Fast track — ArticlesCancer in patients on dialysis for end-stage renal disease: an international collaborative study
Introduction
Although kidney transplantation is an effective treatment for end-stage renal disease (ESRD), dialysis is still the commonest treatment for such patients. Patients maintained on dialysis are potentially at increased risk of cancer for several reasons, including: the presence of chronic infection, especially in the urinary tract; a weakened immune system; previous treatment with immunosuppressive or cytotoxic drugs; nutritional deficiencies; and altered DNA repai.1 in addition, the underlying disease leading to renal failure, the persistent metabolic changes associated with it, and the development of certain complications, such as acquired renal cystic disease, may predispose to cancer.4, 5
Certain types of genitourinary disease are known to predispose to renal or urothelial tumours. For example, the risk of renal cancer is known to be increased in patients with inherited or acquired cystic disease of the kidney.2, 3 Patients with Balkan nephropathy and analgesic nephropathy have a high risk of tumours of the renal pelvis and ureters.4, 5Although the increased risk of cancer after renal transplantation is well documented6, 7, 8, 9, 10, 11, there is less certainty about the risk of cancer in patients treated only with dialysis. Most of the reported studies are too small to detect potentially important findings on less common types of tumours or small increases in risk, or to study the relation between cancer and the various causes of renal failure or the method of dialysis treatment.3, 4, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 By studying several hundred thousand patients with ESRD, we hoped to overcome some of these deficiencies. The aim of this study was to find out the overall and organ-specific risk of cancer in ESRD patients being treated with dialysis who had not undergone transplantation.
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Sources of data
We obtained previously stored data from dialysis registries in three continents: the US Renal Data System20, the European Dialysis and Transplant Associatiob21, and the Australia and New Zealand Dialysis and Transplant Registry.22 The Australia and New Zealand registry, although much smaller than the other two, was the only one with a uniform mechanism of reporting to the central registry for the diagnosis of cancer, and with complete, population-based information on dialysis.22 In view of
Characteristics of the cohort
The original datasets contained information on 963 250 patients. We excluded 131 446 patients in total: 24 014 with no available background cancer rates; 40 830 who started dialysis before 1980; 16 024 with missing data on date of birth or follow-up; 47 866 who had previously had cancer or whose primary renal disease was caused by cancer or amyloidosis; 1963 with AIDS; and 749 with renal failure that occurred after transplantation. The final cohort therefore consisted of 831 804 patients
Discussion
In agreement with several previous reports, our study shows an overall increased risk of cancer in ESRD patients; the risk was highest in Australia and New Zealand, and lower in Europe and in the USA. On the basis of the method used for ascertainment of cancer and the validation study carried out in the ESRD patients in New South Wales, we believe that the higher cancer rates observed in Australia and New Zealand reflect more accurate reporting of cancer in these patients. Because ascertainment
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