Kidney failure related to urinary tract cancer and nephrotoxic cancer treatments is on the rise, and although mortality does not appear to be increased among patients without active malignancy at the start of dialysis, their access to kidney transplantation is limited, investigators concluded.

The mean age- and sex-adjusted incidence, per 1 million inhabitants, of urinary tract cancer-related and nephrotoxin-related kidney failure was 1.80 and 0.43, respectively, Nadia Haddy, MD, of the French Institute of Health and Medical Research (Inserm), and collaborators reported in the Clinical Journal of the American Society of Nephrology. The incidence increased significantly by 2% and 5% annually, respectively, during 2006 to 2015, which is higher than the 0.8% estimated kidney failure rate from other causes. Improved cancer survival in France in recent years is a likely contributor, according to the investigators.

Among patients with nephrotoxin-related kidney failure, those with and without active malignancy had significant 4.2 times and 1.4 times increased mortality risk, respectively, compared with matched controls after adjusting for age, sex, and comorbidities. Among patients with urinary tract cancer-related kidney failure, those with and without active malignancy had 2.0 times and 1.1 times increased mortality risk, respectively.

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In addition, among patients with nephrotoxin-related kidney failure, those with and without active malignancy had a significant 81% and 38% reduced likelihood of being placed on a kidney transplant waiting list, respectively. Patients with urinary tract cancer-related kidney failure had significant 72% and 53% decreased likelihood of being waitlisted, respectively. Once on the waiting listing, however, access to transplantation did not differ significantly between cases and controls.

Dr Haddy’s team conducted the study using data from the French Renal Epidemiology and Information Network registry. The study included 287 patients with kidney failure due to chemotherapy or radiation treatment and 1157 who had kidney failure due to a urinary tract cancer such as renal cell carcinoma, bladder cancer, or upper tract urothelial carcinoma. The investigators matched cases to 11,678 controls without active malignancy who had other kidney failure causes (2 to 10 controls per case).

Several factors may partly explain limited transplant access for patients with cancer-related kidney failure, the investigators explained. Pelvic radiation can cause tissue injury that leads to radiation‐induced atherosclerosis, atrophy, tissue ischemia, and fibrosis, conditions that would contraindicate transplantation. Tissue impairment from surgery also can preclude transplantation. For patients with cancer remission, the optimal waiting time before transplantation is uncertain.

“Close collaboration between nephrologists and oncologists is needed to improve decision-making about kidney transplantation in this rapidly growing patient population to further improve their quality of life and outcomes,” Dr Haddy’s team stated.

“Perhaps the most important finding of this study was the delay to transplant waitlisting in patients with a history of malignancy but without cancer at the initiation of dialysis,” Ankur Shah, MD, and Susie L. Huh, MD, of Warren Alpert Medical School of Brown University in Providence, Rhode Island, commented in an accompanying editorial. “Although several possible reasons for this include pelvic surgeries and radiation, distant organ damage, and concerns over immunosuppression impairing host response to malignant cells, the potential benefits to transplantation for this specific population should be considered.”

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Mansouri I, Alencar de Pinho N, Snanoudj R, et al. Trends and outcomes with kidney failure from antineoplastic treatments and urinary tract cancer in France [published online March 6, 2020]. Clin J Am Soc Nephrol. doi: 10.2215/CJN.10230819

Shah A, Hu SL. Kidney failure with urinary tract cancers [published online March 6, 2020]. Clin J Am Soc Nephrol. doi: 10.2215/CJN.01850220