Screening for acquired cystic kidney disease: a decision analytic perspective

The impact of muscle mass loss and deteriorating physical function on prognosis in patients receiving hemodialysis

Muscle mass loss and worsening physical function are crucial issues in patients receiving hemodialysis (HD). However, few studies have investigated the association between temporal changes in muscle mass and physical function in a large number of HD patients. We examined 286 patients receiving HD (males, 58%; age, 66.8 ± 13.0 years) at a single center, and calculated the percent changes in psoas muscle mass index (%PMI) using computed tomography over two screenings, once per year (July 2011–June 2013). Physical function was evaluated using the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) (range 0–4). The observation period was from July 2012 to June 2021. The median %PMI was -9.5%, and those with the lowest quartile of %PMI (< −20.5%) showed a significantly poor prognosis compared with other patients (p < 0.001). Multivariable logistic regression analysis revealed that these patients tended to have decreased physical function (ECOG-PS 2–4) [odds ratio (OR): 2.46, p < 0.001] and albumin levels (OR: 0.22, p = 0.007). Multiple-factor-adjusted Cox regression analyses showed that %PMI (hazard ratio: 0.99, p = 0.004) and each ECOG-PS stage (1–4 vs. 0) (p < 0.01) were associated with mortality. Augmenting physical activities in daily life and serum albumin levels should be considered to maintain muscle mass and improve the prognosis of patients receiving HD.

An update on cancer after kidney transplantation

The emergence of onconephrology in recent years highlights the importance of the interaction between kidney disease and cancer. Chronic kidney disease (CKD) and cancer are linked with each other in different ways bidirectionally: cancer can cause CKD, whereas CKD itself may be a risk factor for cancer. Kidney transplant recipients (KTRs) have a 2- to 3-fold increased cancer risk when compared with the general population. The elevated risk covers a wide range of cancers. Some are related to CKD, including cancers of the kidney, urinary tract and thyroid, whereas others are related to oncogenic viruses that include non-Hodgkin lymphoma, cervical cancer, nonmelanoma skin cancer and Kaposi's sarcoma. There is no standard protocol regarding how immunosuppressive drugs should be adjusted in patients who develop posttransplant cancers. However, any modification of immunosuppressive regimens should be balanced against the risk of allograft rejection or deterioration in kidney function. Cancer surveillance can be used as a strategy to improve the clinical outcome in KTRs. Although guidelines adopted in the general population have been used as the reference, a personalized approach based on individual cancer risk, life expectancy and concurrent comorbidities has to be adopted.

KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation

The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.

Oncology in nephrology comes of age: A focus on chronic dialysis patients

Dialysis is the commonest modality of renal replacement therapy for patients suffering from end-stage kidney disease. Different registry studies showed that the risks of overall cancer occurrence were significantly higher in chronic dialysis patients than in the age-matched general population. However, the frequency and pattern of different cancers may vary among different geographical areas. Since chronic dialysis patients tend to have multiple comorbidities and a shorter life expectancy, routine cancer screening in all dialysis patients may not be cost-effective; rather screening should be personalized according to the patient's expected survival, candidacy for kidney transplant together with patient preferences.

Epidemiology and screening for renal cancer

PURPOSE

The widespread use of abdominal imaging has affected the epidemiology of renal cell carcinoma (RCC). Despite this, over 25% of individuals with RCC have evidence of metastases at presentation. Screening for RCC has the potential to downstage the disease.

METHODS

We performed a literature review on the epidemiology of RCC and evidence base regarding screening. Furthermore, contemporary RCC epidemiology data was obtained for the United Kingdom and trends in age-standardised rates of incidence and mortality were analysed by annual percentage change statistics and joinpoint regression.

RESULTS

The incidence of RCC in the UK increased by 3.1% annually from 1993 through 2014. Urinary dipstick is an inadequate screening tool due to low sensitivity and specificity. It is unlikely that CT would be recommended for population screening due to cost, radiation dose and increased potential for other incidental findings. Screening ultrasound has a sensitivity and specificity of 82-83% and 98-99%, respectively; however, accuracy is dependent on tumour size. No clinically validated urinary nor serum biomarkers have been identified. Major barriers to population screening include the relatively low prevalence of the disease, the potential for false positives and over-diagnosis of slow-growing RCCs. Individual patient risk-stratification based on a combination of risk factors may improve screening efficiency and minimise harms by identifying a group at high risk of RCC.

