Cancer in kidney transplant recipients

Abstract

Cancer is the second most common cause of mortality and morbidity in kidney transplant recipients after cardiovascular disease. Kidney transplant recipients have at least a twofold higher risk of developing or dying from cancer than the general population. The increased risk of de novo and recurrent cancer in transplant recipients is multifactorial and attributed to oncogenic viruses, immunosuppression and altered T cell immunity. Transplant candidates and potential donors should be screened for cancer as part of the assessment process. For potential recipients with a prior history of cancer, waiting periods of 2-5 years after remission - largely depending on the cancer type and stage of initial cancer diagnosis - are recommended. Post-transplantation cancer screening needs to be tailored to the individual patient, considering the cancer risk of the individual, comorbidities, overall prognosis and the screening preferences of the patient. In kidney transplant recipients diagnosed with cancer, treatment includes conventional approaches, such as radiotherapy and chemotherapy, together with consideration of altering immunosuppression. As the benefits of transplantation compared with dialysis in potential transplant candidates with a history of cancer have not been assessed, current clinical practice relies on evidence from observational studies and registry analyses.

Post renal-transplant malignancy surveillance

“…8 Treatment is challenging in this cohort, as optimal management with intensive chemotherapy and surgery may be limited by comorbidities such as cardiovascular disease, and a hesitancy to reduce immunosuppression given the risk of graft rejection and loss. 1,11…”

“…6,14 Immunosuppression is considered the most important risk factor for post-transplant cancer development via multiple mechanisms, including decreased immune surveillance of cancers, decreased antiviral response facilitating unchecked replication of oncogenic viruses, interference with normal deoxyribonucleic acid repair mechanisms, and possibly direct carcinogenic effect of immunosuppressive agents such as ciclosporin and azathioprine. 5,6,8,11 Viral infections (reactivation of latent infection or primary infection) are implicated in several cancers in both the general population and the immunosuppressed. Viruses associated with carcinogenesis in the post-transplant setting include Epstein-Barr virus (EBV), human herpes virus 8 (HHV-8), human papillomavirus (HPV), Merkel cell polyomavirus, hepatitis B and hepatitis C (Table 2 ).…”

“…10 While there are clear cancer screening programmes for the general population in the UK, it is unclear how to optimally screen transplant recipients in terms of specific cancers and the frequency and modality of screening test. 1,11 Early diagnosis may improve outcomes in the transplant recipient, but treatment is often challenging. 1,5,8,9…”

Assessment of kidney transplant suitability for patients with prior cancers: is it time for a rethink?

“…The prognosis of kidney transplant recipients who have developed incident cancer is relatively poor, with the risk of cancer mortality substantially greater compared to age‐matched general population . In two large contemporaneous population cohorts of kidney transplant recipients from the United Kingdom (UK, 2001–2012) and Australia and New Zealand (1980–2014), standardized mortality ratios (SMRs) were substantially higher in kidney transplant recipients of either gender and across all age groups, with SMRs highest for younger recipients .…”

Management of Immunosuppression in Kidney Transplant Recipients Who Develop Malignancy

“…The median survival of kidney transplant patients with cancer is significantly lower than kidney transplant patients without cancer (2.1 years vs. 8.3 years). Malignancy is currently the second most common cause of death in kidney transplant patients after cardiovascular disease [3].…”