Risk of skin cancer in patients on chronic haemodialysis: a nationwide, population-based study in Taiwan

Risk Factors Associated With Major Adverse Cardiovascular Events and Malignancies in Patients With Rheumatoid Arthritis in a Real-World Setting in Japan

AIM

To identify risk factors associated with major adverse cardiovascular events (MACE) and malignancies in patients with rheumatoid arthritis (RA) using real-world data from Japan.

METHODS

This cohort study used the Real World Data database of medical institutions in Japan. Eligible patients (January 2013-December 2021) had ≥ 1 RA diagnosis, were aged ≥ 18 years, prescribed ≥ 1 antirheumatic drug, had no psoriasis diagnosis, and had a record postindex. Patients had no myocardial infarction/stroke ≤ 31 days (MACE cohort) or malignancy < 1 year (malignancy cohort) before index. Cohorts were determined by incidence of initial MACE or malignancy. Known/exploratory variables were selected using Cox regression models.

RESULTS

Across MACE (n = 16 012) and malignancy (n = 14 545) cohorts, most patients were female and aged ≥ 65 years. Overall, 214 MACE per 43964.7 patient-years (incidence rate 0.49 per 100 patient-years) and 315 malignancies per 40251.6 patient-years (incidence rate 0.78 per 100 patient-years) occurred. Male sex, older age (≥ 65 years), hypertension, renal disease, cerebrovascular disease, and prior X-ray examination were significantly associated with increased MACE risk. Male sex, older age (≥ 50 years), nonsteroidal anti-inflammatory drug use, emphysema, serious infection, malignancy history, and prior X-ray examination were significantly associated with increased malignancy risk. Conversely, glucocorticoid use and fracture diagnosis were significantly associated with reduced malignancy risk.

CONCLUSION

In patients with RA in Japan, male sex, older age, and prior X-ray examination were associated with increased MACE and malignancy risk.

Dermatological Manifestations in Patients With Chronic Kidney Disease: A Review

Chronic kidney disease (CKD) is a progressive disease and has multiple clinical manifestations; when CKD reaches the end stage, at least one cutaneous manifestation appears due to some increased toxin levels or a constant proinflammatory state. Nonspecific manifestations include pruritus, xerosis, pigmentation disorders, acquired ichthyosis, purpuric spots, and nail disorders. Some specific manifestations are bullous dermatoses, acquired perforating dermatoses (APD), eruptive xanthoma, access site infections, calcifying disorders, and nephrogenic systemic fibrosis (NSF). All these cutaneous changes negatively impact patients; early recognition and diagnosis of these dermatoses will make a difference in their quality of treatment. Exploring a patient's skin is fundamental to suspect some diseases and increased toxin levels; pruritus occurs when uremic toxins are raised, and nail disorders are associated with hypoalbuminemia. This review provides the clinician with information on the clinical manifestations that occur in CKD, including epidemiology, pathophysiology, clinical manifestations, diagnosis, histopathology, treatment, and life impact of the dermatoses in CKD.

Hormone replacement therapy did not increase risk of melanoma in Chinese female with menopausal and postmenopausal disorders: A population-based retrospective cohort study in Taiwan

Hormone replacement therapy (HRT) is widely used to relieve symptoms of menopause with proven efficacy. However, there has been significant controversy surrounding the use of HRT because of its potential link with an increased risk of cancer, particularly female reproductive organ cancers. That HRT increases the risk of melanoma is also disputed, and several cohort studies have produced variable results. To delineate the association between HRT and melanoma in Taiwan, we conducted a population-based retrospective cohort study on 14 291 patients who had received HRT and 57 164 population controls in Taiwan between 2000 and 2013. Multivariate odds ratios (ORs) were calculated utilizing conditional logistic regression. Overall, the use of HRT was not significantly correlated with a higher risk of developing melanoma in Taiwan (95% confidence interval 0.386-1.099; p = 0.341). The hazard ratio analysis of melanoma and different HRTs showed there was no significant association between melanoma and the use of oral or external estrogens alone, including conjugated estrogens, estradiol, and estriol. Estrogen plus progesterone combined therapy was associated with a lower risk of melanoma. Only one case of melanoma was observed among the 2880 patients in this subgroup.

Meta-analysis of cancer risk among end stage renal disease undergoing maintenance dialysis

Currently, there is no consensus on whether maintenance dialysis increases cancer risk in patients with end-stage renal disease (ESRD). Therefore, this study was to systematically evaluate the risk of cancer among ESRD patients undergoing maintenance dialysis. Related studies on the impact of maintenance dialysis on cancer risk were retrieved from PubMed, Embase, Cochrane Library, and other databases from their respective inceptions to 19 February 2021. ESRD patients receiving maintenance dialysis were classified into cancer including non-melanoma skin cancer (NMSC) and cancer excluding NMSC. Standardized incidence ratio (SIR) with its 95% confidence interval (95% CI) was calculated to assess cancer risk. Fourteen studies were included in the meta-analysis. The risk of cancer in patients undergoing maintenance dialysis (with or without NMSC) was significantly higher than controls both in cancer including NMSC (SIR = 1.38, 95% CI: 1.27-1.49, P < 0.001) and cancer excluding NMSC (SIR = 1.34, 95% CI: 1.23-1.47, P < 0.001). Subgroup results identified the higher risk of cancer incidence in both men and women receiving maintenance dialysis. Meanwhile, elevated excess risks were observed among patients with younger age and shorter follow-up time (P < 0.001). Meanwhile, the combined SIR of bladder, cervix, colorectum, kidney, liver, thyroid, tongue, and other cancers were all increased (P < 0.05). ESRD patients undergoing dialysis has higher risk of cancer.

