Validity of registry data: Agreement between cancer records in an end-stage kidney disease registry (voluntary reporting) and a cancer register (statutory reporting)

Variations in Risk of Cancer and Death From Cancer According to Kidney Allograft Function, Graft Loss, and Return to Dialysis

BACKGROUND

Cancer incidence and mortality may change with varying kidney allograft function and after graft loss. We aimed to quantify cancer incidence and mortality during periods with a functioning graft and after graft loss.

METHODS

We included all adult Australians aged 20 and above who commenced kidney replacement therapy between 1982 and 2014 using data from Australia and New Zealand Dialysis and Transplant Registry. We calculated the standardized incidence ratios and standardized mortality ratios (standardized against the Australian general population) for dialysis patients and transplant recipients during periods with a functioning graft and after graft loss.

RESULTS

A total of 44 765 dialysis patients without transplants, 13 443 with first kidney transplants, 2951 after first graft loss, 1010 with second transplants, and 279 after second graft loss were followed for 274 660 patient-years. Cancer incidence and mortality (per 100 000 patient-years) were 1564 and 760 in dialysis patients, 1564 and 689 in recipients of first transplants, 1188 and 390 after first graft loss, 1525 and 693 after second transplants, and 1645 and 779 after second graft loss. Cancer standardized incidence ratios and standardized mortality ratios (95% confidence intervals) were 1.15 (1.11-1.20) and 1.29 (1.21-1.36) for dialysis patients, 2.03 (1.94-2.13) and 2.50 (2.33-2.69) for recipients following their first transplant, 1.55 (1.29-1.85) and 1.40 (1.00-1.90) after first graft loss, 2.18 (1.79-2.63) and 3.00 (2.23-3.96) for second transplants, 2.59 (1.56-4.04) and 3.82 (1.75-7.25) after second graft loss.

CONCLUSIONS

In kidney transplant recipients, cancer incidence and mortality are highest during periods with a functioning graft and remained higher than in the general population even after graft loss.

The incidence of cancer recurrence and new cancer following commencement of dialysis in patients with prior cancers

Background

Patients with kidney failure have a higher cancer risk compared with the age-matched general population. However, the outcomes of incident dialysis patients with a prior cancer history are unknown.

Methods

Using Australia and New Zealand Dialysis and Transplant Registry data (2000–2019), the outcomes and survival probabilities of incident dialysis patients with prior cancers and having experienced a cancer recurrence or having developed a new cancer after dialysis commencement were described.

Results

Of 4912 patients with prior cancers before dialysis commencement, 323 (7%) and 343 (7%) patients experienced cancer recurrence or developed new cancers after dialysis initiation, respectively. The median time from dialysis commencement to cancer recurrence was 1.2 years [interquartile range (IQR) 0.5–2.8] and was 2.0 years (IQR 0.7–4.0) for new cancer occurrence. Of those with cancer recurrence, 80% presented with metastatic disease and one in two patients died from cancer, with a median time from cancer recurrence to death of 0.5 years (IQR 0.2–1.7). Of those who developed new cancer, urinary tract and respiratory cancers were the most frequent cancer types, with a median time from new cancer diagnosis to death of 1.3 years (IQR 0.4–3.1). The 3-year survival probabilities on dialysis following cancer recurrence and new cancer were 19% [95% confidence interval (CI) 15–24] and 41% (35–47), respectively.

Conclusion

Among incident dialysis patients with a prior cancer history, 14% experienced cancer recurrence or developed a new cancer. Patients who experienced cancer recurrence or developed new cancer have poor outcomes, with ˂50% surviving beyond 3 years. These findings suggest the need to have a greater understanding of the characteristics, cancer screening, treatment responses and reasons for commencing dialysis in patients with kidney failure and prior cancer history, which may help in the shared clinical decision-making process when considering dialysis for these patients.

Incidence and Outcomes of Early Cancers After Kidney Transplantation

Outcomes of early cancers after kidney transplantation are not well-understood. We included recipients of first live and deceased donor kidney transplants who developed de novo cancers in Australia and New Zealand between 1980-2016. We compared the frequency and stage of specific cancer types that developed early (≤12-months) and late (>12-months) post-transplantation. Risk factors for death were evaluated using multivariable Cox regression analyses. Of 2,759 recipients who developed de novo cancer, followed-up for 40,035 person-years, 243 (8.8%) patients were diagnosed with early cancer. Post-transplant lymphoproliferative disease, urinary cancers and melanoma were the most common cancer types (26%, 18%, and 12%) and the majority were either in-situ or locally invasive lesions (55%, 84%, and 86%). Tumors arising early from the gastrointestinal and respiratory systems were uncommon but aggressive, with 40% presenting with metastatic disease at time of diagnosis. Overall, 32% of patients with early cancers died within a median of 4.7 months (IQR:0.6-16) post-diagnosis and 91% were cancer-related deaths. Older recipient and donor age were associated with an increased risk of all-cause death. Early cancers, though infrequent in kidney transplant recipients, are associated with poor outcomes, as nearly 1 in 3 died from cancer-related death; with majority of deaths occurring within 12-months of cancer diagnosis.

