). Finally, 62 patients died from such an incident cancer event and each 10 mg/dL higher apoA-IV concentrations were associated with a lower risk for fatal cancer (HR = 0.62, 95%CI 0.44-0.88, P = 0.007). CONCLUSIONS Our data indicate an association of high apoA-IV concentrations with reduced frequencies of a history of cancer as well as incident fatal and non-fatal cancer events in a large cohort of patients with CKD.
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Affiliation(s)
- Barbara Kollerits
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Schöpfstraße 41, Innsbruck, 6020, Austria
| | - Simon Gruber
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Schöpfstraße 41, Innsbruck, 6020, Austria
| | - Inga Steinbrenner
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Johannes P Schwaiger
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Schöpfstraße 41, Innsbruck, 6020, Austria
| | - Hansi Weissensteiner
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Schöpfstraße 41, Innsbruck, 6020, Austria
| | - Sebastian Schönherr
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Schöpfstraße 41, Innsbruck, 6020, Austria
| | - Lukas Forer
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Schöpfstraße 41, Innsbruck, 6020, Austria
| | - Fruzsina Kotsis
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
- Department of Medicine IV - Nephrology and Primary Care, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Ulla T Schultheiss
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
- Department of Medicine IV - Nephrology and Primary Care, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Heike Meiselbach
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- German Chronic Kidney Disease Study, Erlangen, Germany
| | - Christoph Wanner
- Division of Nephrology, Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- German Chronic Kidney Disease Study, Erlangen, Germany
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Schöpfstraße 41, Innsbruck, 6020, Austria.
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6
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Rostami M, Yalin SF, Altiparmak MR, Guven M. Investigation of APE1 and OGG1 expression in chronic hemodialysis patients. Mol Biol Rep 2024; 51:144. [PMID: 38236479 DOI: 10.1007/s11033-023-09152-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/13/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND The role of DNA repair mechanisms is of significant importance in diseases characterized by elevated oxidative DNA damage, such as chronic kidney disease. It is imperative to thoroughly understand the functions of molecules associated with DNA repair mechanisms, not only for assessing susceptibility to diseases but also for monitoring disease progression. In this research, we investigated the APE1 and OGG1 gene expression levels, both of which are involved in the base excision repair (BER) mechanism in chronic hemodialysis patients with malignancy (HPM; n = 8) and without malignancy (HP; n = 36) in pre- and post-dialysis period and 37 healty persons. We also assessed how these values correlate with the clinical profiles of the patients. METHODS AND RESULTS We conducted gene expression analysis using real-time polymerase chain reaction (qRT-PCR). No significant differences in APE1 gene expression levels were observed in pre-dialysis when comparing the HP and HPM groups to the control group. The expression levels of the OGG1 gene were significantly lower in both the HP and HPM groups in pre- and post-dialysis periods compared to the control group. Dialysis procedures led to a reduction in APE1 and OGG1 gene expression levels in both HP and HPM groups. CONCLUSIONS The findings of our study elucidate the impact of alterations in the base excision repair (BER) mechanism, including the hemodialysis process, in end-stage renal disease (ESRD).
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Affiliation(s)
- Manouchehr Rostami
- Department of Medical Biology, Cerrahpasa Medicine Faculty, Istanbul University-Cerrahpasa, Istanbul, 34098, Turkey
| | - Serkan Feyyaz Yalin
- Department of Nephrology, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
| | - Mehmet Riza Altiparmak
- Department of Nephrology, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Mehmet Guven
- Department of Medical Biology, Cerrahpasa Medicine Faculty, Istanbul University-Cerrahpasa, Istanbul, 34098, Turkey.
