NLR Outperforms Low Hemoglobin and High Platelet Count as Predictive and Prognostic Biomarker in Metastatic Renal Cell Carcinoma Treated with Immune Checkpoint Inhibitors

BACKGROUND

Reliable biomarkers in renal cell carcinoma (RCC) remain elusive. While several markers have been shown to be associated with prognosis, and may aid in risk assessment, predictive biomarkers of response to immune checkpoint inhibitors (ICIs) have not been established. Previous studies have shown that a high pretreatment neutrophil-lymphocyte ratio (NLR) is a negative prognostic factor in RCC. However, a clinically useful cut-off for the predictive and prognostic value of NLR has not been well defined.

METHODS

We conducted a retrospective analysis of 132 patients with previously untreated metastatic clear cell RCC (ccRCC) who received first line ICI-based therapy. ICI-based therapy included anti-PD-1/PD-L1 alone or in combination with anti-CTLA-4 or VEGF-TKI. Platelet, haemoglobin, neutrophil and lymphocyte counts were collected prior to treatment and at 12-weeks after treatment initiation. Radiologic response at 12-weeks and overall survival (OS) data was also collected.

RESULTS

Low haemoglobin, high platelet count, and NLR ≥3 were statistically significant negative predictive biomarkers when assessed at 12-weeks, but not at baseline. Median OS was shorter in patients with low haemoglobin (20.3 months vs. 51.6 months, P = .009), high platelet count (14.3 months vs. 43.8 months, P = .003), and NLR ≥ 3 (17.5 months vs. 40.3 months, P < .001) at 12-weeks. In an IMDC-risk adjusted analysis, only NLR ≥3 at 12-weeks remained statistically significant (OR of 2.11, P = .003) A dynamic change towards lower absolute NLR overtime was associated with longer OS. In patients who had baseline NLR ≥ 3, those who achieved NLR < 3 at 12-weeks demonstrated significant longer median OS compared to those whose NLR remained persistently ≥ 3 (40.3 months vs. 14.7 months, P = .004).

CONCLUSION

NLR ≥3, low haemoglobin and elevated platelet count after 12-weeks of ICI-based first line therapy were negatively prognostic and predictive in patients with metastatic RCC. Normalization of NLR in patients with baseline elevation was associated with longer median OS and response to therapy. These results suggest that monitoring of routine haematologic biomarkers during therapy may provide important predictive and prognostic information, beyond what is available with baseline risk assessment scoring systems.

Top advances of the year: Genitourinary cancer

There have been significant advances in the treatment of urology cancers, with a number of practice-changing treatments. There is now greater clarity on the role of the use of immunotherapies in renal cell carcinoma. The use of triplet combinations with immune checkpoint inhibition with anti-vascular endothelial growth factor tyrosine kinase inhibitors in the front-line setting for metastatic disease (COSMIC313) has been explored. The use of adjuvant therapy has been complicated by a series of negative immune therapy trials. Promising results with the HIF-2α transcription factor inhibitor, belzutifan, alone or in combination with other agents, have been reported. Antibody drug conjugates, including enfortumab vedotin and sacituzumab govitecan, have continued to show activity in urothelial cancer with promising clinical outcomes. This has led to further exploration of the combination of these novel agents with immunotherapy and accelerated Food and Drug Administration approvals. Data are also discussed regarding intensification for front-line therapy of metastatic castrate sensitive prostate cancer. The combination of androgen-signaling inhibitors, docetaxel, and androgen deprivation therapy (PEACE-1, ARASENS), as well as the use of abiraterone acetate for adjuvant therapy in high-risk disease (STAMPEDE), is included. There is also growing evidence for the use of the radioligand therapy 177 Lu-PSMA-617 in metastatic castrate resistant disease, with an established overall survival benefit in this patient population (VISION, TheraP). PLAIN LANGUAGE SUMMARY: There have been many advancements in the treatment of cancers of the kidney, bladder, and prostate in the past year. Several studies using new therapies or new combinations of therapies have improved the chances of patients living longer with these cancers, especially those with advanced disease. Here, we discuss a selection of the most compelling recently published data that have changed the way these cancers are treated, as well as those that are expected to change treatment in the near future.