National and international kidney failure registries: characteristics, commonalities, and contrasts

Registries are essential for health infrastructure planning, benchmarking, continuous quality improvement, hypothesis generation, and real-world trials. To date, data from these registries have predominantly been analyzed in isolated "silos," hampering efforts to analyze "big data" at the international level, an approach that provides wide-ranging benefits, including enhanced statistical power, an ability to conduct international comparisons, and greater capacity to study rare diseases. This review serves as a valuable resource to clinicians, researchers, and policymakers, by comprehensively describing kidney failure registries active in 2021, before proposing approaches for inter-registry research under current conditions, as well as solutions to enhance global capacity for data collaboration. We identified 79 kidney-failure registries spanning 77 countries worldwide. International Society of Nephrology exemplar initiatives, including the Global Kidney Health Atlas and Sharing Expertise to support the set-up of Renal Registries (SharE-RR), continue to raise awareness regarding international healthcare disparities and support the development of universal kidney-disease registries. Current barriers to inter-registry collaboration include underrepresentation of lower-income countries, poor syntactic and semantic interoperability, absence of clear consensus guidelines for healthcare data sharing, and limited researcher incentives. This review represents a call to action for international stakeholders to enact systemic change that will harmonize the current fragmented approaches to kidney-failure registry data collection and research.

Factors influencing fertility rates in Australian women receiving kidney replacement therapy: Analysis of linked ANZDATA registry and perinatal data over 22 years

BACKGROUND

Pregnancy in women receiving kidney replacement therapy (KRT) is uncommon, and trends and factors influencing fertility rates remain poorly defined.

METHODS

The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) was linked to mandatory perinatal datasets (all births from 1991-2013, ≥20 weeks' gestation) in four Australian jurisdictions. Overall, age and era-specific fertility rates were calculated based on general and KRT population denominators.

RESULTS

From 2,948,084 births, 248 babies were born to 168 mothers receiving KRT (37 babies born to 31 dialysed mothers; 211 babies born to 137 transplanted mothers). Substantial agreement between ANZDATA and perinatal datasets was observed for birth events and outcomes. Transplanted women had higher fertility rates than dialysed women in all analyses, with 21.4 live births/1000 women/year (95% CI: 18.6-24.6) in transplanted women, 5.8 (95% CI: 4.1-8.1) in dialysed women and 61.9 (95% CI: 61.8-62.0) in the Non-KRT cohort. Fertility rates for dialysed women rose in recent years. After adjusting for maternal age and treatment modality, Caucasian women had higher fertility rates, while women with pre-existing diabetes, or transplanted women with exposure to KRT for ≤3.0 years had lower rates. As expected, transplanted women with a pre-conception estimated glomerular filtration rate (eGFR) of < 45 or transplant-to-pregnancy interval of < 1.0 year had lower fertility rates. Geographical location, socioeconomic status and primary disease (glomerulonephritis vs. other) did not affect fertility rates.

CONCLUSIONS

Reporting of births to ANZDATA is sufficiently accurate to justify ongoing data collection. Rising fertility rates in dialysed women may indicate permissive attitudes towards pregnancy. Treatment modality, ethnicity, diabetes, pre-conception eGFR, transplant-to-pregnancy interval and duration of KRT exposure were associated with fertility rates. These factors should be considered when counselling women with kidney disease about parenthood.

[Localized Prostate cancer in candidates for renal transplantation and recipients of a kidney transplant: The French Guidelines from CTAFU]

OBJECTIVE

To define guidelines for the management of localized prostate cancer (PCa) in kidney transplant (KTx) candidates and recipients.

METHOD

A systematic review (Medline) of the literature was conducted by the CTAFU to report prostate cancer epidemiology, screening, diagnosis and management in KTx candidates and recipients with the corresponding level of evidence.