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7
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Luo L, Vart P, Kieneker LM, van der Vegt B, Bakker SJL, Gruppen EG, Casteleijn NF, de Boer RA, Suthahar N, de Bock GH, Aboumsallem JP, Gansevoort RT. Mediators of the association between albuminuria and incident cancer: the PREVEND study. Clin Kidney J 2024; 17:sfad295. [PMID: 38213496 PMCID: PMC10783233 DOI: 10.1093/ckj/sfad295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Indexed: 01/13/2024] Open
Affiliation(s)
- Li Luo
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lyanne M Kieneker
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bert van der Vegt
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stephan J L Bakker
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Eke G Gruppen
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Niek F Casteleijn
- Department of Urology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rudolf A de Boer
- Erasmus MC, Cardiovascular Institute, Thorax Center, Department of Cardiology, Rotterdam, The Netherlands
| | - Navin Suthahar
- Erasmus MC, Cardiovascular Institute, Thorax Center, Department of Cardiology, Rotterdam, The Netherlands
| | - Geertruida H de Bock
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joseph Pierre Aboumsallem
- Erasmus MC, Cardiovascular Institute, Thorax Center, Department of Cardiology, Rotterdam, The Netherlands
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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8
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Kanbay M, Copur S, Yilmaz ZY, Tanriover C, Hasbal NB, Ortiz A, Perazella MA. A novel risk factor for malignancy: Albuminuria. Eur J Intern Med 2023; 118:22-31. [PMID: 37741791 DOI: 10.1016/j.ejim.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/03/2023] [Accepted: 09/10/2023] [Indexed: 09/25/2023]
Abstract
Cancer is the second leading cause of death among the adult population following cardiovascular diseases. Prevention and earlier diagnosis are among the cornerstones in the management of malignancies. Albuminuria is a diagnostic criterion for chronic kidney disease and has been associated with multiple conditions including cardiovascular diseases and systemic inflammation while the association between albuminuria and malignancy has been inadequately addressed. Large-scale observational studies with long follow-up periods demonstrate a statistically significant association between albuminuria and overall malignancy incidence, especially urothelial malignancy incidence. However, the underlying pathophysiology linking these two entities is not a straightforward causal relationship but most likely a multidirectional relationship including a causal link. In this narrative review, we evaluate the clinical studies investigating the association between albuminuria and malignancy along with potential underlying mechanisms linking them. We also summarize data on the impact of treatment modalities prescribed for albuminuria and/or proteinuria on the prevention or prognosis of malignancies.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Section of Nephrology, Koc University School of Medicine, Istanbul, Turkey.
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Zeynep Y Yilmaz
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Cem Tanriover
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Nuri Baris Hasbal
- Department of Medicine, Section of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Alberto Ortiz
- Department of Medicine, Universidad Autonoma de Madrid and IIS-Fundacion Jimenez Diaz, Madrid, Spain
| | - Mark A Perazella
- Department of Internal Medicine Section of Nephrology, Yale University School of Medicine, CT, USA
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9
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Ciorcan M, Negru Ș, Bardan R, Cumpănaș A, Mattar I, Bitar Y, Chișavu L, Marc L, Schiller A, Mihăescu A. The Impact of Chronic Kidney Disease on the Mortality Rates of Patients with Urological Cancers-An Analysis of a Uro-Oncology Database from Eastern Europe. J Pers Med 2023; 13:1572. [PMID: 38003887 PMCID: PMC10672193 DOI: 10.3390/jpm13111572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/26/2023] Open
Abstract
(1) Background: The relationship between chronic kidney disease (CKD) and urological cancers is complex, as most of these cancers are diagnosed in patients with advanced ages, when the kidney function may be already impaired. On the other hand, urological cancers could represent a risk factor for CKD, significantly reducing the life expectancy of the patients. The main objective of our study was to analyze the impact of CKD on the overall mortality of patients diagnosed with the most frequent types of urological cancers. (2) Material and Methods: We conducted an observational retrospective cohort study on a group of 5831 consecutive newly diagnosed cancer patients, followed over a 2-year period (2019-2020), from a large Oncology Hospital in Romania. From this group, we selected only the patients diagnosed with urological malignancies, focusing on prostate cancer, bladder cancer and renal cancer; finally, 249 patients were included in our analysis. (3) Results: In the group of patients with prostate cancer (n = 146), the 2-year overall mortality was 62.5% for patients with CKD, compared with 39.3% for those with no initial CKD (p < 0.05). In the group of patients with bladder cancer (n = 62), the 2-year overall mortality was 80% for patients with initial CKD, compared with 45.2% for the patients with no initial CKD (p < 0.05). Finally, in the group of patients with renal cell carcinoma (n = 41), the 2-year overall mortality was 60% for patients with initial CKD, compared with 50% for the patient group with no initial CKD (p < 0.05). Various correlations between specific oncologic and nephrological parameters were also analyzed. (4) Conclusions: The presence of CKD at the moment of the urological cancer diagnosis is associated with significantly higher 2-year mortality rates.