IMvigor011: a study of adjuvant atezolizumab in patients with high-risk MIBC who are ctDNA+ post-surgery

The standard-of-care for muscle-invasive bladder cancer is radical surgery with neoadjuvant cisplatin-based chemotherapy. Despite curative intent from these interventions, relapse rates post-surgery remain high, with approximately 50% of patients developing local or distant recurrence within 2 years of surgery and a 5-year survival of only 50-60%. Identifying patients who are high risk for relapse post-surgery is a priority. Monitoring patients for circulating tumor DNA (ctDNA) is a minimally invasive approach that appears attractive for selecting patients potentially suitable for adjuvant treatment with checkpoint inhibitors. IMvigor011 (NCT04660344) is a global, double-blind, randomized phase III study assessing the efficacy of atezolizumab (anti-PD-L1) versus placebo in patients with high-risk muscle-invasive bladder cancer who are ctDNA positive post-cystectomy. The primary end point is disease-free survival in participants who are ctDNA positive within 20 weeks of cystectomy.

DNA alterations in papillary renal cancer

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Background: The characterisation of DNA alternations in papillary renal cancer (PRC) is unclear. The CALYPSO trial (NCT02819596) prospectively evaluated combination therapy of savolitinib (MET inhibitor) and durvalumab (PD-L1 inhibitor) in PRC. The trial showed high response rates (RR) in the MET-driven population. Here we explore the relationship between MET, PD-L1 and TMB in these tumours and the relevance of other biomarkers including PIK3CA, PTEN and KRAS. Methods: FoundationOne analysis from 41 samples of PRC patients enrolled on the CALYPSO trial was performed. The relevance of co-positivity between MET/PD-L1 and MET/TMB as well as analysis of other DNA alterations such as PIK3CA, PTEN and KRAS was explored. Outcome parameters were correlated with RR, PFS and OS. Results: 41% of patients were MET-driven, 66% were PD-L1+ (vCPS≥1) and 3% were TMB >10mut/Mb. Further testing used TMB ≥ median (2.52mut/Mb) 32% of patients were both MET-driven and PD-L1+. 17% of patients were both MET-driven and TMB ≥ median. RR and survival outcomes for combinations are shown in the table. The overall RR in MET driven and non-MET-driven patients was 52.9% and 13%, respectively. The median PFS and OS in the MET-driven group was 12.0 months (95% CI: 2.9-19.4) and 27.4 months (95% CI: 9.3-not reached [NR]), respectively, compared to a median PFS and OS in the non-MET-driven group of 2.7 months (95% CI: 0.5-5.0) and 7.5 months (95% CI: 0.0-16.0), respectively. PIK3CA, PTEN and KRAS mutations occurred in 1, 4 and 2 patients, with RR of 0% (0/1), 25% (1/4) and 50% (1/2), in the PIK3CA, PTEN and KRAS groups, respectively. Conclusions: MET-driven papillary cancers have low mutational burden, but high PD-L1 expression. Small patient numbers limit definitive conclusions, but responses occur irrespective of the immune biomarkers investigated. Other DNA alterations are rare and did not appear to influence outcomes in this cohort. These data support the design of the SAMETA trial (NCT05043090), further investigating the savolitinib and durvalumab combination. [Table: see text]

Real-world Practice Patterns and Safety of Concurrent Radiotherapy and Cabozantinib in Metastatic Renal Cell Carcinoma: Results from the International Metastatic Renal Cell Carcinoma Database Consortium

BACKGROUND

There is a paucity of data on the safety of cabozantinib use in combination with radiotherapy.

OBJECTIVE

To report the practice patterns, safety, and efficacy of cabozantinib with radiotherapy in metastatic renal cell carcinoma (mRCC).

