Jagadeesh Puvvula Pharm D MPH Scott Campbell Phd MBA Apar Kishor Ganti MD MS Ketki Tendulkar MD VA Nebraska Western Iowa Health Care System and University Of Nebraska Medical Center INTRODUCTION ID: 913400
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Slide1
Incidence of Cancer in Chronic Kidney Disease
Jagadeesh Puvvula, Pharm D, MPH, Scott Campbell,
Phd
, MBA, Apar Kishor Ganti, MD, MS, Ketki Tendulkar, MD
VA Nebraska Western Iowa Health Care System and University Of Nebraska Medical Center
Slide2INTRODUCTION
Cancer leading cause of morbidity and mortality in the United States.
>15% of US adults are estimated to have Chronic Kidney disease (CKD).
Previous studies have shown an increased risk of certain cancers in dialysis patients.
Kidney dysfunction leads to retention of metabolic waste products and causes disruption of multiple pathways - to increase cancer risk.
Current evidence is less robust and not unanimous about the type and site-specific cancer incidence.
In an attempt to clarify literature variability, we undertook this analysis of the risk of cancer across ranges of renal insufficiency at our cancer center.
Slide3METHODS
Adult patients (> 18 years) with a diagnosis of CKD who received care at our institution from 2008 – 2018 from UNMC clinical data warehouse (CDW).
CDW - monthly data extracts from the enterprise EHR, de-identified and managed using international data standards (SNOMED CT, ICD-10-CM, LOINC and
RxNorm
); maintained in an i2b2 database (Informatics from Integrating Biology and the Bedside).
Crude and age-adjusted incidence rate - based on the CKD patients who were eventually diagnosed with a primary malignancy.
We extracted cancer incidence information from CDC Wonder Database, to compare US, Nebraska and Omaha-Council Bluffs region with our sample (CKD patients).
Population estimates for Omaha region extracted from US Census Bureau 2010 Decennial Census data to calculate the age-adjusted incidence for the
Slide4RESULTS
We identified 20,400 patients with CKD.
Of these, 813 developed an invasive malignancy.
The most common malignancies diagnosed were: digestive system (n=129), urinary tract (n=105), respiratory tract (n=96), melanoma and other invasive skin cancers (n=95) and hematologic malignancies (n=90).
Patients with CKD had a much higher incidence of cancer (3220/100,000 population) as compared to the general population in Nebraska (645/100,000 population).
Cancers that had the highest incidence as compared to the general population were hematologic malignancies (412.6 vs. 18.7/100,000), skin cancer (412.7 vs. 30.6/100,000) and urinary system (454.8 vs. 54.3/100,000).
Slide5Classification
Frequency
Percent
At risk
Crude
All cancer cases
813
20400
5269.61
Digestive system
129
14.84
20400
632.35
Urinary system
105
12.08
20400
514.71
Respiratory system
96
11.05
20400
470.59
Skin
95
10.93
20400
465.69
Leukemia
90
10.36
20400
441.18
Male genital system
87
10.01
11240
774.02
Breast
66
7.59
20400
323.53
Sarcoma, NOS
38
4.37
20400
186.27
Female genital system
30
3.45
9160
147.06
Oral cavity and Pharynx
18
2.07
20400
88.24
Neuroendocrine carcinoma, NOS
11
1.27
20400
53.92
Carcinoma in situ, NOS
10
1.15
20400
49.02
Endocrine system
10
1.15
20400
49.02
Other Genitourinary Cancers
9
1.04
20400
44.12
Bone and joint
4
0.46
20400
19.61
Brain and other nervous system
2
0.23
20400
9.80
Mesothelioma and soft tissue
2
0.23
20400
9.80
Slide6Standard Population
Age distribution -
standard population
Cohort population
Cancer
GI
Urinary
RespiratorySkin cancerLeukemiaAge 18 - 592400740.7838251082178.98245.52322.24214.83306.90306.9060 - 69331770.108324192578.8187.8577.5267.1862.0251.6870 - 79189470.061864933318.5257.6836.3742.6438.8733.8680+140890.0459996167143.9624.6118.6516.4114.9220.14Total3062871204003220.27415.67454.78341.06422.71412.58
Standard population estimates retrieved from US Census Bureau 2010 Decennial census for Omaha
Slide7Slide8DISCUSSION
Possible link between the chronic inflammatory microenvironment in CKD and cancer
Inflammatory pro-oxidant microenvironment in patients with reduced GFR, is thought to contribute to cancer development
CKD - immune dysfunction with alterations of the renin-angiotensin system, and endothelial abnormalities, may increase cancer risk
Commonly prescribed medications, such as anti-
hypertensives
and statins - associated with higher cancer risk.
Uremic milieu with accumulation of
indoxyl
sulfate, p-cresyl sulfate, or nitric oxide - state of impaired DNA repair, nutritional deficiency, and accumulation of carcinogens.The reason for the increased risk of cancer in patients with CKD needs to be studied further.
Slide9CONCLUSIONS
CKD patients have a significantly increased incidence of cancer. In our center-representative study we found a modestly higher cancer risk in individuals with CKD.
Detection bias and reverse causality may partly explain the higher risk of cancer during the first year of follow-up, but it is less likely to explain the higher risks in the long term.
Our findings may help healthcare policy makers develop appropriate guidelines for cancer screening and monitoring for patients with CKD
given recent advances
in cancer care.
Slide10REFERENCES
https://nccd.cdc.gov/ckd
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