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Affiliation(s)
- Mircea Ciorcan
- Department of Clinical Practical Skills, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania;
- Center of Advanced Research in Cardiovascular Pathology and Hemostaseology, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Șerban Negru
- Department of Oncology, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania;
- Oncohelp Oncology Center, 300239 Timișoara, Romania
| | - Răzvan Bardan
- Department of Urology, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania;
- Department of Urology, Clinical Emergency County Hospital, 300723 Timișoara, Romania; (I.M.); (Y.B.)
| | - Alin Cumpănaș
- Department of Urology, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania;
- Department of Urology, Clinical Emergency County Hospital, 300723 Timișoara, Romania; (I.M.); (Y.B.)
| | - Iasmina Mattar
- Department of Urology, Clinical Emergency County Hospital, 300723 Timișoara, Romania; (I.M.); (Y.B.)
| | - Yahya Bitar
- Department of Urology, Clinical Emergency County Hospital, 300723 Timișoara, Romania; (I.M.); (Y.B.)
| | - Lazăr Chișavu
- Department of Nephrology, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania; (L.C.); (L.M.); (A.S.); (A.M.)
- Department of Nephrology, Clinical Emergency County Hospital, 300723 Timișoara, Romania
- Center for Molecular Research in Nephrology and Vascular Disease, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Luciana Marc
- Department of Nephrology, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania; (L.C.); (L.M.); (A.S.); (A.M.)
- Department of Nephrology, Clinical Emergency County Hospital, 300723 Timișoara, Romania
- Center for Molecular Research in Nephrology and Vascular Disease, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Adalbert Schiller
- Department of Nephrology, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania; (L.C.); (L.M.); (A.S.); (A.M.)
- Department of Nephrology, Clinical Emergency County Hospital, 300723 Timișoara, Romania
- Center for Molecular Research in Nephrology and Vascular Disease, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Adelina Mihăescu
- Department of Nephrology, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania; (L.C.); (L.M.); (A.S.); (A.M.)
- Department of Nephrology, Clinical Emergency County Hospital, 300723 Timișoara, Romania
- Center for Molecular Research in Nephrology and Vascular Disease, Victor Babes University of Medicine and Pharmacy, 300041 Timișoara, Romania
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Brown RB, Bigelow P, Dubin JA, Mielke JG. High Dietary Phosphorus Is Associated with Increased Breast Cancer Risk in a U.S. Cohort of Middle-Aged Women. Nutrients 2023; 15:3735. [PMID: 37686766 PMCID: PMC10490459 DOI: 10.3390/nu15173735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
Research has shown that high amounts of dietary phosphorus that are twice the amount of the U.S. dietary reference intake of 700 mg for adults are associated with all-cause mortality, phosphate toxicity, and tumorigenesis. The present nested case-control study measured the relative risk of self-reported breast cancer associated with dietary phosphate intake over 10 annual visits in a cohort of middle-aged U.S. women from the Study of Women's Health Across the Nation. Analyzing data from food frequency questionnaires, the highest level of daily dietary phosphorus intake, >1800 mg of phosphorus, was approximately equivalent to the dietary phosphorus levels in menus promoted by the United States Department of Agriculture. After adjusting for participants' energy intake, this level of dietary phosphorus was associated with a 2.3-fold increased risk of breast cancer incidence compared to the reference dietary phosphorus level of 800 to 1000 mg, which is based on recommendations from the U.S. National Kidney Foundation, (RR: 2.30, 95% CI: 0.94-5.61, p = 0.07). Despite the lack of statistical significance, likely due to the small sample size of the cohort, the present nested case-control study's clinically significant effect size, dose-response, temporality, specificity, biological plausibility, consistency, coherence, and analogy with other research findings meet the criteria for inferred causality in observational studies, warranting further investigations. Furthermore, these findings suggest that a low-phosphate diet should be tested on patients with breast cancer.