CONCLUSION

The incidence of RCC is increasing. The optimal screening modality and target population remain to be elucidated. An analysis of the benefits and harms of screening for patients and society is warranted.

Use of mammalian target of rapamycin inhibitors after failure of tyrosine kinase inhibitors in patients with metastatic renal cell carcinoma undergoing hemodialysis: A single-center experience with four cases

We retrospectively identified patients with end-stage renal disease undergoing hemodialysis treated with the mammalian target of rapamycin inhibitors as a second- and/or third-line targeted therapy after treatment failure with the tyrosine kinase inhibitors for metastatic renal cell carcinoma. Patient medical records were reviewed to evaluate the response to therapies and treatment-related toxicities. Four patients were identified. All patients had undergone nephrectomy, and one had received immunotherapy before targeted therapy. Two patients had clear cell histology, and the other two had papillary histology. All patients were classified into the intermediate risk group according to the Memorial Sloan-Kettering Cancer Center risk model. All patients were treated with everolimus as a second- or third-line therapy, and two patients were treated with temsirolimus as a second- or third-line therapy after treatment failure with sorafenib or sunitinib. The median duration of everolimus therapy was 6.7 months, whereas that of temsirolimus was 9.5 months. All patients had stable disease as the best response during each period of therapy. There were no severe adverse events. The use of mammalian target of rapamycin inhibitors in patients who previously failed to respond to tyrosine kinase inhibitors appears to be feasible in patients with end-stage renal disease requiring hemodialysis.

Clinical symptoms predict poor overall survival in chronic-dialysis patients with renal cell carcinoma associated with end-stage renal disease

OBJECTIVE

To evaluate which clinical symptoms predict the survival of patients with renal cell carcinoma associated with end-stage renal disease under chronic dialysis.

METHODS

We retrospectively evaluated 401 patients with renal cell carcinoma associated with end-stage renal disease who underwent radical nephrectomy at our institute up through December 2012. Patients were divided into two groups: the symptomatic group and the incidental group, by diagnosis. We compared the clinicopathologic features and patient survival of the two groups and investigated prognostic factors using Cox multivariate analysis.

RESULTS

Of the 401 patients, 124 (30.9%) were in the symptomatic group and 277 (69.0%) in the incidental group. The symptomatic group included more advanced tumors in terms of larger tumor size, higher stage and higher grade compared with the incidental group. The 5-year cancer-specific survival and overall survival of the symptomatic and incidental groups were 76.9 vs. 95.3% (P < 0.001) and 64.2 vs. 84.9% (P < 0.001), respectively. On multivariate analysis, the presence of symptoms, higher age, higher stage, diabetic nephropathy and longer hemodialysis duration were independent prognostic factors.

CONCLUSIONS

Symptomatic detection was significantly associated with worse overall survival in patients with renal cell carcinoma associated with end-stage renal disease as well as sporadic renal cell carcinoma. The high incidence of renal cell carcinoma as well as the poor oncologic outcome in patients with longer dialysis therapy may suggest an important role for routine screening in these patients.

[Clinical study of renal cell carcinoma in dialysis patients: a single center experience]

PURPOSE

Because of a higher incidence in dialysis patients, regular screening for renal cell carcinoma (RCC) is considered beneficial in this population. RCC is associated with a high incidence of acquired cystic disease of the kidney (ACDK), and it has been suggested that these conditions are related. This study was designed to examine the efficacy of RCC screening for dialysis patients and the relationship between RCC and ACDK.

PATIENTS AND METHODS

This study enrolled 624 dialysis patients treated between August 2005 and June 2011 at our hospital. Screening for RCC was performed by annual abdominal ultrasonography. Factors analyzed were as follows: RCC morbidity, incidence, diagnostic method, and survival rate; and the RCC and ACDK comorbidity rate.

RESULT

RCC was diagnosed in 12 patients. RCC morbidity and incidence rates were 2.08% and 0.33%, respectively. Diagnosis of RCC was made by abdominal ultrasonography screening (N = 7, group A), abdominal ultrasonography or computed tomography for other disease (N = 2, group B) or detailed examination after appearance of symptoms (N = 3, group C). With the exception of one death from other disease, all group A and group B patients survived the follow-up period. In contrast, all group C patients died of RCC within 6 months of diagnosis; only one of these patients underwent RCC screening. The RCC/ACDK comorbidity rate was 91.7% (p = 0.0026).

