Kidney transplantation in patients with previous renal cancer: a critical appraisal of current evidence and guidelines

Abstract

Due to the increasing occurrence of renal cell carcinoma (RCC) in the general population and the high prevalence of chronic kidney disease among cancer patients, many people with a previous RCC are considered as potential candidates for renal transplantation. They should accordingly be evaluated to assess their life expectancy and the risk that the chronic immunosuppressive therapy needed after grafting might impair their long-term outcome.Current guidelines on listing patients for renal transplantation suggest that no delay is required for subjects with small or incidentally discovered RCC, while the recommendations for patients who have been treated for a symptomatic RCC or for those with large or invasive tumours are conflicting.The controversial results reported by even recent studies focussing on the cancer risk in kidney graft recipients with a prior history of malignancy do not help to clarify the doubts arising in everyday clinical practice.Several tools, including integrated scoring systems, are currently available to assess the prognosis of patients with a previous RCC and, although they have not been validated in subjects receiving long-term immunosuppressive drugs, they can be used to identify patients suitable to be listed for grafting. Among these, the Leibovich score is currently the most widely used as it has proved simple and reliable enough and helps categorize renal transplant candidates. According to this system, subjects with a score from 0 to 2 are at low risk and may be listed without delay, while those with a score of 6 or higher should be excluded from grafting. In addition, other factors have an established positive prognostic value, including cromophobe or clear cell papillary tumour, or G1 grade cancer, while medullary or Bellini's duct carcinoma or those with sarcomatoid dedifferentiation at histological examination should be excluded.Pending studies specifically focussing on cancer risk evaluation in people already treated for malignancy receiving long-term immunosuppressive therapy, all other patients had better be submitted to careful individual evaluation by an Oncologist and Urologist before being listed for renal transplantation.listing previous

Clinical features and outcomes in kidney transplant recipients with renal cell carcinoma: a single-center study

“…Therefore, KT candidates are screened for malignant tumors, and RCC is detected occasionally. Previous studies have recommended a waiting time of 2 to 5 years for KT in patients with ESRD with RCC but suggested no delay in patients with asymptomatic and small RCC [12–15]. However, this recommendation was based mainly on overseas studies.…”

“…As kidney transplant (KT) recipients typically receive immunosuppressive therapy, cancer recurrence after KT is a clinically important issue. Therefore, there are guidelines regarding waiting time for KT in patients with ESRD and RCC [12]. Previous studies have suggested a waiting period of 2 to 5 years before KT in patients with symptomatic RCC and no delay in patients with incidental early-stage RCC [13–15], which is sometimes diagnosed during the pre-KT workup.…”

Distribution and association of cancer with mortality in end-stage renal disease patients receiving dialysis

“…A higher percentage of deaths was observed in the cancer group in the total sample, a likely reflection of the higher age in this group as this difference was not observed in the age matched sample. A significantly lesser proportion of patients in the cancer group received a kidney transplant, which may indicate a mindful risk-based approach in the transplant work-up [21].…”

Transplant or dialysis: What’s the better choice for RCC-induced ESRD patients? A 20-year analysis of OPTN/UNOS data

“…However, pre-TM is considered a relative contraindication because pre-TM itself is a risk factor for cancer recurrence and renal cancer recurs in up to 21% of cases ( 14 ) as well because immunosuppressive therapies throughout a recipient’s life contribute to the risk of cancer onset and recurrence ( 15 ). Although some guidelines on KTX for RCC-induced ESRD have been reported, few studies have reported the exact number of RCC-induced ESRD patients who successfully received transplantation ( 16 ).…”