UV Exposure and the Risk of Keratinocyte Carcinoma in Skin of Color: A Systematic Review

Importance

Ultraviolet radiation exposure is an important modifiable risk factor for keratinocyte carcinoma (KC) in fair-skinned non-Hispanic White populations; however, the evidence for this relationship in darker-skinned populations is less certain.

Objective

To assess and synthesize the published data concerning the association between UV exposure and the risk of KC in individuals with skin of color.

Evidence Review

PubMed, Cochrane, and Web of Science databases were searched from database origin through January 2022. Studies deemed eligible included UV exposure as a risk factor for KC in individuals with skin of color, defined as any race other than non-Hispanic White, Fitzpatrick skin types IV to VI, or tanning ability of rarely or never burns. The UV index, irradiance, latitude, history of phototherapy, history of sunburn, or occupational exposure were used as measures of exposure. The Oxford Centre for Evidence-Based Medicine guidelines were used to assess evidence quality.

Findings

A total of 72 716 articles appeared in the search. After duplicate removal, 29 393 database records were screened, 454 full-text articles were assessed, a forward and reverse citation search was performed, and 12 articles, with clinical data spanning the years 1990 to 2019, met inclusion criteria. More than 32 970 KCs in individuals with skin of color were included. Eight studies found no association between UV exposure and KC, while 4 studies showed a positive association. Study types included 1 ecological study, 9 cohort studies, and 2 case-control studies. The quality of the studies was rated from moderate to low (2b to 4).

Conclusions and Relevance

Results of this systematic review show that the evidence assessing the association of UV exposure with KC is of moderate to low quality. The studies that found no association were among patients receiving phototherapy. Studies assessing nonphototherapy-related UV exposure, such as geographic location or occupation, found small positive associations in primarily East Asian individuals. There were no studies performed in the US, no studies among Black individuals, and only 1 study among a Hispanic population. Further research is required to better assess whether these associations exist across populations of patients with darker skin types.

A Metastatic Well-differentiated Squamous Cell Carcinoma in a Patient with an Arteriovenous Fistula

Patients receiving hemodialysis have an increased risk of developing nonmelanoma skin cancers, such as cutaneous squamous cell carcinoma (SCC). Management of SCC usually relies on complete surgical excision of the primary tumor and may require regional lymph node dissection due to lymphatic spread. An 81-year-old man with an arteriovenous fistula (AVF) presented with an unusually aggressive metastatic well-differentiated SCC, necessitating an axillary dissection for lymph node metastasis. He had been referred for radiotherapy to complete his oncological treatment following excision of the primary SCC on his forearm. An AVF site is subjected to significant changes in circulatory pressure, leading to reduced lymphatic drainage and likely focal immunosuppression. Increased lymphatic burden, combined with repeated trauma to the fistula in an immunosuppressed patient, potentially precipitated the development of an SCC on the affected limb. The individual risk factors for SCC such as sites of chronic inflammation and repeated trauma, host immunosuppression, and renal disease are well established. This patient demonstrates the perfect storm of all these risk factors, leading to a highly malignant metastatic SCC. As the standards of renal care improve and the number of patients with AVF increases, we must remain vigilant in the management of SCCs in these patients.

The influence of climate change on skin cancer incidence - A review of the evidence

BACKGROUND

Climate change is broadly affecting human health, with grave concern that continued warming of the earth's atmosphere will result is serious harm. Since the mid-20th century, skin cancer incidence rates have risen at an alarming rate worldwide.

OBJECTIVE

This review examines the relationship between climate change and cutaneous carcinogenesis.

METHODS

A literature review used the National Institutes of Health databases (PubMed and Medline), the Surveillance, Epidemiology, and End Results and International Agency for Research on Cancer registries, and published reports by federal and international agencies and consortia, including the Australian Institute of Health and Welfare, Climate and Clean Air Coalition, U.S. Environmental Protection Agency, Intergovernmental Panel on Climate Change, National Aeronautics and Space Administration, National Oceanic and Atmospheric Administration, United Nations Environment Programme, World Health Organization, and World Meteorological Organization.

RESULTS

Skin cancer risk is determined by multiple factors, with exposure to ultraviolet radiation being the most important. Strong circumstantial evidence supports the hypothesis that factors related to climate change, including stratospheric ozone depletion, global warming, and ambient air pollution, have likely contributed to the increasing incidence of cutaneous malignancy globally and will continue to impose a negative on influence skin cancer incidence for many decades to come.