CONCLUSION

Results indicate that regular screening of dialysis patients for RCC is beneficial. RCC was associated with a high incidence of ACDK, indicating that there is a relationship between these two diseases.

KDIGO clinical practice guideline for the care of kidney transplant recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Hepatic resection versus radiofrequency ablation for hepatocellular carcinoma in cirrhotic individuals not candidates for liver transplantation: a Markov model decision analysis

BACKGROUND

Several observational studies have suggested that radiofrequency ablation (RFA) may have survival benefits similar to hepatic resection (HR) in cirrhotic patients affected by hepatocellular carcinoma (HCC) are not candidates for liver transplantation. A small randomized controlled trial confirmed these findings, although underpowered to detect a significant difference at 5-year interval.

METHODS

A Markov model was created to simulate a randomized trial comparing the quality of life-adjusted survival for individuals undergoing HR versus RFA for HCCs less than 5 cm in diameter.

RESULTS

HR was the best therapeutic option with 5.33 (standard deviation +/-.42) versus 3.91 (standard deviation +/-.38) quality-adjusted life years except for in individuals older than 75 years of age (P = .02, log rank test). One-way sensitivity analysis showed that RFA was the preferred strategy if the perioperative mortality of HR was more than 30%, if the percentage of patients with negative margins was less than 60%, and if RFA could be performed at least 60% of the time for recurrent disease after a previous ablation. The quality of life associated with both procedures did not influence the results of this model.

CONCLUSIONS

HR provided better quality of life-adjusted survival as ablation therapy was associated with increased risk of local recurrent disease requiring multiple sessions. For older individuals, RFA appears to be the best therapeutic option. If the probability of ablation for recurrent disease is equal in the 2 arms, survival benefits of RFA is similar to HR.

Preventive health care in chronic kidney disease and end-stage renal disease

The complex care that must be provided for patients with renal disease might interfere with provision of basic preventive measures in this population. Preventive health care, including infection screening and prophylaxis, vaccinations, management of blood glucose and lipid levels, and cancer screening, is important, as it might decrease acute morbidity and mortality. This Review highlights useful preventive and health maintenance strategies for patients with chronic kidney disease and those with end-stage renal disease.

Spontaneous retroperitoneal hemorrhage due to acquired cystic kidney disease

A patient with end-stage renal disease on maintenance hemodialysis developed sudden severe abdominal pain and distension. He suffered a decline in his hematocrit and subsequent abdominal imaging revealed a large left-sided retroperitoneal hemorrhage in the setting of atrophic, severely cystic kidneys. He underwent selective left renal artery angiography and embolization due to continued hemorrhage with stabilization in his condition. However, he became paraparetic within hours of the embolization procedure due to spinal cord infarct. Acquired cystic kidney disease is a very common entity in patients with chronic kidney disease. Complications include cystic hemorrhage or infection, erythrocytosis, and renal cell carcinoma. Screening of patients for cystic disease and malignant transformation remains a controversial topic; however, most advocate abdominal imaging after 3 to 5 years on dialysis.

Screening, diagnosis, and treatment of cancer in long-term dialysis patients

Some have suggested that the American Cancer Society guidelines for cancer screening be applied to patients who are on long-term dialysis and have used cancer screening as a means of assessing delivered preventive health care to patients with ESRD. However, cancer screening is effective only when it leads to survival benefit (usually expressed as days of life saved) without incurring high financial costs. Certain cancers such as human papillomavirus-associated cervical and tongue cancer and urologic malignancies are more common among dialysis patients, yet because the expected remaining lifetime of most dialysis patients is shorter than the time lived to develop malignancy, cancer screening in dialysis patients as applied to the general population is ineffective from the perspective of both cost and survival benefit. Cancer screening in dialysis patients is therefore best provided in an individual patient-focused manner. The occurrence, diagnosis, and treatment of cancer as well as issues related to cancer screening in dialysis patients are discussed.

[Cystic diseases of the kidney]

Cystic diseases of the kidney constitute a heterogeneous family. Most renal cysts are benign and asymptomatic, and don't have any impact on renal function. These "simple" cysts are usually managed conservatively. However, some renal cysts may be symptomatic or may have atypical radiological presentation, leading to suspicion of malignant tumour; puncture or surgical investigation may be indicated in such cases. The other cystic renal diseases include specific entities, either genetic or acquired during development. Some malformative syndromes are often associated, and renal function may be impaired. In such cases, nephrectomy is required.

