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Brief Report
February 6, 2019

Variation in Nonmelanoma Skin Cancer Incidence by Treatment Modality Among Patients Receiving Multiple Kidney Transplants

Author Affiliations
  • 1Department of Nephrology and Kidney Transplantation, Beaumont Hospital Dublin, Ireland
  • 2Royal College of Surgeons in Ireland, Dublin, Ireland
  • 3National Cancer Registry Ireland, Cork Airport Business Park, Cork, Ireland
  • 4National Lung Transplantation Center, Mater University Hospital, Dublin, Ireland
  • 5National Liver Transplant Center, St Vincent’s University Hospital, Dublin, Ireland
  • 6Department of Oncology, Beaumont Hospital, Dublin, Ireland
  • 7Department of Dermatology, Beaumont Hospital, Dublin, Ireland
  • 8Department of Dermatology, Mater Misericordiae University Hospital, University College Dublin, School of Medicine, Dublin, Ireland
  • 9Department of Otolaryngology–Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
JAMA Dermatol. 2019;155(5):594-598. doi:10.1001/jamadermatol.2018.4660
Key Points

Question  Is kidney transplant failure and return to dialysis treatment associated with risk of nonmelanoma skin cancer (NMSC) that is different from the risk of the general population?

Findings  This study of Irish national registry data suggests that periods of transplant allograft failure are associated with reduced risk of NMSC, and receipt of a subsequent transplant is associated with increased risk. However, the lower risk associated with the period of graft failure is still substantially higher than that of the general population.

Meaning  These findings may help physicians in counseling transplant recipients about the risks of skin cancer and also serve as a reminder that cancer surveillance should continue during periods of graft failure.

Abstract

Importance  Existing data suggest that nonmelanoma skin cancer (NMSC) is more common in renal transplant recipients than in maintenance dialysis patients. However, whether the risk of NMSC varies as the treatment modality for end-stage kidney disease (ESKD) changes between dialysis and transplantation is not well described.

Objective  To determine whether the incidence of NMSC is attenuated during periods of graft loss with a return to dialysis in those who receive multiple kidney transplants.

Design, Setting, and Participants  Retrospective analysis of data from recipients of kidney transplants from the Irish National Kidney Transplant Service database, linked with the Irish Cancer Registry, from 1994 to 2014. All analysis took place between January 10, 2018 and March 31, 2018. Standardized incidence ratios (SIRs) were calculated for NMSC incidence in comparison with the general population using Irish census data as the denominator. Incidence of NMSC was calculated with modality of treatment for ESKD varying over time; incidence rates and rate ratios associated with dialysis intervals were calculated using Poisson regression; and disease was defined according to International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes for cancer diagnosis.

Exposures  Kidney transplantation.

Main Outcomes and Measures  Incidence rates per 1000 patient-years and incident rate ratios of NMSC after kidney transplant.

Results  Data from the records of 3821 deceased or living donor kidney transplant recipients were assessed; 2399 (62.8%) male and 1422 (37.2%) female recipients; mean (SD) age at time of first data recorded, 41.9 (16.0) years. A total of 3433 recipients were included who had a functioning transplant on January 1, 1994, or received a transplant after that date up to December 31, 2014: 3215 received 1 transplant, 522 a second kidney transplant, and 84 had 3 or more kidney transplants. Periods of treatment with a functioning transplant were associated with a higher incidence of NMSC diagnosis than periods of graft failure: adjusted incidence rate ratio (aIRR), 2.19 (95% CI, 1.56-3.07), P < .001. The aIRRs of NMSC fell from 41.7 (95% CI, 39.38-44.15) per 1000 patient-years in the first transplant to 19.29 (95% CI, 13.41-27.76) in the dialysis period following the first allograft failure. Incidence similarly rose and fell following each subsequent consecutive transplant.

Conclusions and Relevance  In recipients of multiple kidney transplants, while the incidence of NMSC fell during periods defined by transplant failure, there was residual elevated risk. While ascertainment bias may have contributed to the observed trends, the stagnant incidence of invasive cancer overall highlights the need for continued cancer surveillance during graft failure.

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