DESIGN, SETTING, AND PARTICIPANTS

An international multicenter retrospective study was conducted. Patients with mRCC treated with cabozantinib at any line of therapy and who received radiotherapy between 30 d prior to the start date of cabozantinib and 30 d following discontinuation of cabozantinib, from 2014 to 2020, were included. Concurrent use was defined as the use of cabozantinib on radiotherapy treatment days during any course of radiotherapy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcomes of interest were the rate of grade ≥3 adverse events (AEs) occurring within 90 d of receipt of radiotherapy. Secondary outcomes included hospitalization rate and patterns of cabozantinib and radiotherapy use. Baseline characteristics and AEs were presented descriptively.

RESULTS AND LIMITATIONS

A total of 127 consecutive patients were included. Most patients had clear cell histology (88%), had International Metastatic Renal Cell Carcinoma Database Consortium intermediate-risk disease (57%), and had received at least one prior line of therapy (93%). Of 127 patients, 67 (53%) received concurrent cabozantinib with radiotherapy, while the remaining held cabozantinib on radiotherapy days. Overall, grade 3-4 AEs occurred in 6.3% (n = 8/127) of patients. No grade 5 events were observed. In patients treated with conventional palliative radiotherapy (n = 88), the rate of grade 3-4 AEs in those who had concurrent versus those who had nonconcurrent cabozantinib was 6.3% (n = 3/48) versus 5.0% (n = 2/40). No patient was hospitalized due to radiotherapy-related toxicity. In patients treated with stereotactic ablative body radiotherapy (SABR; n = 50), the rate of grade 3-4 AEs in those who had concurrent versus those who had nonconcurrent cabozantinib was 3.6% (n = 1/28) versus 9.1% (n = 2/22). One patient in the nonconcurrent group was hospitalized due to muscle weakness suspected to be related to associated vasogenic edema 19 d after SABR for multiple brain metastases.

CONCLUSIONS

In this real-world study of patients with mRCC treated with cabozantinib, 53% of patients received radiotherapy concurrently, with few grade 3-4 AEs reported within 90 d of receiving radiotherapy. The use of radiotherapy and cabozantinib requires a risk-benefit assessment of patient and disease characteristics to optimize therapy regimens.

PATIENT SUMMARY

Our study reports the real-world experience of using radiotherapy in patients receiving cabozantinib for metastatic kidney cancer. Over half of the patients continued taking cabozantinib while receiving radiotherapy, and few patients developed serious side effects. The combined use of radiotherapy and cabozantinib requires a careful risk-benefit assessment to achieve optimal treatment outcomes.

The effect of anti-cancer therapy on immunological response to COVID-19 vaccination

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Background: The efficacy of SARS-COV-2 vaccination has been demonstrated in healthy individuals. Immune responses are less well characterised in cancer patient groups, especially those receiving anticancer therapy (e.g. immune therapy, chemotherapy and targeted therapies. We aim to assess the immune response to the SARS-COV-2 vaccination in patients with solid organ cancer on different systemic anti-cancer therapies. Methods: All patients received 2 doses of COVID-19 mRNA vaccination as part of the UK National vaccination programme; with the second booster dose administered within 12 weeks of the first dose. All patients received either BNT162b2 (Pfizer/BioNTech) or ChAdOx1 S (AstraZeneca) vaccines. Sequential serum samples were collected pre-booster dose vaccination (baseline/within -30 days) and after second dose SARS-COV-2 vaccination, at 14-35 days and 36-63 days. Presence and titres of serum Anti-SARS-CoV-2 Spike protein (S) antibody titres were measured. Seroconversion is defined as a response ≥0.8 U/ml, and maximum response to Anti-S is defined as ≥250 U/ml. Responses were measured in 3 patient groups according to the type of anti-cancer therapy: chemotherapy (CHT group), immune therapy (IO group) and targeted therapies, mainly VEGF TKI (TT group). Results: Overall, 61 patients were recruited: 45.9%(28/61) in CHT group, 32.8% (20/61) in IO group and 21.3% (13/61) in the TT group. Baseline characteristics were comparable between patient groups. In response to the booster dose vaccination at 14-35 days, the number of patients who seroconverted was 79.3% (23/29), 94.7% (18/19) and 84.6% (11/13) in the CHT, IO and TT groups, respectively. At this same time point, 51.7% (15/29) in the CHT group achieved maximum anti-S titre levels (≥250 U/ml), compared with 78.9% (15/19) of patients in IO group and 69.2% (9/13) of patients in TT group. All 3 groups demonstrated a significant increase in Anti-S antibodies at 14-35 days after second dose vaccine when compared to pre-booster serum levels, with the largest increase seen in the IO group with a mean Anti-S increase of 149.1 U/ml (SD±105.0, p < 0.0001) followed by the TT group mean increase 120.2 U/ml (SD ±110.8, p < 0.01) and the CHT group, mean increase 83.0 U/ml (SD ±108.4, p < 0.001). Anti-S antibody levels were sustained at 36-63 days post-booster across all groups. However only IO patients had a sustained immune response to vaccination, with median Anti-S titres level of ≥250 U/ml and a significant drop was seen in the CHT group (median Anti-S level 138, p < 0.05). Conclusions: Anti-S titres increase following vaccination in all 3 groups but remain most sustained in the IO group at 36-63 days post-vaccination. Chemotherapy and other targeted therapy treated patients may benefit from early COVID-19 vaccine boosters, compared to patients receiving immune therapy.