RESULTS

KTx recipients are at similar risk for PCa as general population. Thus, PCa screening in this setting is defined according to global French guidelines from CCAFU. Systematic screening is proposed in candidates for renal transplant over 50 y-o. PCa diagnosis is based on prostate biopsies performed after multiparametric MRI and preventive antibiotics. CCAFU guidelines remain applicable for PCa treatment in KTx recipients with some specificities, especially regarding lymph nodes management. Treatment options in candidates for KTx need to integrate waiting time and access to transplantation. Current data allows the CTAFU to propose mandatory waiting times after PCa treatment in KTx candidates with a weak level of evidence.

CONCLUSION

These French recommendations should contribute to improve PCa management in KTx recipients and candidates, integrating oncological objectives with access to transplantation.

Body mass index, weight-adjusted immunosuppression and the risk of acute rejection and infection after kidney transplantation: a cohort study

BACKGROUND

Body mass index (BMI) is associated with patient outcomes after kidney transplantation. We hypothesized that immunosuppression (IS) dosing is a contributing factor.

METHODS

Using Australia and New Zealand Dialysis and Transplant registry data, we included all adult kidney-only transplant recipients over 2000-14 treated with prednisolone, mycophenolate and tacrolimus/cyclosporin (n = 7919). The exposure was BMI and the outcomes were time to: (i) acute rejection, (ii) fatal infection, (iii) cancer and (iv) graft; and (v) patient survival. We modelled BMI and IS dosing (in quartiles) as time-varying covariates in extended Cox models.

RESULTS

Compared with a BMI of 25 kg/m2, a BMI of 35 was associated with acute rejection after adjusting for demographics and comorbidities [adjusted hazard ratio (aHR) = 1.29, 95% confidence interval (CI) 1.12-1.49]. This association virtually disappeared after correcting for IS (aHR = 1.09, 95% CI 0.93-1.29). A BMI of 35 was non-significantly associated with fewer fatal infections (aHR = 0.91, 95% CI 0.66-1.25), but this reversed after adjusting for IS (aHR = 1.54, 95% CI 1.03-2.28). Results for cancer were not significantly altered after adjusting for IS. Results for lower BMI were similarly not significantly altered though generally associated with worse outcomes.

CONCLUSIONS

Our findings show that the associations between high BMI, acute rejection and fatal infection after kidney transplantation were significantly altered after correcting for IS suggesting that relative under-dosing of obese patients may partially explain these associations.

Incidence and predictors of post-transplant lymphoproliferative disease after kidney transplantation during adulthood and childhood: a registry study

Background

Differences in the epidemiology of post-transplant lymphoproliferative disease (PTLD) between adult and paediatric kidney transplant recipients remain unclear.

Methods

Using the Australian and New Zealand Dialysis and Transplant Registry (1963-2015), the cumulative incidences of PTLD in children (age <20 years) and adults were calculated using a competing risk of death model and compared with age-matched population-based data using standardized incidence ratios (SIRs). Risk factors for PTLD were assessed using Cox proportional hazards regression.

Results

Among 23 477 patients (92% adult, 60% male), 505 developed PTLD, with 50 (10%) occurring in childhood recipients. The 25-year cumulative incidence of PTLD was 3.3% [95% confidence interval (CI) 2.9-3.6] for adult recipients and 3.6% (95% CI 2.7-4.8) for childhood recipients. Childhood recipients had a 30-fold increased risk of lymphoma compared with the age-matched general population [SIR 29.5 (95% CI 21.9-38.8)], higher than adult recipients [SIR 8.4 (95% CI 7.7-9.2)]. Epstein-Barr virus (EBV)-negative recipient serology [adjusted hazard ratio (aHR) 3.33 (95% CI 2.21-5.01), P < 0.001], year of transplantation [aHR 0.93 for each year after the year 2000 (95% CI 0.88-0.99), P = 0.02], induction with an agent other than anti-CD25 monoclonal antibody [aHR 2.07 (95% CI 1.16-3.70), P = 0.01] and having diabetes [aHR 3.49 (95% CI 2.26-5.38), P < 0.001] were independently associated with PTLD.

Conclusions

Lymphoma occurs at similar rates in adult and paediatric recipients, but has been decreasing since the year 2000. EBV-negative patients and those with diabetes or induction agent other than anti-CD25 monoclonal antibody are at substantially increased risk of PTLD.

Overall and Site-Specific Cancer Mortality in Patients on Dialysis and after Kidney Transplant

Background Patients with ESRD have a substantially increased cancer risk, but few studies have examined the patterns of cancer mortality along a patient's journey from dialysis to transplantation.

METHODS

We identified all Australian patients on dialysis and patients with transplants from 1980 to 2014 from the Australia and New Zealand Dialysis and Transplant Registry. Using standardized mortality ratios (SMRs), we compared cancer mortality among patients on dialysis and patients with transplants versus the general population (overall and by age, sex, year, and site); we also performed a subgroup analysis excluding patients with preexisting cancers.