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Affiliation(s)
- Ronald B. Brown
- School of Public Health Sciences, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - Philip Bigelow
- School of Public Health Sciences, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - Joel A. Dubin
- School of Public Health Sciences, University of Waterloo, Waterloo, ON N2L 3G1, Canada
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - John G. Mielke
- School of Public Health Sciences, University of Waterloo, Waterloo, ON N2L 3G1, Canada
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11
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Mahmud S, Abbas TO, Mushtak A, Prithula J, Chowdhury MEH. Kidney Cancer Diagnosis and Surgery Selection by Machine Learning from CT Scans Combined with Clinical Metadata. Cancers (Basel) 2023; 15:3189. [PMID: 37370799 DOI: 10.3390/cancers15123189] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Kidney cancers are one of the most common malignancies worldwide. Accurate diagnosis is a critical step in the management of kidney cancer patients and is influenced by multiple factors including tumor size or volume, cancer types and stages, etc. For malignant tumors, partial or radical surgery of the kidney might be required, but for clinicians, the basis for making this decision is often unclear. Partial nephrectomy could result in patient death due to cancer if kidney removal was necessary, whereas radical nephrectomy in less severe cases could resign patients to lifelong dialysis or need for future transplantation without sufficient cause. Using machine learning to consider clinical data alongside computed tomography images could potentially help resolve some of these surgical ambiguities, by enabling a more robust classification of kidney cancers and selection of optimal surgical approaches. In this study, we used the publicly available KiTS dataset of contrast-enhanced CT images and corresponding patient metadata to differentiate four major classes of kidney cancer: clear cell (ccRCC), chromophobe (chRCC), papillary (pRCC) renal cell carcinoma, and oncocytoma (ONC). We rationalized these data to overcome the high field of view (FoV), extract tumor regions of interest (ROIs), classify patients using deep machine-learning models, and extract/post-process CT image features for combination with clinical data. Regardless of marked data imbalance, our combined approach achieved a high level of performance (85.66% accuracy, 84.18% precision, 85.66% recall, and 84.92% F1-score). When selecting surgical procedures for malignant tumors (RCC), our method proved even more reliable (90.63% accuracy, 90.83% precision, 90.61% recall, and 90.50% F1-score). Using feature ranking, we confirmed that tumor volume and cancer stage are the most relevant clinical features for predicting surgical procedures. Once fully mature, the approach we propose could be used to assist surgeons in performing nephrectomies by guiding the choices of optimal procedures in individual patients with kidney cancer.
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Affiliation(s)
- Sakib Mahmud
- Department of Electrical Engineering, Qatar University, Doha 2713, Qatar
| | - Tariq O Abbas
- Urology Division, Surgery Department, Sidra Medicine, Doha 26999, Qatar
- Department of Surgery, Weill Cornell Medicine-Qatar, Doha 24811, Qatar
- College of Medicine, Qatar University, Doha 2713, Qatar
| | - Adam Mushtak
- Clinical Imaging Department, Hamad Medical Corporation, Doha 3050, Qatar
| | - Johayra Prithula
- Department of Electrical and Electronics Engineering, University of Dhaka, Dhaka 1000, Bangladesh
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12
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Di Paola R, De A, Izhar R, Abate M, Zappavigna S, Capasso A, Perna AF, La Russa A, Capasso G, Caraglia M, Simeoni M. Possible Effects of Uremic Toxins p-Cresol, Indoxyl Sulfate, p-Cresyl Sulfate on the Development and Progression of Colon Cancer in Patients with Chronic Renal Failure. Genes (Basel) 2023; 14:1257. [PMID: 37372437 DOI: 10.3390/genes14061257] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/09/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023] Open
Abstract
Chronic kidney disease (CKD) induces several systemic effects, including the accumulation and production of uremic toxins responsible for the activation of various harmful processes. Gut dysbiosis has been widely described in CKD patients, even in the early stages of the disease. The abundant discharge of urea and other waste substances into the gut favors the selection of an altered intestinal microbiota in CKD patients. The prevalence of bacteria with fermentative activity leads to the release and accumulation in the gut and in the blood of several substances, such as p-Cresol (p-C), Indoxyl Sulfate (IS) and p-Cresyl Sulfate (p-CS). Since these metabolites are normally eliminated in the urine, they tend to accumulate in the blood of CKD patients proportionally to renal impairment. P-CS, IS and p-C play a fundamental role in the activation of various pro-tumorigenic processes, such as chronic systemic inflammation, the increase in the production of free radicals and immune dysfunction. An up to two-fold increase in the incidence of colon cancer development in CKD has been reported in several studies, although the pathogenic mechanisms explaining this compelling association have not yet been described. Based on our literature review, it appears likely the hypothesis of a role of p-C, IS and p-CS in colon cancer development and progression in CKD patients.