Avelumab in locally advanced or metastatic urothelial carcinoma

INTRODUCTION

Outcomes for patients with advanced or metastatic urothelial carcinoma (UC) remain poor. Targeting the programmed death ligand 1 (PD-(L)1) immune checkpoint pathway has emerged as a useful target in patients with UC. Avelumab is a PD-L1 inhibitor, resulting in restoration of a cytotoxic, antitumour T cell response. Results from the JAVELIN bladder 100 trial has resulted in a new standard of care of platinum-based chemotherapy sequenced by maintenance avelumab in advanced or metastatic UC.

AREAS COVERED

This review covers the clinical evidence for avelumab in UC. This includes the maintenance approach with avelumab, which has become standard of care, following platinum-based chemotherapy.

EXPERT OPINION

Immune checkpoint inhibitor treatment in metastatic UC holds much promise, but has not been optimised. First line maintenance avelumab is an attractive option for these patients. Future research will significantly change the landscape of treatment in the near future.

Patient outcomes following disease progression with enfortumab-vedotin (EV) in metastatic urothelial carcinoma (mUC)

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Background: Enfortumab Vedotin (EV) is an antibody drug conjugate (ADC), licensed for use in metastatic urothelial carcinoma (mUC), following disease progression with platinum-based chemotherapy (ChT) and immune checkpoint inhibitors (ICIs). A patient cohort now exists with disease progression following EV with no guidance for subsequent treatment. This retrospective observational study assessed patient outcomes post EV progression. Methods: Patients were identified from 3 centres in Europe (St Bartholomew’s Hospital, University Hospital Virgen Del Rocio and Hospital Universitario 12 de Octubre). Data was collected regarding treatments prior to and post EV, length of EV treatment and overall survival (OS) post EV progression. Descriptive statistics and survival analyses comparing survival outcomes stratified by treatment post EV progression were performed in SPSS (Version 27). Results: All 24 patients had received both an ICI and ChT prior to receiving EV. 10 patients received further treatment following disease progression on EV. 8 patients received ChT (6 patients platinum based, 1 patient paclitaxel, 1 patient vinflunine), 1 patient received radical radiotherapy and 1 patient received derazantinib. No patient received further ICI therapy post EV progression. 2 patients had achieved complete radiological response with EV and had no evidence of disease progression. Point bi-serial correlation showed no significant association between length of EV treatment and receiving further treatment post disease progression on EV. There was also no significant association between pre EV survival length and further treatment post disease progression on EV. Survival analysis (Kaplain-Meier, Mantel-Cox Log Rank) revealed a statistically significant difference in mean OS. Mean OS was 1 month in patients who received no further treatment vs 7 months in patients who received treatment post progression on EV (Chi-Square 16.569, p = 0.000). Conclusions: Less than half of patients who progressed on EV received subsequent treatment. Patients who did receive treatment had significantly increased OS. There is a clear gap in literature and evidence-based guidance for treatment following EV progression and further studies are required with larger samples accounting for confounding factors to further evaluate best practise post disease progression on EV.