RESULTS

We followed 52,936 patients on dialysis and 16,820 transplant recipients for 170,055 and 128,352 patient-years, respectively. There were 2739 cancer deaths among patients on dialysis and 923 cancer deaths among transplant recipients. Overall, cancer SMRs were 2.6 for patients on dialysis and 2.7 for transplant recipients. For patients on dialysis, SMRs were highest for multiple myeloma (30.5), testicular cancer (17.0), and kidney cancer (12.5); for transplant recipients, SMRs were highest for non-Hodgkin lymphoma (10.7), kidney cancer (7.8), and melanoma (5.8). Some 61.0% of patients on dialysis and 9.6% of transplant recipients who experienced cancer death had preexisting cancer. The SMRs for de novo cancer was 1.2 for patients on dialysis and 2.6 for transplant recipients.

CONCLUSIONS

Patients on dialysis and transplant recipients experienced >2.5-fold increased risk of cancer death compared with the general population. This increased risk was largely driven by preexisting cancers in patients on dialysis and de novo cancers in patients with transplants.

Recurrent glomerulonephritis after kidney transplantation: risk factors and allograft outcomes

Recurrent glomerulonephritis after kidney transplantation is a feared complication because it is unpredictable and may have a negative impact on graft outcomes. To better understand this we collected data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry accumulated over 30 years. The incidence, risk factors, and outcomes of recurrent glomerulonephritis in transplant recipients were determined using adjusted Cox proportional hazard and competing risk modeling. A total of 6,597 recipients with biopsy-proven glomerulonephritis as the primary cause of end-stage kidney disease were followed for 51,871 person-years (median duration 7.7 years). The four most common types of glomerulonephritis were IgA nephropathy in 2501 patients, focal segmental glomerulosclerosis (FSGS) in 1403, membranous in 376, and membranoproliferative (MPGN) nephropathy in 357 patients. Among these four types, recurrence was reported in 479 of 4637 patients, and of these, 212 lost their allograft due to recurrence. Older age at transplantation (adjusted hazard ratio [per year increase] 0.96 [95% confidence interval 0.95 - 0.97]) was associated with a lower risk of recurrence. Significantly, the five-year graft survival was 30% for recipients with recurrent MPGN and 57-59% for recipients with FSGS, IgA, and membranous nephropathy. Transplant recipients with recurrent disease were twice as likely to lose their allografts compared to those without recurrence (adjusted hazard ratio 2.04 [1.81-2.31]). Thus, recurrent glomerulonephritis remains a significant cause of graft loss in transplant recipients.

Incidence and Predictors of Cancer Following Kidney Transplantation in Childhood

Cancer risk is increased substantially in adult kidney transplant recipients, but the long-term risk of cancer in childhood recipients is unclear. Using the Australian and New Zealand Dialysis and Transplant Registry, the authors compared overall and site-specific incidences of cancer after transplantation in childhood recipients with population-based data by using standardized incidence ratios (SIRs). Among 1734 childhood recipients (median age 14 years, 57% male, 85% white), 289 (16.7%) developed cancer (196 nonmelanoma skin cancers, 143 nonskin cancers) over a median follow-up of 13.4 years. The 25-year cumulative incidences of any cancer were 27% (95% confidence intervals 24-30%), 20% (17-23%) for nonmelanoma skin cancer, and 14% (12-17%) for nonskin cancer (including melanoma). The SIR for nonskin cancer was 8.23 (95% CI 6.92-9.73), with the highest risk for posttransplant lymphoproliferative disease (SIR 45.80, 95% CI 32.71-62.44) and cervical cancer (29.4, 95% CI 17.5-46.5). Increasing age at transplantation (adjusted hazard ratio [aHR] per year 1.10, 95% CI 1.06-1.14), white race (aHR 3.36, 95% CI 1.61-6.79), and having a functioning transplant (aHR 2.27, 95% CI 1.47-3.71) were risk factors for cancer. Cancer risk, particularly for virus-related cancers, is increased substantially after kidney transplantation during childhood.

