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Au EH, Wong G, Howard K, Chapman JR, Castells A, Roger SD, Bourke MJ, Macaskill P, Turner R, Lim WH, Lok CE, Diekmann F, Cross N, Sen S, Allen RD, Chadban SJ, Pollock CA, Tong A, Teixeira-Pinto A, Yang JY, Kieu A, James L, Craig JC. Factors Associated With Advanced Colorectal Neoplasia in Patients With CKD. Am J Kidney Dis 2021; 79:549-560. [PMID: 34461168 DOI: 10.1053/j.ajkd.2021.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 07/16/2021] [Indexed: 12/19/2022]
Abstract
RATIONALE & OBJECTIVE The risk of developing colorectal cancer in patients with chronic kidney disease (CKD) is twice that of the general population, but the factors associated with colorectal cancer are poorly understood. The aim of this study was to identify factors associated with advanced colorectal neoplasia in patients with CKD. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS Patients with CKD stages 3-5, including those treated with maintenance dialysis or transplantation across 11 sites in Australia, New Zealand, Canada, and Spain, were screened for colorectal neoplasia using a fecal immunochemical test (FIT) as part of the Detecting Bowel Cancer in CKD (DETECT) Study. EXPOSURE Baseline characteristics for patients at the time of study enrollment were ascertained, including duration of CKD, comorbidities, and medications. OUTCOME Advanced colorectal neoplasia was identified through a 2-step verification process with colonoscopy following positive FIT and 2-year clinical follow-up for all patients. ANALYTICAL APPROACH Potential factors associated with advanced colorectal neoplasia were explored using multivariable logistic regression. Sensitivity analyses were performed using grouped LASSO (least absolute shrinkage and selection operator) logistic regression. RESULTS Among 1,706 patients who received FIT-based screening-791 with CKD stages 3-5 not receiving kidney replacement therapy (KRT), 418 receiving dialysis, and 497 patients with a functioning kidney transplant-117 patients (6.9%) were detected to have advanced colorectal neoplasia (54 with CKD stages 3-5 without KRT, 34 receiving dialysis, and 29 transplant recipients), including 9 colorectal cancers. The factors found to be associated with advanced colorectal neoplasia included older age (OR per year older, 1.05 [95% CI, 1.03-1.07], P<0.001), male sex (OR, 2.27 [95% CI, 1.45-3.54], P<0.001), azathioprine use (OR, 2.99 [95% CI, 1.40-6.37], P=0.005), and erythropoiesis-stimulating agent use (OR, 1.92 [95% CI, 1.22-3.03], P=0.005). Grouped LASSO logistic regression revealed similar associations between these factors and advanced colorectal neoplasia. LIMITATIONS Unmeasured confounding factors. CONCLUSIONS Older age, male sex, erythropoiesis-stimulating agents, and azathioprine were found to be significantly associated with advanced colorectal neoplasia in patients with CKD.
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Affiliation(s)
- Eric H Au
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia.
| | - Germaine Wong
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| | - Kirsten Howard
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| | - Antoni Castells
- Gastroenterology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Simon D Roger
- Department of Renal Medicine, Gosford Hospital, Gosford, Australia
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Westmead, Australia
| | - Petra Macaskill
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Robin Turner
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Biostatistics Unit, Dunedin School of Medicine, Otago University, Christchurch, New Zealand
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Charmaine E Lok
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Nicholas Cross
- Department of Nephrology and Kidney Transplantation, Christchurch Hospital, Otago University, Christchurch, New Zealand
| | - Shaundeep Sen
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, Australia
| | - Richard D Allen
- Department of Renal Medicine, Royal Prince Alfred Hospital, and Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, and Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Carol A Pollock
- Department of Medicine, Northern Clinical School, Kolling Institute of Medical Research, Sydney, Australia
| | - Allison Tong
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jean Y Yang
- School of Mathematics and Statistics, University of Sydney, Sydney, Australia
| | - Anh Kieu
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Laura James
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Krishnan A, Teixeira-Pinto A, Lim WH, Howard K, Chapman JR, Castells A, Roger SD, Bourke MJ, Macaskill P, Williams G, Lok CE, Diekmann F, Cross N, Sen S, Allen RDM, Chadban SJ, Pollock CA, Turner R, Tong A, Yang JYH, Williams N, Au E, Kieu A, James L, Francis A, Wong G, Craig JC. Health-Related Quality of Life in People Across the Spectrum of CKD. Kidney Int Rep 2020; 5:2264-2274. [PMID: 33305120 PMCID: PMC7710842 DOI: 10.1016/j.ekir.2020.09.