Immune Checkpoint Inhibitors in Front-line Therapy for Urothelial Cancer

Immune checkpoint inhibitors are the standard-of-care front-line treatment option for PD-L1-positive, cisplatin-ineligible metastatic urothelial carcinoma. The data supporting this are based on two single-arm trials. Randomised trials to confirm these findings and test new combinations have recently been performed. It was hoped that these trials would clarify some of the previous uncertainties. In this report we summarise the findings from these trials and perform a combined analysis. The results show that immune checkpoint inhibitor monotherapy is not superior to chemotherapy as things currently stand. The chemoimmunotherapy combination shows a probable efficacy signal, but this appears to be insufficient to change practice. PATIENT SUMMARY: In this report, we summarise the outcomes of three recent trials that investigated immunotherapy (IMT) on its own and combined with chemotherapy (CT) for patients with metastatic bladder cancer who had not previously received any treatment. We show that IMT on its own is not better than CT for these patients. There is a sign that combined CT and IMT probably has a benefit, but it does not seem to be large enough to justify a change in treatment recommendations.

Dynamic changes in full blood count (FBC) occurring in patients treated with immune checkpoint inhibitors (ICIs) to predict responses in patients with metastatic renal cell carcinoma (mRCC)

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Background: ICI transformed the treatment of 1L mRCC, yet early clinical predictors of response are still unknown. Methods: Retrospective database analysis from Barts Cancer Institute, London was carried out. Patients with treatment naïve mRCC were identified and grouped according to their 1L treatment: 1: VEGF inhibitor 2: IO/IO 3: IO/VEGF Data on hemoglobin, neutrophil-to-lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR) at baseline, 6weeks and 12weeks after treatment initiation was correlated with outcome. Results: Between Jan 2014 - Dec 2019; 28, 29 and 21 patients received 1L VEGF, IO/IO or IO/VEGF respectively. Patient receiving 1L VEGF inhibitors showed a decrease in Hb levels both in responding and non-responding groups (significant group effect: F(1,6) = 6.6, p = 0.04); significant time effect:F(2,12) = 12.4, p = 0.001). Group x time interaction was not significant. NLR levels decreased both in responding and non-responding groups over time (significant time effect: F(2,12) = 16.7, p = 0.001. PLR levels in non-responders increased over time, whereas in responding group, PLR levels steadily decreased over 6 and 12 weeks (significant time effect: F(2,12) = 0.3, 0.044). Patients receiving IO/IO combination therapy; within the non-responder group, Hb levels didn’t change significantly whereas in the responding group Hb levels increased significantly and overtook Hb levels of non-responding group (P = 0.001). NLR levels significantly decreased in the responding group (0.041) and a similar trend was observed at 12 weeks with a decrease in PLR among non-responders, with a significant group affect (F(1,5) = 0.18, 0.035). In patient treated with 1L IO/VEGF, among non-responders Hb levels increased slightly, only to return to baseline levels again at 12 weeks after treatment initiation. Whereas, Hb levels in the responding group increased significantly in both 6weeks and 12weeks after starting therapy. Significant time effect:F(2,20) = 3.65, p = 0.044. NLR levels in the responding group presented a steady decrease over time with a significant group and time effect. Both responders and non-responders experienced an increase in PLR over time. However, while PLR decreased at 12 weeks among responders, it continued to increase among non responders (significant time effect: F(2,20) = 0.3, 0.03), (significant group effect: F(1,10) = 0.05, 0.005) and significant interaction: F(2,20) = 0.1, 0.01) Conclusions: Close monitoring of FBC changes may predict response to ICI.

Cytoreductive nephrectomy in metastatic renal cell carcinoma: outcome of patients treated with a multidisciplinary, algorithm-driven approach

PURPOSE

Metastatic renal cell carcinoma (mRCC) represents a significant and rising burden of disease, with rapidly evolving treatment modalities. The role of cytoreductive nephrectomy (CN) is controversial in this setting. As such, London Cancer has pursued a multidisciplinary team (MDT) approach when assessing suitability for surgery.