Long-term allograft and patient outcomes of kidney transplant recipients with and without incident cancer - a population cohort study

The excess risk for cancer in kidney transplant recipients is substantial, but the allograft and patient survivals after cancer development are under-studied. This is a population-based cohort study of all primary live and deceased donor kidney transplant recipients in Australia and New Zealand between 1990-2012. The risks of overall graft loss and death with a functioning graft in kidney transplant recipients with and without incident cancer were determined using adjusted Cox regression analysis, with incident cancer considered as a time-varying covariate in the models. In those with incident cancer, types and cancer stage at diagnoses were reported. Of 12,545 transplant recipients followed for a median of 6.9 years (91,380 patient-years), 1184 (9.4%) developed incident cancers at a median of 5.8 years post-transplant. Digestive, kidney and urinary tract cancers were the most common cancer types, although digestive and respiratory tract cancers were more aggressive, with 40% reported as advanced cancers at time of cancer diagnosis. Cancer-related deaths accounted for approximately 80% of recipients with a prior cancer history. Compared with recipients with no prior cancer, the adjusted hazard ratios (HR) for overall graft loss and death with functioning graft were 4.34 (95%CI 3.90, 4.82; p<0.001) and 9.53 (95%CI 8.30, 10.95; <0.001) among those with a prior cancer. Incident cancer after kidney transplantation is a significant risk factor for death with a functioning graft, with the majority of deaths attributed to cancer. A greater understanding of the barriers to screening and treatment approaches following cancer diagnosis may lead to improve survival in kidney transplant recipients with cancer.

Cytomegalovirus and cancer after kidney transplantation: Role of the human leukocyte antigen system?

BACKGROUND

The role of cytomegalovirus (CMV) in cancer development after transplantation remains uncertain. We aimed to determine the association between donor and recipient CMV serological status and the risk of cancer development after kidney transplantation.

METHODS

Using data from the Australian and New Zealand Dialysis and Transplant (ANZDATA) Registry, we assessed the association between CMV donor/recipient (D/R) serological status and the risk of solid organ cancers in primary adult deceased-donor kidney transplant patients between 1990 and 2012.

RESULTS

Of 8140 recipients, a total of 895 (11%) recipients developed incident cancers during a follow-up time of 51 555 person-years. Human leukocyte antigen (HLA) mismatches was an effect modifier between CMV serological status and cancer (P=.03 for interaction). In recipients who have received 0-2 HLA-ABDR mismatched kidneys, the adjusted hazard ratios for cancer incidence among those with CMV D-/R-, CMV D-/R+, and CMV D+/R- were 0.47 (95% confidence interval [CI]: 0.24-0.91), 1.42 (95% CI: 0.97-2.07), and 1.02 (95% CI: 0.67-1.57), respectively compared with the reference of CMV D+/R+. A similar association was not observed in those with >2 HLA-ABDR mismatches.

CONCLUSION

CMV D-/R- status was associated with a reduced risk of cancer in kidney transplant recipients who have received well-matched renal allografts, suggesting a potential role of HLA matching in cancer development.

The validity of pediatric cancer diagnoses in a population-based general cancer registry in Ontario, Canada

BACKGROUND

Data from population-based cancer registries are increasingly used to conduct research and guide policy. However, few validation studies of cancer registry data have been conducted, particularly among children. We therefore aimed to determine the validity of pediatric diagnostic data in the Ontario Cancer Registry (OCR).

METHODS

All children diagnosed with any malignancy between 2000-2011 in Ontario, Canada were identified through the Pediatric Oncology Group of Ontario Networked Information System (POGONIS), a pediatric cancer registry actively maintained by trained data managers, and linked to the OCR. International Classification of Diseases for Oncology codes for each patient were taken from the OCR and converted to International Classification of Childhood Cancer (ICCC-3) diagnostic groups and subgroups using published algorithms. OCR-based ICCC-3 groupings were then validated by comparing them to gold standard diagnostic information from POGONIS.

RESULTS

A total of 4448 patients met inclusion criteria; 4073 (91.6 %) were successfully linked to the OCR. Diagnostic accuracy was excellent for many childhood solid tumors. For example, the OCR correctly identified all cases of retinoblastoma [kappa = 1.00, 95th confidence interval (CI) 1.00-1.00] and nearly all cases of neuroblastoma (kappa = 0.97, 95th CI 0.96-0.99). Hematologic and central nervous system (CNS) cancers, the most common childhood malignancies, were however often misclassified with inferior kappas (acute lymphoblastic leukemia - 0.77, 95th CI 0.75-0.80; Burkitt lymphoma - 0.02, 95th CI 0.02-0.07).

CONCLUSIONS

Misclassification of common pediatric hematologic and CNS cancers was significant and may lead to inaccurate incidence and survival estimates using cancer registry data. Validation studies of pediatric data in other registries are necessary to identify practices and procedures leading to the highest quality information.