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Affiliation(s)
- Rossella Di Paola
- Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Ananya De
- Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Raafiah Izhar
- Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Marianna Abate
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Silvia Zappavigna
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Anna Capasso
- Department of Oncology, Livestrong Cancer Institutes, Dell Medical School, The University of Texas, Austin, TX 75063, USA
| | - Alessandra F Perna
- Nephrology and Dialysis Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Antonella La Russa
- Department of Sperimental Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | | | - Michele Caraglia
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
- Biogem S.c.a.r.l. Research Institute, 83031 Ariano Irpino, Italy
| | - Mariadelina Simeoni
- Nephrology and Dialysis Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
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13
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Iio K, Kabata D, Iio R, Shibamoto S, Watanabe Y, Morita M, Imai Y, Hatanaka M, Omori H, Isaka Y. Decreased thymic output predicts progression of chronic kidney disease. Immun Ageing 2023; 20:8. [PMID: 36788556 PMCID: PMC9926722 DOI: 10.1186/s12979-023-00333-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is age-related disease, and decreased renal function is associated with the premature aging of T cells and increased incidence of other age-related diseases. However, the relationship between T cell senescence and CKD progression remains unclear. Here, we investigated the relationship between T cell senescence, as indicated by decreased thymic output and increased proportion of highly differentiated CD28- T cells, and CKD progression. RESULTS A total of 175 patients with non-dialysis-dependent CKD were enrolled in this study. Thymic output was assessed based on the CD45RA+CD31+CD4+ cell (recent thymic emigrant [RTE]) counts (RTEs) (/mm3) and the proportion of RTE among CD4+ T cells (RTE%). Highly differentiated T cells were assessed based on the proportion of CD28- cells among CD4+ T cells (CD28-/CD4+) and CD28- cells among CD8+ T cells (CD28-/CD8+). The primary outcome was estimated glomerular filtration rate (eGFR) decline of ≥40% or initiation of renal replacement therapy. The association between T cell senescence and renal outcomes was examined using Cox proportional hazards models and restricted cubic splines. The median age was 73 years, 33% were women, and the median eGFR was 26 mL/min/1.73 m2. The median RTEs, RTE%, CD28-/CD4+, and CD28-/CD8+ were 97.5/mm3, 16.2, 5.3, and 49.7%, respectively. After a median follow-up of 1.78 years, renal outcomes were observed in 71 patients. After adjusting for age, sex, eGFR, proteinuria, diabetes, and cytomegalovirus seropositivity, decreased RTEs, which corresponded to decreased thymic output, significantly and monotonically increased the risk of poor renal outcome (p = 0.04), and decreased RTE% and increased highly differentiated CD28-/CD4+ T cells also tended to monotonically increase the risk (p = 0.074 and p = 0.056, respectively), but not CD28-/CD8+ T cells. CONCLUSIONS Decreased thymic output in CKD patients, as well as increased highly differentiated CD4+ T cells, predicted renal outcomes. Thus, the identification of patients prone to CKD progression using T cell senescence, particularly decreased RTE as a biomarker, may help to prevent progression to end-stage kidney disease.
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Affiliation(s)
- Kenichiro Iio
- Department of Nephrology, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashimachi Kawachinagano, Osaka, Japan.
| | - Daijiro Kabata
- grid.258799.80000 0004 0372 2033Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Rei Iio
- grid.416985.70000 0004 0378 3952Department of Kidney Disease and Hypertension, Osaka General Medical Center, Osaka, Japan
| | - Shinichi Shibamoto
- grid.471868.40000 0004 0595 994XDepartment of Nephrology, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashimachi Kawachinagano, Osaka, Japan
| | - Yuuki Watanabe
- grid.471868.40000 0004 0595 994XDepartment of Nephrology, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashimachi Kawachinagano, Osaka, Japan
| | - Masashi Morita
- grid.471868.40000 0004 0595 994XDepartment of Nephrology, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashimachi Kawachinagano, Osaka, Japan
| | - Yosuke Imai
- grid.471868.40000 0004 0595 994XDepartment of Nephrology, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashimachi Kawachinagano, Osaka, Japan
| | - Masaki Hatanaka
- grid.471868.40000 0004 0595 994XDepartment of Nephrology, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashimachi Kawachinagano, Osaka, Japan
| | - Hiroki Omori
- grid.471868.40000 0004 0595 994XDepartment of Nephrology, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashimachi Kawachinagano, Osaka, Japan
| | - Yoshitaka Isaka
- grid.136593.b0000 0004 0373 3971Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
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14
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Delaye M, Rousseau A, Try M, Massard C, Campedel L, Hilmi M, Bagnis C. Inclusion of patients with chronic kidney disease in randomized phase 3 clinical trials in patients with prostate, breast, lung, and colorectal cancer. Cancer Med 2022; 12:3172-3175. [PMID: 36156460 PMCID: PMC9939176 DOI: 10.1002/cam4.5171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 11/07/2022] Open
Abstract
The objective of this study was to determine the proportion of phase 3 clinical trials investigating a systemic therapy for patients with prostate, breast, lung, or colorectal cancer that excluded patients with Chronic Kidney Disease (CKD) and the exclusion criteria chosen, if any. A search was conducted using the ClinicalTrials.gov database to identify eligible studies. Of the 268 included trials, 185 (69%) had at least one renal exclusion criteria. Of these 185 trials, 116 (63%) had an undefined exclusion criterion. Only disease site was associated with exclusion of patients with CKD in the univariate analysis, but no factors in the multivariate analysis. There are several potential barriers to including patients with CKD in clinical trials. Nevertheless, solutions can be proposed to allow the inclusion of these patients. This would allow them to access to innovative therapeutic strategies, but also allow a better applicability of trial results to this patient population.