METHODS

A retrospective analysis of treatment-naive synchronous mRCC patients, managed via a renal-specialist MDT, was conducted between January 2015 and December 2018. An MDT selection algorithm for CN-using the International Metastatic Renal Cell Carcinoma Database Consortium score (IMDC), performance status and metastatic disease burden-was developed.

RESULTS

87 treatment-naive synchronous mRCC patients received either CN (n = 18), Systemic therapy (ST) alone (n = 43) or Best supportive care (BSC) (n = 26). Progression free survival (PFS) and overall survival (OS) were assessed. 51% and 39% were IMDC intermediate and poor risk. Median PFS was 28.6 months and 4.5 months in the CN group and ST alone group, respectively, Hazard Ratio for death was 3.63 [(95% CI 1.68-7.83) p < 0.05]. OS remains immature for the CN group, but a median OS of 12.8 months was observed in the ST group and 5.0 months for BSC. 1-year OS rate for CN, ST and BSC groups was 77.8%, 55.8% and 23.10%, respectively.

CONCLUSION

These findings describe outcomes of an unselected series of patients treated via an MDT-driven, protocolised treatment pathway. MDT pathway-based decision making may improve patient selection for CN. Further research is needed to evaluate the role of CN amongst a growing landscape of treatment strategies, including immune checkpoint inhibitors and combination therapies. Multi-disciplinary team, pathway-based treatment strategy may improve patient selection for cytoreductive nephrectomy in patients with metastatic renal cell carcinoma.

Outcomes after first-line therapy for immune/immune or immune/VEGF combinations

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Background: The introduction of first line immune combination or immune/VEGF therapy in metastatic renal cancer has changed treatment landscape. Here we compare outcomes of these combinations with patients treated with first line sunitinib. The focus is on the impact of subsequent treatments. Methods: This retrospective analysis was performed at Barts Cancer Institute for consecutive patients from April 2015 when front line immune therapy was first used at our institution. Only patients enrolled on reported prospective trials were included to avoid selection bias. Patients were treated with VEGF targeted therapy (n=35) (group V), PD-1 + CTLA4 (n=15) (group I/I) or a combination of PD-L1 + VEGF TKI inhibitor (n=29) (group I/V). The primary analysis focused on the proportion of patients who received second line therapy and their outcome. Results: 79 patients received first line therapy for clear cell RCC. IMDC good, intermediate and poor risk occurred in 27.8%, 60.8% and 11.4% respectively. Front line response rates for V, I/I and I/V groups were 34.3%, 46.7% and 65.5% and PFS in V, I/I and I/V groups were 11mo (95%CI 6-16), 18mo (95% CI 0-41) and 36mo (95% CI 13-59), respectively (P= 0.016). OS in the 3 groups were immature but not significantly different. Second line therapy occurred in 87.5%, 92.9% and 81.8% in the V, I/I and I/V groups respectively (in those who progressed after initial therapy). Second line response rate post first line V, I/I and I/V were 11%, 0% and 0% respectively as per RECIST 1.1. 63% of patients receiving VEGF front line therapy subsequently received immune therapy. 95% of patients receiving first line immune/immune or immune/VEGF combination therapy received VEGF therapy in the second line. Only 70% of patients who progressed on second line therapy got 3rd line therapy across all arms. Conclusions: Response rates after front line immune combination therapy are modest. The sequencing of PD-1 therapy after VEGF monotherapy appears particularly relevant in outcomes. A high proportion of patients are sequencing therapy and reaching third line which may help improve outcomes.

Development and evaluation of dedicated low clearance transplant clinics for patients with failing kidney transplants

BACKGROUND

Recipients with failing kidney transplants (RFKTs) may receive sub-optimal care compared with patients with native kidney disease. The aim of this study is to compare the outcomes of RFKTs managed in a dedicated low clearance transplant clinic (LCTC) compared with those attending a general transplant clinic.