Cumulative Doses of T-Cell Depleting Antibody and Cancer Risk after Kidney Transplantation

T-cell depleting antibody is associated with an increased risk of cancer after kidney transplantation, but a dose-dependent relationship has not been established. This study aimed to determine the association between cumulative doses of T-cell depleting antibody and the risk of cancer after kidney transplantation. Using data from the Australian and New Zealand Dialysis and Transplant Registry between 1997–2012, we assessed the risk of incident cancer and cumulative doses of T-cell depleting antibody using adjusted Cox regression models. Of the 503 kidney transplant recipients with 2835 person-years of follow-up, 276 (55%), 209 (41%) and 18 (4%) patients received T-cell depleting antibody for induction, rejection or induction and rejection respectively. The overall cancer incidence rate was 1,118 cancers per 100,000 patient-years, with 975, 1093 and 1377 cancers per 100,000 patient-years among those who had received 1–5 doses, 6–10 doses and >10 doses, respectively. There was no association between cumulative doses of T cell depleting antibody and risk of incident cancer (1–5: referent, 6–10: adjusted hazard ratio (HR) 1.19, 95%CI 0.48–2.95, >10: HR 1.42, 95%CI 0.50–4.02, p = 0.801). This lack of association is contradictory to our hypothesis and is likely attributed to the low event rates resulting in insufficient power to detect significant differences.

The risk of cancer in recipients of living-donor, standard and expanded criteria deceased donor kidney transplants: a registry analysis

BACKGROUND

Kidneys from expanded criteria deceased donors may elicit a strong inflammatory response, predisposing recipients to an increased risk of cancer after transplantation. We aimed to determine the association between donor types and cancer risk after kidney transplantation.

METHODS

Using the Australian and New Zealand Dialysis and Transplant Registry, we assessed the association between different donor types (living donor, standard, and expanded criteria deceased donors) and the risk of cancer after kidney transplantation using adjusted Cox proportional hazard and competing risk models.

RESULTS

Over a median follow-up period of 4.4 years in 7,040 patients (34,684 patient-years), 468 patients (6.6%) developed cancer. The overall risks for cancer were 1,080, 1,444, and 2,018 per 100,000 patient-years for recipients of living donor, standard, and expanded criteria deceased donor kidneys, respectively. Compared to recipients of living-donor kidneys, recipients of expanded criteria deceased donor kidneys were at an increased risk of cancer (adjusted hazard ratio [HR], 1.52; 95% confidence interval [95% CI], 1.15-2.02; P = 0.004), particularly for genitourinary cancer (adjusted HR, 1.79; 95% CI, 1.03-3.10; P = 0.038) and post-transplant lymphoproliferative disease (adjusted HR, 2.72; 95% CI, 1.38-5.37; P = 0.004).

CONCLUSION

Recipients of expanded criteria deceased donor kidneys are at substantially increased risk of cancer, especially cancers with a viral etiology. Allocation of expanded criteria deceased donor kidneys to potential recipients should balance the harms, such as the excess risk of cancer against the survival gains and quality-of-life benefits associated with transplantation.

Rural Versus Urban Health Service Utilization and Outcomes for Renal Patients in New South Wales: Protocol for a Data Linkage Study

BACKGROUND

Kidney disease is a significant burden on health systems globally, with the rising prevalence of end stage kidney disease in Australia mirrored in many other countries. Approximately 25% of the Australian population lives in regional and rural areas and accessing complex tertiary services is challenging.

OBJECTIVE

We aim to compare the burden and outcomes of chronic kidney disease and end stage kidney disease in rural and urban regions of New South Wales (Australia's most populous state) using linked health data.

METHODS

This is a retrospective cohort study and we have defined two cohorts: one with end stage kidney disease and one with chronic kidney disease. The end stage kidney disease cohort was defined using the Australia and New Zealand Dialysis and Transplant Registry, identifying all patients living in NSW receiving renal replacement therapy at any time between 01/07/2000 and 31/07/2010. The chronic kidney disease cohort used the NSW Admitted Patient Data Collection (APDC) to identify patients with a diagnostic code relating to chronic renal failure during any admission between 01/07/2000 and 31/07/2010. Both cohorts were linked to the NSW APDC, the Registry of Births, Deaths and Marriages, and the Central Cancer Registry allowing derivation of outcomes by categories of geographical remoteness.

RESULTS

To date, we have identified 10,505 patients with 2,384,218 records in the end stage kidney disease cohort and 159,033 patients with 1,599,770 records in the chronic kidney disease cohort.

CONCLUSIONS

This study will define the geographical distribution of end stage and chronic kidney disease and compare the health service utilization between rural and urban renal populations.

Characterization and risk of blood-borne virus transmission in organ transplantation: what are the priorities?