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Affiliation(s)
- Matthieu Delaye
- Department of Medical Oncology, Institut CurieVersailles Saint‐Quentin UniversitySaint‐CloudFrance,Groupe de Recherche Interdisciplinaire Francophone en Onco‐néphrologie (GRIFON)ParisFrance
| | - Adrien Rousseau
- Groupe de Recherche Interdisciplinaire Francophone en Onco‐néphrologie (GRIFON)ParisFrance,Department of Medical OncologyGustave Roussy Cancer CampusVillejuifFrance
| | - Mélanie Try
- Groupe de Recherche Interdisciplinaire Francophone en Onco‐néphrologie (GRIFON)ParisFrance,Nephrology department, Bicêtre HospitalAPHP Paris‐Saclay UniversityLe Kremlin‐BicêtreFrance
| | - Christophe Massard
- Department of Medical Oncology, Eugene Marquis Cancer InstituteUniversity of RennesRennesFrance
| | - Luca Campedel
- Groupe de Recherche Interdisciplinaire Francophone en Onco‐néphrologie (GRIFON)ParisFrance,Service d'OncologieCHU Gabriel Montpied, Université Clermont AuvergneClermont‐FerrandFrance
| | - Marc Hilmi
- Department of Medical Oncology, Institut CurieVersailles Saint‐Quentin UniversitySaint‐CloudFrance
| | - Corinne Bagnis
- Groupe de Recherche Interdisciplinaire Francophone en Onco‐néphrologie (GRIFON)ParisFrance,Nephrology department, Pitié Salpetrière HospitalAPHP Sorbonne UniversityParisFrance
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15
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Perioperative Complications and Oncologic Outcomes after Radical Cystectomy in End-Stage Renal Disease Patients with Bladder Cancer Obtained Using a Standardized Reporting System. Cancers (Basel) 2022; 14:cancers14143512. [PMID: 35884573 PMCID: PMC9324134 DOI: 10.3390/cancers14143512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/12/2022] [Accepted: 07/18/2022] [Indexed: 11/20/2022] Open
Abstract
Background: We investigated the use of a standardized reporting system to study perioperative complications and oncologic outcomes after radical cystectomy in end-stage renal disease (ESRD) patients with bladder cancer. Methods: We reviewed retrospective outcomes in 141 ESRD patients with bladder cancer who underwent radical cystectomy between 2004 and 2015. Complications were graded using the Clavien−Dindo classification system with 0−2 classified as “No Major Complications” and Clavien 3−5 as “Major Complications”. Low-volume surgeons were classified as those performing fewer than nine cases during the study. Fisher’s exact test along with the chi-squared test, two-tailed t tests, logistic regression, and the Cox proportional hazard model were used to evaluate all clinically meaningful covariates. Results: Ninety-nine (99, 70.2%) patients had no major complications, and forty-two (29.8%) patients had major complications. Patients in the major complications group were older, had a higher Charlson comorbidity index (CCI), and had a longer hospitalization duration than those in the no major complications group (all, p < 0.05). Major complications were also more common when the procedure was performed by low-volume surgeons (p = 0.003). In multivariate logistic regression models, CCI ≥ 5 (p = 0.006) and low-volume surgeon (p = 0.004) were independent predictors of major complications. According to multivariate analysis with the Cox hazards regression, male sex, age > 70 years, CCI ≥ 5, bladder cancer stage ≥ 3, lymphovascular invasion, and experiencing major complications were significant poor prognostic factors for overall survival (all, p < 0.05). Conclusions: Accurate reporting of complications is necessary for preoperative counseling, identifying modifiable risk factors, and planning risk mitigation strategies. High comorbidity and low-volume surgeons were interrelated as notable risk factors for major complications. In addition to tumor-related factors, male sex, older age, and major complications significantly influence overall survival.
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