METHODS

We undertook a retrospective analysis of patients with failing kidney transplants comparing two clinics-a LCTC versus a general transplant clinic. Kidney transplant recipients with an eGFR < 20 ml/min were included. A cross-sectional analysis was undertaken of all patients with two consecutive follow-up visits between the dates of January and July 2016 in either clinic, with follow-up to event or December 2017.

RESULTS

Data were analysed for 141 kidney transplant recipients; 60 in the LCTC and 81 in the general transplant clinic. More patients in the LCTC cohort were non-white and early transplant recipients. A significantly greater proportion of LCTC versus general transplant patients had received documented discussions regarding their hepatitis vaccine status (63.3% vs. 17.3%, p < 0.001), counselled regarding dialysis modality (98.3% vs. 55.6%, p < 0.001) and had documented decision regarding re-transplantation (80.0% vs. 58.0%, p = 0.006). No difference was noted in the comparison of any clinical or biochemical parameters. More patients seen in the LCTC lost their kidney allograft (HR: 2.09, 95%CI: 1.17-3.72, p = 0.013) but patient survival was equivalent (p = 0.343).

CONCLUSION

Our data suggest the management of RFKTs within LCTCs can focus attention on renal replacement therapy planning and counselling, but further work is warranted to investigate for any benefit in hard outcomes such as survival.

Mortality risk after cancer diagnosis in kidney transplant recipients: the limitations of analyzing hospital administration data alone

Administrative data are frequently used for epidemiological studies but its usefulness to analyze cancer epidemiology after kidney transplantation is unclear. In this retrospective population-based cohort study, we identified every adult kidney-alone transplant performed in England (2003-2014) using administrative data from Hospital Episode Statistics. Results were compared to the hospitalized adult general population in England to calculate standardized incidence and mortality ratios. Data were analyzed for 19,883 kidney allograft recipients, with median follow-up 6.0 years' post-transplantation. Cancer incidence was more common after kidney transplantation compared to the general population in line with published literature (standardized incidence ratio 2.47, 95% CI: 2.34-2.61). In a Cox proportional hazards model, cancer development was associated with increasing age, recipients of deceased kidneys, frequent readmissions within 12 months post-transplant and first kidney recipients. All-cause mortality risk for kidney allograft recipients with new-onset cancer was significantly higher compared to those remaining cancer-free (42.0% vs. 10.3%, respectively). However, when comparing mortality risk for kidney allograft recipients to the general population after development of cancer, risk was lower for both cancer-related (standardized mortality ratio 0.75, 95% CI: 0.71-0.79) and noncancer-related mortality (standardized mortality ratio 0.90, 95% CI: 0.85-0.95), which contradicts reported literature. Although some plausible explanations are conceivable, our analysis likely reflects the limitations of administrative data for analyzing cancer data. Future studies require record linkage with dedicated cancer registries to acquire more robust and accurate data relating to cancer epidemiology after transplantation.

Pre-existing diabetes is a risk factor for increased rates of cellular rejection after kidney transplantation: an observational cohort study

AIM

To investigate whether people with diabetes have an elevated risk of kidney allograft rejection in a well characterized clinical cohort in the setting of contemporary immunosuppression.

METHODS

We conducted a retrospective cohort study including all kidney allograft recipients at a single centre between 2007 and 2015, linking clinical, biochemical and histopathological data from electronic patient records.

RESULTS

Data were analysed for 1140 kidney transplant recipients. The median follow-up was 4.4 years post-transplantation, and 117 of the kidney transplant recipients (10.2%) had diabetes at time of transplantation. Kidney allograft recipients with vs without diabetes were older (53 vs 45 years; P<0.001) and more likely to be non-white (41.0% vs 26.4%; P=0.001). Kidney allograft recipients with vs without diabetes had a higher risk of cellular rejection (19.7% vs 12.4%; P=0.024), but not of antibody-mediated rejection (3.4% vs 3.7%; P=0.564). Graft function and risk of death-censored graft loss were similar in the two groups, but kidney allograft recipients with diabetes had a higher risk of death and overall graft loss than those without diabetes. In a Cox regression model of non-modifiable risk factors at time of transplantation, diabetes was found to be an independent risk factor for cellular rejection (hazard ratio 1.445, 95% CI 1.023-1.945; P=0.042).