ABSTRACT 

Blood-borne virus transmission through organ transplantation, although rare, has been associated with severe complications in recipients. There are few data available to ascertain the risk of infection in organ transplantation for known and emerging pathogens, as most information comes from events of transmission, which are rare and not always well characterized. The balance between quality of life through organ transplantation and the risks of donor-derived infection can be improved through advances in donor screening, enhanced monitoring and a multidisciplinary approach to improving donor assessment and recipient biosurveillance. The involvement of investigators with clinical, laboratory, surveillance and policy expertise is critical to bridge research knowledge and clinical practice.

Variation in centre-specific survival in patients starting renal replacement therapy in England is explained by enhanced comorbidity information from hospitalization data

BACKGROUND

Unadjusted survival on renal replacement therapy (RRT) varies widely from centre to centre in England. Until now, missing data on case mix have made it impossible to determine whether this variation reflects genuine differences in the quality of care. Data linkage has the capacity to reduce missing data.

METHODS

Modelling of survival using Cox proportional hazards of data returned to the UK Renal Registry on patients starting RRT for established renal failure in England. Data on ethnicity, socioeconomic status and comorbidity were obtained by linkage to the Hospital Episode Statistics database, using data from hospitalizations prior to starting RRT.

RESULTS

Patients with missing data were reduced from 61 to 4%. The prevalence of comorbid conditions was remarkably similar across centres. When centre-specific survival was compared after adjustment solely for age, survival was below the 95% limit for 6 of 46 centres. The addition of variables into the multivariable model altered the number of centres that appeared to be 'outliers' with worse than expected survival as follows: ethnic origin four outliers, socioeconomic status eight outliers and year of the start of RRT four outliers. The addition of a combination of 16 comorbid conditions present at the start of RRT reduced the number of centres with worse than expected survival to one.

CONCLUSIONS

Linked data between a national registry and hospital admission dramatically reduced missing data, and allowed us to show that nearly all the variation between English renal centres in 3-year survival on RRT was explained by demographic factors and by comorbidity.

Do older adults with cancer fall more often? A comparative analysis of falls in those with and without cancer

PURPOSE/OBJECTIVES

To examine whether a history of cancer increased the likelihood of a fall in community-dwelling older adults, and if cancer type, stage, or time since diagnosis increased falls.

DESIGN

A longitudinal, retrospective, cohort study.

SETTING

A home- and community-based waiver program in Michigan.

SAMPLE

862 older adults aged 65 years or older with cancer compared to 8,617 older adults without cancer using data from the Minimum Data Set-Home Care and Michigan cancer registry.

METHODS

Reports of falls were examined for 90-180 days. Generalized estimating equations were used to compare differences between the groups.

MAIN RESEARCH VARIABLES

Cancer, falls, patient characteristics, comorbidities, medications, pain, weight loss, vision, memory recall, and activities, as well as cancer type, stage, and time since diagnosis.

FINDINGS

A fall occurred at a rate of 33% in older adults with cancer compared to 29% without cancer (p < 0.00). Those with a history of cancer were more likely to fall than those without cancer (adjusted odds ratio 1.16; 95% confidence interval [1.02, 1.33]; p = 0.03). No differences in fall rates were determined by cancer type or stage, and the odds of a fall did not increase when adding time since cancer diagnosis.

CONCLUSIONS

The fall rate was higher in older adults with cancer than in older adults without cancer.

IMPLICATIONS FOR NURSING

Nurses need to assess fall risk and initiate fall prevention measures for older adults at the time of cancer diagnosis.

KNOWLEDGE TRANSLATION

When caring for older adults with cancer, nurses should be aware of an increased risk for falls. Healthcare staff also should be aware of an increased risk for falls in that population during cancer treatment. Evidence-based fall prevention measures should be included in care plans for older adult cancer survivors.

Time on dialysis and cancer risk after kidney transplantation

BACKGROUND

Increasing time on dialysis is an established risk factor for certain cancer types for patients on dialysis, but the relationship between the time on dialysis and cancer risk after transplantation is unclear. We aimed to determine if the length of time on maintenance dialysis before the first kidney transplantation was associated with the risk of site-specific and overall incident cancers after transplantation.

METHODS

Using the Australia and New Zealand Dialysis and Transplant Registry, we assessed the association between both all cancers (except for nonmelanocytic skin cancers) and site-specific cancer incidence and the duration on dialysis before the first transplantation using adjusted Cox proportional hazards and competing risk models.