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/08/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction People with chronic kidney disease (CKD) experience reduced quality of life (QoL) because of the high symptom and treatment burden. Limited data exist on the factors associated with overall and domain-specific QoL across all CKD stages. Methods Using data from a prospective, multinational study (Australia, New Zealand, Canada, and Spain) in 1696 participants with CKD, we measured overall and domain-specific QoL (pain, self-care, activity, mobility, anxiety/depression) using the EuroQoL, 5 dimension, 3 level. Multivariable linear regression and logistic modeling were used to determine factors associated with overall and domain-specific QoL. Results QoL for patients with CKD stages 3 to 5 (n = 787; mean, 0.81; SD, 0.20) was higher than in patients on dialysis (n = 415; mean, 0.76; SD, 0.24) but lower than in kidney transplant recipients (n = 494; mean, 0.84; SD, 0.21). Factors associated with reduced overall QoL (β [95% confidence intervals]) included being on dialysis (compared with CKD stages 3–5: –0.06 [–0.08 to –0.03]), female sex (–0.03 [–0.05 to –0.006]), lower educational attainment (– 0.04 [–0.06 to –0.02), lacking a partner (–0.04 [–0.06 to –0.02]), having diabetes (–0.05 [–0.07 to –0.02]), history of stroke (–0.09 [–0.13 to –0.05]), cardiovascular disease (–0.06 [–0.08 to –0.03]), and cancer (–0.03 [–0.06 to –0.009]). Pain (43%) and anxiety/depression (30%) were the most commonly affected domains, with dialysis patients reporting decrements in all 5 domains. Predictors for domain-specific QoL included being on dialysis, presence of comorbidities, lower education, female sex, and lack of a partner. Conclusions Being on dialysis, women with CKD, those with multiple comorbidities, lack of a partner, and lower educational attainment were associated with lower QoL across all stages of CKD.
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Affiliation(s)
- Anoushka Krishnan
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Kirsten Howard
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| | - Antoni Castells
- Gastroenterology Department, Hospital Clinic, University of Barcelona, IDIBAPS, CIBEREHD, Barcelona, Spain
| | - Simon D Roger
- Department of Renal Medicine, Gosford Hospital, Gosford, Australia
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Westmead, Australia
| | - Petra Macaskill
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Gabrielle Williams
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Charmaine E Lok
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Barcelona, Spain
| | - Nicholas Cross
- Department of Nephrology and Kidney Transplantation, Christchurch Hospital and Otago University, Christchurch, New Zealand
| | - Shaundeep Sen
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Renal Medicine, Concord Repatriation General Hospital, Concord, Australia
| | - Richard D M Allen
- Department of Renal Medicine, Royal Prince Alfred Hospital, and Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, and Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Carol A Pollock
- Department of Medicine, Northern Clinical School, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Robin Turner
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Biostatistics Unit, Dunedin School of Medicine, University of Otago, Christchurch, New Zealand
| | - Allison Tong
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jean Y H Yang
- School of Mathematics and Statistics, The University of Sydney, Sydney, Australia
| | - Narelle Williams
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Eric Au
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Anh Kieu
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Laura James
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Anna Francis
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Germaine Wong
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Wong G, Hope RL, Howard K, Chapman JR, Castells A, Roger SD, Bourke MJ, Macaskill P, Turner R, Williams G, Lim WH, Lok CE, Diekmann F, Cross NB, Sen S, Allen RDM, Chadban SJ, Pollock CA, Tong A, Teixeira-Pinto A, Yang JYH, Williams N, Au EHK, Kieu A, James L, Craig JC. One-Time Fecal Immunochemical Screening for Advanced Colorectal Neoplasia in Patients with CKD (DETECT Study). J Am Soc Nephrol 2019; 30:1061-1072. [PMID: 31040191 DOI: 10.1681/asn.2018121232] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 02/25/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In patients with CKD, the risk of developing colorectal cancer is high and outcomes are poor. Screening using fecal immunochemical testing (FIT) is effective in reducing mortality from colorectal cancer, but performance characteristics of FIT in CKD are unknown. METHODS To determine the detection rates and performance characteristics of FIT for advanced colorectal neoplasia (ACN) in patients with CKD, we used FIT to prospectively screen patients aged 35-74 years with CKD (stages 3-5 CKD, dialysis, and renal transplant) from 11 sites in Australia, New Zealand, Canada, and Spain. All participants received clinical follow-up at 2 years. We used a two-step reference standard approach to estimate disease status. RESULTS Overall, 369 out of 1706 patients who completed FIT (21.6%) tested positive; 323 (87.5%) underwent colonoscopies. A total of 1553 (91.0%) completed follow-up; 82 (4.8%) had died and 71 (4.2%) were lost. The detection rate of ACN using FIT was 6.0% (5.6%, 7.4%, and 5.6% for stages 3-5 CKD, dialysis, and transplant). Sensitivity, specificity, and positive and negative predictive values of FIT for ACN were 0.90, 0.83, 0.30, and 0.99, respectively. Of participants who underwent colonoscopy, five (1.5%) experienced major colonoscopy-related complications, including bowel perforation and major bleeding. CONCLUSIONS FIT appears to be an accurate screening test for patients with CKD, such that a negative test may rule out the diagnosis of colorectal cancer within 2 years. However, the risk of major complications from work-up colonoscopy are at least ten-fold higher than in the general population.