CONCLUSIONS

Kidney allograft recipients with diabetes at transplantation should be counselled regarding their increased risk of cellular rejection but reassured regarding the lack of any adverse impact on short-to-medium term allograft function or survival.

Do outcomes after kidney transplantation differ for black patients in England versus New York State? A comparative, population-cohort analysis

OBJECTIVES

Inferior outcomes for black kidney transplant recipients in the USA may not be generalisable elsewhere. In this population cohort analysis, we compared outcomes for black kidney transplant patients in England versus New York State.

DESIGN

Retrospective, comparative, population cohort study utilising administrative data registries.

SETTINGS AND PARTICIPANTS

English data were derived from Hospital Episode Statistics, while New York State data were derived from Statewide Planning and Research Cooperative System. All adults receiving their first kidney-alone allograft between 2003 and 2013 were eligible for inclusion.

MEASURES

The primary outcome measure was mortality post kidney transplantation (including inhospital death, 30-day mortality and 1-year mortality). Secondary outcome measures included postoperative admission length of stay, risk of rehospitalisation, development of cardiac events, stroke, cancer or fracture and finally transplant rejection/failure. Cox proportional hazards regression was used to investigate relationship between ethnicity, country and outcome.

RESULTS

Black patients comprised 6.5% of the English cohort (n=1215/18 493) and 23.0% of the New York State cohort (n=2660/11 602). Compared with New York State, black kidney transplant recipients in England were more likely younger, male, living-donor kidney recipients and had dissimilar medical comorbidities. Inpatient mortality was not statistically different, but death within 30 days, 1 year or kidney transplant rejection/failure was lower among black patients in England versus black patients in New York State. In adjusted regression analysis, with black ethnicity the reference group, white patients had reduced risk for 30-day mortality (OR 0.62 (95% CI 0.44 to 0.86)) and 1-year mortality (OR 0.79 (95% CI 0.63 to 0.99)) in New York State but no difference was observed in England. Compared with England, black kidney transplant patients in New York State had increased HR for kidney transplant rejection rejection/failure by median follow-up (HR 2.15, 95% CI 1.91 to 2.43).

CONCLUSIONS

Outcomes after kidney transplantation for black patients may not be translatable between countries.

Cancer-related outcomes in kidney allograft recipients in England versus New York State: a comparative population-cohort analysis between 2003 and 2013

It is unclear whether cancer‐related epidemiology after kidney transplantation is translatable between countries. In this population‐cohort study, we compared cancer incidence and all‐cause mortality after extracting data for every kidney‐alone transplant procedure performed in England and New York State (NYS) between 2003 and 2013. Data were analyzed for 18,493 and 11,602 adult recipients from England and NYS respectively, with median follow up 6.3 years and 5.5 years respectively (up to December 2014). English patients were more likely to have previous cancer at time of transplantation compared to NYS patients (5.6% vs. 3.5%, P < 0.001). Kidney allograft recipients in England versus NYS had increased cancer incidence (12.3% vs. 5.9%, P < 0.001) but lower all‐cause mortality during the immediate postoperative stay (0.7% vs. 1.0%, P = 0.011), after 30‐days (0.9% vs. 1.8%, P < 0.001) and after 1‐year post‐transplantation (3.0% vs. 5.1%, P < 0.001). However, mortality rates among patients developing post‐transplant cancer were equivalent between the two countries. During the first year of follow up, if patients had an admission with a cancer diagnosis, they were more likely to die in both England (Odds Ratio 4.28 [95% CI: 3.09–5.93], P < 0.001) and NYS (Odds Ratio 2.88 [95% CI: 1.70–4.89], P < 0.001). Kidney allograft recipients in NYS demonstrated higher hazard ratios for developing kidney transplant rejection/failure compared to England on Cox regression analysis. Our analysis demonstrates significant differences in cancer‐related epidemiology between kidney allograft recipients in England versus NYS, suggesting caution in translating post‐transplant cancer epidemiology between countries.