Renal Cell Carcinoma Detected by Screening Shows Better Patient Survival Than That Detected Following Symptoms in Dialysis Patients

There is an apparent advantage to early or incidental diagnosis of renal cell carcinoma in the general population. We investigated whether the prognosis of dialysis patients with renal cell carcinoma is better if renal cell carcinoma is detected by screening of patients without symptoms rather than by examination after the appearance of the symptoms. Two groups in which renal cell carcinomas were detected by screening (N = 721) and by symptoms (n = 76) were compared. The model tested consisted of patient age and duration of dialysis in addition to the detection by screening or symptoms. Cox proportional hazard model was used to compare survival rates between the groups. The hazard ratio of death from all causes in patients with renal cell carcinoma detection by screening was 0.653 and the risk of death was reduced by 35%, compared with that in the group with detection due to symptoms. Moreover, the 50% survival rate in the group detected by symptoms was 80 months and the ratio of those detected by screening was 119 months. Therefore, screening provided a survival benefit of 39 months (3.3 years) in death from all causes after adjustment for age and duration of dialysis. The survival rate was best in young patients with a short duration of dialysis and renal cell carcinoma detected by screening. In dialysis patients with renal cell carcinoma, the survival rate in the group detected by screening was better than that in the group detected by symptoms. Especially, there was a large effect of screening for renal cell carcinoma in the young dialysis patients.

Decision analysis and its application in clinical medicine

Decision analysis is increasingly used to address difficult medical problems. Case-by-case models designed for individual patients facing complex trade-offs in their medical care often help individual clinical decision making, but are expensive and time consuming. On the other hand, generic models addressing broad clinical questions that can be adapted from one patient to another, can often make valid projections about specific outcomes, such as life expectancy, quality-adjusted life expectancy, and cost-effectiveness issues, and represent a useful approach to clinical decision making.

Renal cell carcinoma in acquired cystic kidney disease: volume growth rate determined by helical computed tomography

The aim of this study is to determine the growth rate and behavior of renal cell carcinoma in chronic hemodialysis patients with acquired cystic kidney disease (ACKD). Renal cell carcinomas in 17 hemodialysis patients (mean age, 52 +/- 11 years; mean hemodialysis duration, 7.2 +/- 3.3 years) with ACKD were examined with helical computed tomography (CT) for 0.5 to 6.0 years (mean, 2.1 +/- 1.9 years). The 17 renal cell carcinomas were histologically proven and graded after nephrectomy (16 patients) or autopsy (1 patient). Tumor volume was estimated by counting the number of pixels in the tumor and a 1-cm(2) area on helical computed tomographic scan using a personal computer. Estimated volume growth rates and doubling times of the carcinoma were correlated with histological grades. Fifteen of the 17 neoplasms (88%) were less than 3 cm in diameter at initial CT. The overall volume growth rate was 0.07 to 17.34 cm(3)/y (mean, 4.14 +/- 5.66 cm(3)/y), and the estimated volume-doubling time was 0. 08 to 23.31 years (mean, 5.09 +/- 6.99 years). The mean growth rate of the 3 grade 3 carcinomas was 6.01 +/- 4.50 cm(3)/y (range, 0.88 to 9.28 cm(3)/y), which was significantly greater than that of the 9 grade 1 carcinomas (0.40 +/- 0.40 cm(3)/y; range, 0.09 to 1.37 cm(3)/y) or the 5 grade 2 tumors (0.79 +/- 0.74 cm(3)/y; range, 0.12 to 2.00 cm(3)/y). Eleven of the 17 carcinomas (65%) had more than a 1-year volume-doubling time. The 3 grade 3 neoplasms and 1 of the grade 2 lesions had less than a 0.5-year doubling time.

Non-Hodgkin's lymphoma of the thyroid and adrenal glands

We report a case of non-Hodgkin's lymphoma(NHL) with simultaneous involvement of both thyroid and bilateral adrenal glands. Literature review on a computerized search showed that this is an extremely rare condition. The final diagnosis of diffuse large B cell lymphoma was confirmed by biopsies of thyroid gland, enlarged cervical lymph node, and adrenal gland. The significant endocrine dysfunction of the thyroid, adrenal or other endocrine glands was absent in our case. The patient responded dramatically to three cycles of chemotherapy with no complication or endocrine dysfunction and continues to be followed.

