Elsevier

The Lancet

Volume 354, Issue 9173, 10 July 1999, Pages 93-99
The Lancet

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Cancer in patients on dialysis for end-stage renal disease: an international collaborative study

https://doi.org/10.1016/S0140-6736(99)06154-1Get rights and content

Summary

Background

Previous studies have suggested that the frequency of cancer is higher in patients with end-stage renal disease (ESRD) than in the general population, but have not established whether this increase is confined to certain cancers or to certain categories of ESRD patients. The aim of this study was to examine the risk of cancer in a large cohort of patients treated by dialysis but not transplantatih

Methods

We assembled a cohort of 831804 patients who received dialysis during the period 1980–94 for ESRD in the USA, Europe, Australia, or New Zealand. We compared the observed frequency cancer among these patients during 2045035 person-years of follow-up with the frequency of cancer in the respective background populations.

Findings

During average follow-up of 2–5 years, 25 044 (3%) of 831804 patients developed cancer compared with an expected number of 21 185 (standardised incidence ratio 1–18 [95% Cl 1-17-1. 20]). We observed a higher risk of cancer in patients younger than 35 years (3-68 [–39-3-99]), and the risk gradually decreased with increasing age. High risks were observed for cancer of the kidney (3-60 [3-45-3-76]), bladder (1-50][1-42-1-57]), and thyroid and other endocrine organs (2-28 [2-[2-3-54]). Excess cancers appeared in several organs for which viruses have been suspected as causative agents, whereas cancers of the lung, colorectum, prostate, breast, and stomach were not consistently increased

Interpretation

The overall risk of cancer is increased in patients with ESRD, and the distribution of tumour types resembles the pattern seen after transplantation (although we have no data to make the comparison with skin cancer). The excess risk can largely be ascribed to effects of underlying renal or urinary-tract disease, or of loss of renal function, on the kidney and bladder, and to increased susceptibility to viral carcinogenesis. The relative risk, which is especially high in younger patients, gradually diminishes with age

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.

Section snippets

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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