Dr Paul Harden
Consultant Nephrologist, The
Churchill Hospital, Oxford
The
progressive success of renal transplantation has resulted in a growing
population of patients alive with a functioning transplant (estimate >
20,000 in the UK). Moreover long-term graft survival is increasing, exposing a
higher proportion of recipients to long-term risks and complications of
immunosuppression. In the USA, cancer is the third commonest cause of death in
renal transplant recipients (1.4/1000 person years) and equates to a 3-5 fold
increased incidence compared with the general population.
Non-melanoma
skin cancer (NMSC) accounts for >90% of cancer post-transplantation with a
prevalence of >30% and annual incidence of 10% in patients with a functioning
transplant for >10 years in the UK. Male sex, increasing age, cigarette
smoking and duration of immunosuppression are associated with increasing risk.
This results in significant morbidity and a mortality of 2% in European renal
transplant recipients, placing considerable burden on health care services.
Targeted surveillance strategies can identify lesions early in those at highest
risk prompting appropriate treatment.
Overall
load of immunosuppression increases risk of NMSC. Recent observations with mTOR
inhibitors have demonstrated both inhibition of tumour growth and reduction of
metastatic potential in experimental models of cancer post-transplantation and
in the clinical setting of Kaposi’s sarcoma post-transplant. Switching
immunosuppressive regimens to include an mTOR inhibitor may provide a valuable
tool to treat individuals with post-transplant cancer and is currently the
subject of several international clinical trials.
During
this session I shall also discuss the risk of other neoplasms post-transplantation
and the role of clinical screening. This will include breast, cervical, colon
and prostate cancer. Post-transplant lymphoproliferative disorder will not be
discussed in detail.
The
multidisciplinary team need to be aware of the increased risk of certain
cancers in the long-term transplant recipient. It is important to develop a
strategy for early detection and treatment of cancers which may include
modulation of immunosuppressive regimens.
References
1. European
Best Practice Guidelines for Renal Transplantation (Part 2): Berthoux F et
al. Nephrol Dial Transplant 2002: 17
(Suppl 4); 32-36.
2. Cohen D
and Galbraith C. General health management and long-term care of the renal
transplant recipient. Am J Kid Dis 2001: 38 (Suppl 6); S10-S24.
3. Kasiske B
et al. The evaluation of renal transplant candidates: Clinical practice
guidelines. J Am Soc Nephrol 1995: 6; 1-34.
4. Stallone G
et al. Sirolimus for Kaposi’s sarcoma in renal transplant recipients.
a. New Eng J
Med 2005: 252; 25-31.
5. Ramsay
HM et al. Clinical risk factors for non-melanoma skin cancer following renal
transplantation. Am J Kid
Dis 2000: 36; 167-176.