RESULTS

Over a median follow-up of 4.4 years (interquartile range, 1.7-7.7 years), the total cumulative incidence of all cancers after the first kidney transplantation was 15.0 per 1000 patient-years. There was a linear relationship between the duration of dialysis and the risk of cancer after transplantation (Ptrend=0.02). The excess risks for lung and urinary tract cancers were highest among recipients who had been on dialysis for the longest duration before transplantation (adjusted hazard ratio [95% confidence interval], 3.32 [1.00-11.4]; P=0.05 and 2.57 [1.33-4.95]; P=0.005, respectively).

CONCLUSION

Increasing time on dialysis is a significant risk factor for common solid organ cancers, such as lung cancer, and urinary tract cancers in kidney transplant recipients, irrespective of age. Strategies to improve cancer surveillance among recipients who had been on dialysis for a longer time may be warranted.

A practical framework for data management processes and their evaluation in population-based medical registries

INTRODUCTION

We present a framework for data management processes in population-based medical registries. Existing guidelines lack the concreteness we deem necessary for them to be of practical use, especially concerning the establishment of new registries. Therefore, we propose adjustments and concretisations with regard to data quality, data privacy, data security and registry purposes.

MATERIALS AND METHODS

First, we separately elaborate on the issues to be included into the framework and present proposals for their improvements. Thereafter, we provide a framework for medical registries based on quasi-standard-operation procedures.

RESULTS

The main result is a concise and scientifically based framework that tries to be both broad and concrete. Within that framework, we distinguish between data acquisition, data storage and data presentation as sub-headings. We use the framework to categorise and evaluate the data management processes of a German cancer registry.

DISCUSSION

The standardisation of data management processes in medical registries is important to guarantee high quality of the registered data, to enhance the realisation of purposes, to increase efficiency and to enable comparisons between registries. Our framework is destined to show how one central impediment for such standardisations - lack of practicality - can be addressed on scientific grounds.

Mycophenolate versus azathioprine for kidney transplantation: a 15-year follow-up of a randomized trial

BACKGROUND

The use of mycophenolate mofetil (MMF) is associated with less acute rejection than azathioprine (AZA) early after kidney transplantation. However, the long-term impact of MMF versus AZA is less well studied.

METHODS

The Tricontinental Mycophenolate Mofetil Renal Transplantation Study was a double-blind randomized placebo-controlled trial of MMF versus AZA, together with cyclosporine and steroids, first reported in 1996. We analyzed the long-term outcomes of the Australian cohort of patients enrolled in this study using follow-up data from the Australia and New Zealand Dialysis and Transplant Registry. Patient and graft survival, cancer incidence, and estimated kidney function were compared on an intention-to-treat basis.

RESULTS

A total of 133 Australian patients participated in the study: 45 were randomized to AZA, 44 were randomized to MMF 2 g/d, and 44 were randomized to MMF 3 g/d. Baseline characteristics were similar between the groups. Median follow-up was 13.8 years, during which there were 97 graft failures, 75 deaths, and 1 lost to follow-up. There were no statistically significant differences between the groups in long-term patient or graft survival, cancer incidence, or kidney function. Death-censored graft survival was best in the group with 3 g/d MMF and worst in the group with 2 g/d MMF. By 5 years, 42% of the MMF group had switched permanently to AZA, whereas crossover from AZA to MMF was rare.

CONCLUSIONS

This long-term examination, although limited by small numbers, found little evidence for the superiority of MMF over AZA.

Incidence of metastatic breast cancer in an Australian population-based cohort of women with non-metastatic breast cancer at diagnosis

OBJECTIVES

To estimate the incidence of metastatic breast cancer (MBC) in Australian women with an initial diagnosis of non-metastatic breast cancer.

DESIGN, SETTING AND PARTICIPANTS

A population-based cohort study of all women with non-metastatic breast cancer registered on the New South Wales Central Cancer Register (CCR) in 2001 and 2002 who received care in a NSW hospital.

MAIN OUTCOME MEASURES

5-year cumulative incidence of MBC; prognostic factors for MBC.

RESULTS

MBC was recorded within 5 years in 218 of 4137 women with localised node-negative disease (5-year cumulative incidence, 5.3%; 95% CI, 4.6%-6.0%); and 455 of 2507 women with regional disease (5-year cumulative incidence, 18.1%; 95% CI, 16.7%-19.7%). The hazard rate for developing MBC was highest in the second year after the initial diagnosis of breast cancer. Determinants of increased risk of MBC were regional disease at diagnosis, age less than 50 years and living in an area of lower socio-economic status.

CONCLUSIONS

Our Australian population-based estimates are valuable when communicating average MBC risks to patients and planning clinical services and trials. Women with node-negative disease have a low risk of developing MBC, consistent with outcomes of adjuvant clinical trials. Regional disease at diagnosis remains an important prognostic factor.