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NDT Advance Access originally published online on July 8, 2009
Nephrology Dialysis Transplantation 2009 24(10):3225-3231; doi:10.1093/ndt/gfp331
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© The Author [2009]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org


The pattern of excess cancer in dialysis and transplantation

John H. Stewart1, Claire M. Vajdic2, Marina T. van Leeuwen3, Janaki Amin3, Angela C. Webster4,5,6, Jeremy R. Chapman5,6, Stephen P. McDonald6,7, Andrew E. Grulich3 and Margaret R. E. McCredie1

1 Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand 2 UNSW Cancer Research Centre, Prince of Wales Clinical School, University of New South Wales 3 National Centre in HIV Epidemiology and Clinical Research, University of New South Wales 4 School of Public Health, University of Sydney 5 Centre for Transplant and Renal Research, Millennium Institute, Westmead Hospital, University of Sydney, Sydney, NSW 6 Australia and New Zealand Dialysis and Transplant Registry, Queen Elizabeth Hospital 7 Disciplines of Medicine and Public Health, University of Adelaide, Adelaide, SA, Australia

Correspondence and offprint requests to: Margaret R. E. McCredie; E-mail: margaret.mccredie{at}otago.ac.nz



  Abstract

Background. After transplantation, cancer risk varies from no increase for several common cancers to a many-fold increase for a number of, chiefly virus-associated, cancers. The smaller excess of cancer in dialysis has been less well described, but two studies suggested that impaired immunity might be responsible.

Methods. In a population-based cohort study of 28 855 patients who received renal replacement therapy (RRT), we categorized incident cancers as end-stage kidney disease (ESKD) related, immune deficiency related, not related to immune deficiency, or of uncertain status, according to whether they were, or were not, increased in published reports of cancer in ESKD prior to starting RRT, organ transplantation or human immunodeficiency virus infection. Standardized incidence ratios for, and excess burdens of, cancer were calculated for all persons normally resident in Australia starting treatment by dialysis or renal transplantation from 1982 to 2003.

Results. The risk for ESKD-related cancers was increased 4-fold in dialysis and during transplant function. For immune deficiency-related cancers, the increase was 1.5 (95% CI 1.3–1.6) times in dialysis, and 5-fold after transplantation. ESKD- or immune deficiency-related cancers contributed to ~90% of the excess burden of cancer, 48% and 36%, respectively, in dialysis, and 10% and 78% after transplantation. The remaining excess malignancy was contributed by cancers whose relationship with ESKD and immune deficiency is not yet certain.

Conclusions. In RRT, the increase in cancer is restricted, largely if not wholly, to cancers with origins in ESKD or related to immune deficiency. For the former, the cancer risk is similar in dialysis and transplantation, but for immune deficiency-related cancers, the relative risk is much greater after transplantation.

Keywords: cancer; dialysis; end-stage kidney disease; immune deficiency; renal transplantation

Received for publication: 4. 4.09
Accepted in revised form: 15. 6.09


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