Prospective pretransplant ultrasound screening in 206 patients for acquired renal cysts and renal cell carcinoma

BACKGROUND

Numerous studies have reported an increased prevalence of renal cell carcinoma in association with acquired cystic kidney disease (ACKD). In 1995, the clinical practice guidelines of the American Society of Transplant Physicians for evaluation of renal transplant candidates recommend not screening for ACKD and renal cell carcinoma, on the basis of the low frequency of cancer and reported regression of ACKD after transplantation. The objective of this study was to prospectively evaluate the prevalence of ACKD and renal cancer during renal transplant evaluation.

METHODS

A total of 206 consecutive adult patients evaluated for renal transplantation underwent a routine renal ultrasound. Patients with a suspicious ultrasound underwent a contrasted computed tomographic scan of the kidneys followed by excision of kidneys with solid, enhancing (>10 Hounsfield units) lesions.

RESULTS

Sixty-three (30.6%) of 206 patients had ACKD, with a greater proportion being male, African-American, and dialysis-dependent for a longer duration. Eight patients (3.8%) had histologically proven localized cancer (six unilateral, two bilateral), seven in association with ACKD and one in association with autosomal dominant polycystic kidney disease. With a mean follow-up of 14 months (range, 3-33 mo), there has been no recurrence. The positive predictive value of a solid lesion on ultrasound was 100% (8 of 8 patients).

CONCLUSION

With the high prevalence (3.4%) of renal cell carcinoma in association with ACKD and the concern that immunosuppression accelerates the growth of preexisting cancers, we continue to recommend ultrasound screening of the native kidneys before renal transplantation.

Current concepts and controversies in imaging of renal cystic diseases

Renal cystic disease compromises a diverse group of inherited and acquired entities. This article reviews the clinical, pathologic, and radiologic findings of eight renal cystic diseases. For each entity, the current concepts of pathogenesis and pathophysiology are discussed. When appropriate, controversies concerning terminology, management, and malignant potentials are addressed. Renal cystic diseases that are discussed include autosomal dominant and autosomal recessive polycystic kidney disease, medullary sponge kidney, medullary cystic disease, multicystic, dysplastic kidney, von Hippel-Lindau disease, acquired cystic kidney disease, and tuberous sclerosis.

Cost-effectiveness of screening for detection of small hepatocellular carcinoma in western patients with Child-Pugh class A cirrhosis

BACKGROUND AND AIM

The incidence of hepatocellular carcinoma is increased in patients with cirrhosis. Therefore, surveillance for detection of small tumors has been proposed. The aim of this study was to determine the clinical and economical effects of screening for small hepatocellular carcinoma in Western patients with Child-Pugh class A cirrhosis.

METHODS

Based on a decision analysis model representing the natural history of cirrhosis and the continuing risk of developing cancer, we compared a strategy of performing ultrasound and alpha-fetoprotein dosage every 6 months with a strategy of seeking tumors only if they are clinically suspected. In both strategies, partial hepatectomy was performed for patients with compensated cirrhosis and diagnosed with resectable tumors. We did not consider orthotopic liver transplantation as a therapeutic option. Data were drawn from MEDLINE search.

RESULTS

For most patients seen in the daily practice, screening provides negligible benefits in life expectancy (< 3 months), even when the incidence of cancer is high (6% per year), and despite our choice of consistent biases in favor of screening. The cost-effectiveness ratios of systematic surveillance range between $48,000 and $284,000 for each additional life-year gained, more than other common medical practices. However, for a minority of patients with a predicted cirrhosis-related survival rate above 80% at 5 years (the "ideal" candidates) screening may increase mean life expectancy by 3 to 9 months depending on age, cancer incidence (1.5% to 6% per year), and survival rate after surgery (40% to 60% at 3 years). In this clinical setting, the cost-effectiveness ratios range between $26,000 and $55,000 for each additional life-year gained.

CONCLUSIONS

For most patients with cirrhosis seen in the daily practice, biannual screening to detect symptomless tumors accessible to surgical resection provides negligible benefit in life expectancy. In addition, the cost-effectiveness ratios incurred by this strategy is more important than that of many current medical practices. On the other hand, for well-targeted patients with the longest reported cirrhosis-related survival rate, screening may substantially increase mean life expectancy, at lower costs. Careful selection of these patients with a favorable cirrhosis-related prognosis requires further studies.