CONCLUSION

Because much of the data are based on animal studies and computer simulations, establishing a direct and definitive link remains challenging. More epidemiologic studies are needed to prove causality in skin cancer, but the evidence for overall harm to human health as a direct result of climate change is clear. Global action to mitigate these negative impacts to humans and the environment is imperative.

Uremic pruritus and long-term morbidities in the dialysis population

Background

Uremic pruritus (UP) is a multifactorial problem that contributes to low quality of life in dialysis patients. The long-term influences of UP on dialysis patients are still poorly understood. This study aims to elucidate the contribution of UP to long-term outcomes.

Materials and method

We used the Taiwan National Health Insurance Research Database to conduct this study. Patients on chronic dialysis were included and divided into UP and non-UP groups according to the long-term prescription of antihistamine in the absence of other indications. The outcomes include infection-related hospitalization, catheter-related infection, major adverse cardiac and cerebrovascular events (MACCE) and parathyroidectomy.

Results

After propensity score matching, 14,760 patients with UP and 29,520 patients without UP were eligible for analysis. After a mean follow-up of 5 years, we found that infection-related hospitalization, MACCE, catheter-related infection, heart failure and parathyroidectomy were all slightly higher in the UP than non-UP group (hazard ratio: 1.18 [1.16–1.21], 1.05 [1.01–1.09], 1.16 [1.12–1.21], 1.08 [1.01–1.16] and 1.10 [1.01–1.20], respectively). Subgroup analysis revealed that the increased risk of adverse events by UP was generally more apparent in younger patients and patients who underwent peritoneal dialysis.

Conclusion

UP may be significantly associated with an increased risk of long-term morbidities.

Increased cancer risk in patients undergoing dialysis: a population-based cohort study in North-Eastern Italy

BACKGROUND

In southern Europe, the risk of cancer in patients with end-stage kidney disease receiving dialysis has not been well quantified. The aim of this study was to assess the overall pattern of risk for de novo malignancies (DNMs) among dialysis patients in the Friuli Venezia Giulia region, north-eastern Italy.

METHODS

A population-based cohort study among 3407 dialysis patients was conducted through a record linkage between local healthcare databases and the cancer registry (1998-2013). Person-years (PYs) were calculated from 30 days after the date of first dialysis to the date of DNM diagnosis, kidney transplant, death, last follow-up or December 31, 2013, whichever came first. The risk of DNM, as compared to the general population, was estimated using standardized incidence ratios (SIRs) and 95% confidence intervals (CIs).

RESULTS

During 10,798 PYs, 357 DNMs were diagnosed in 330 dialysis patients. A higher than expected risk of 1.3-fold was found for all DNMs combined (95% CI: 1.15-1.43). The risk was particularly high in younger dialysis patients (SIR = 1.88, 95% CI: 1.42-2.45 for age 40-59 years), and it decreased with age. Moreover, significantly increased DNM risks emerged during the first 3 years since dialysis initiation, especially within the first year (SIR = 8.52, 95% CI: 6.89-10.41). Elevated excess risks were observed for kidney (SIR = 3.18; 95% CI: 2.06-4.69), skin non-melanoma (SIR = 1.81, 95% CI: 1.46-2.22), oral cavity (SIR = 2.42, 95% CI: 1.36-4.00), and Kaposi's sarcoma (SIR = 10.29, 95% CI: 1.25-37.16).

CONCLUSIONS

The elevated risk for DNM herein documented suggest the need to implement a targeted approach to cancer prevention and control in dialysis patients.

Environmental effects of ozone depletion, UV radiation and interactions with climate change: UNEP Environmental Effects Assessment Panel, update 2017

The Environmental Effects Assessment Panel (EEAP) is one of three Panels of experts that inform the Parties to the Montreal Protocol. The EEAP focuses on the effects of UV radiation on human health, terrestrial and aquatic ecosystems, air quality, and materials, as well as on the interactive effects of UV radiation and global climate change. When considering the effects of climate change, it has become clear that processes resulting in changes in stratospheric ozone are more complex than previously held. Because of the Montreal Protocol, there are now indications of the beginnings of a recovery of stratospheric ozone, although the time required to reach levels like those before the 1960s is still uncertain, particularly as the effects of stratospheric ozone on climate change and vice versa, are not yet fully understood. Some regions will likely receive enhanced levels of UV radiation, while other areas will likely experience a reduction in UV radiation as ozone- and climate-driven changes affect the amounts of UV radiation reaching the Earth's surface. Like the other Panels, the EEAP produces detailed Quadrennial Reports every four years; the most recent was published as a series of seven papers in 2015 (Photochem. Photobiol. Sci., 2015, 14, 1-184). In the years in between, the EEAP produces less detailed and shorter Update Reports of recent and relevant scientific findings. The most recent of these was for 2016 (Photochem. Photobiol. Sci., 2017, 16, 107-145). The present 2017 Update Report assesses some of the highlights and new insights about the interactive nature of the direct and indirect effects of UV radiation, atmospheric processes, and climate change. A full 2018 Quadrennial Assessment, will be made available in 2018/2019.