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Affiliation(s)
- Germaine Wong
- Sydney School of Public Health, Faculty of Medicine and Health, .,Centre for Transplant and Renal Research, and.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Richard L Hope
- Department of Gastroenterology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Kirsten Howard
- Sydney School of Public Health, Faculty of Medicine and Health
| | | | - Antoni Castells
- Gastroenterology Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute, Barcelona, Spain; and.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Spain
| | - Simon D Roger
- Department of Renal Medicine, Gosford Hospital, Gosford, Australia
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Petra Macaskill
- Sydney School of Public Health, Faculty of Medicine and Health
| | - Robin Turner
- Sydney School of Public Health, Faculty of Medicine and Health.,Biostatistics Unit, Dunedin School of Medicine, University of Otago, Christchurch, New Zealand
| | - Gabrielle Williams
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Wai Hon Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Charmaine E Lok
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Clinical and Provincial Hospital of Barcelona, Barcelona, Spain
| | - Nicholas B Cross
- Department of Nephrology and Kidney Transplantation, Christchurch Hospital, Christchurch, New Zealand.,Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Shaundeep Sen
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, Australia
| | - Richard D M Allen
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Carol A Pollock
- Department of Medicine, Northern Clinical School, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Narelle Williams
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Eric Hoi Kit Au
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Anh Kieu
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Laura James
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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James LJ, Wong G, Craig JC, Ju A, Williams N, Lim WH, Cross N, Tong A. Beliefs and Attitudes to Bowel Cancer Screening in Patients with CKD: A Semistructured Interview Study. Clin J Am Soc Nephrol 2017; 12:568-576. [PMID: 28153937 PMCID: PMC5383392 DOI: 10.2215/cjn.10090916] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 12/19/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVES Bowel cancer is a leading cause of cancer-related death in people with CKD. Shared decision making regarding cancer screening is particularly complex in CKD and requires an understanding of patients' values and priorities, which remain largely unknown. Our study aimed to describe the beliefs and attitudes to bowel cancer screening in patients with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Face to face, semistructured interviews were conducted from April of 2014 to December of 2015 with 38 participants ages 39-78 years old with CKD stages 3-5, on dialysis, or transplant recipients from four renal units in Australia and New Zealand. Thematic analysis was used to analyze the transcripts. RESULTS Five themes were identified: invisibility of cancer (unspoken stigma, ambiguity of risk, and absence of symptomatic prompting); prioritizing kidney disease (preserving the chance of transplantation, over-riding attention to kidney disease, protecting graft survival, and showing loyalty to the donor); preventing the crisis of cancer (evading severe consequences and cognizant of susceptibility); cognitive resistance (reluctance to perform a repulsive procedure, intensifying disease burden threshold, anxiety of a positive test, and accepting the inevitable); and pragmatic accessibility (negligible financial effect, convenience, and protecting anonymity). CONCLUSIONS Patients with CKD understand the potential health benefits of bowel cancer screening, but they are primarily committed to their kidney health. Their decisions regarding screening revolve around their present health needs, priorities, and concerns. Explicit consideration of the potential practical and psychosocial burdens that bowel cancer screening may impose on patients in addition to kidney disease and current treatment is suggested to minimize decisional conflict and improve patient satisfaction and health care outcomes in CKD.
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Affiliation(s)
- Laura J. James
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia
| | - Jonathan C. Craig
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia
| | - Angela Ju
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia
| | - Narelle Williams
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia
| | - Wai H. Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia; and
| | - Nicholas Cross
- Department of Nephrology, Christchurch Hospital, Christchurch, New Zealand
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia
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Kotwal S, Webster AC, Cass A, Gallagher M. A review of linked health data in Australian nephrology. Nephrology (Carlton) 2016; 21:457-66. [DOI: 10.1111/nep.12721] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 12/09/2015] [Accepted: 01/05/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Sradha Kotwal
- The George Institute for Global Health; The University of Sydney
| | - Angela C Webster
- Sydney School of Public Health; The University of Sydney
- Centre for Transplant and Renal Research; Westmead Hospital
| | - Alan Cass
- Menzies School of Health Research; Charles Darwin University; Darwin
| | - Martin Gallagher
- The George Institute for Global Health; The University of Sydney
- Concord Clinical School; The University of Sydney; Sydney Australia
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Kiberd B. Colorectal cancer screening in kidney disease patients: working backwards. Nephrol Dial Transplant 2012; 28:774-7. [DOI: 10.1093/ndt/gfs523] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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