Nephrology, Dialysis and Renal Transplantation Unit, Ospedali Riuniti, Ancona, Italy.
, Bologna, Italy.
J Nephrol. 2019 Feb;32(1):57-64. doi: 10.1007/s40620-018-0542-y. Epub 2018 Oct 16.
Due to the increasing occurrence of renal cell carcinoma (RCC) in the general population and the high prevalence of chronic kidney disease among cancer patients, many people with a previous RCC may eventually require renal replacement therapy including kidney transplantation. They should accordingly be evaluated to assess their life expectancy and the risk that the chronic immunosuppressive therapy needed after grafting might impair their long-term outcome. Current guidelines on listing patients for renal transplantation suggest that no delay is required for subjects with small or incidentally discovered RCC, while the recommendations for patients who have been treated for a symptomatic RCC or for those with large or invasive tumours are conflicting. The controversial results reported by even recent studies focusing on the cancer risk in kidney graft recipients with a prior history of malignancy do not help to clarify the doubts arising in everyday clinical practice. Several tools, including integrated scoring systems, are currently available to assess the prognosis of patients with a previous RCC and, although they have not been validated in subjects receiving long-term immunosuppressive drugs, they can be used to identify patients suitable to be listed for grafting. Among these, the Leibovich score is currently the most widely used as it has proved simple and reliable enough and helps categorize renal transplant candidates. According to this system, subjects with a score from 0 to 2 are at low risk and may be listed without delay, while those with a score of 6 or higher should be excluded from grafting. In addition, other factors have an established positive prognostic value, including chromophobe or clear cell papillary tumour, or G1 grade cancer; on the contrary, medullary or Bellini's duct carcinoma or those with sarcomatoid dedifferentiation at histological examination should be excluded. All other patients would be better submitted to careful individual evaluation by an Oncologist before being listed for renal transplantation, pending studies specifically focusing on cancer risk evaluation in people already treated for malignancy receiving long-term immunosuppressive therapy.
由于普通人群中肾细胞癌 (RCC) 的发病率不断增加，以及癌症患者中慢性肾脏病的高发率，许多以前患有 RCC 的人最终可能需要包括肾移植在内的肾脏替代治疗。因此，应该对他们进行评估，以评估他们的预期寿命以及移植后所需的慢性免疫抑制治疗可能对其长期预后造成的影响。目前关于将患者列入肾移植名单的指南表明，对于偶然发现或小的 RCC 患者无需等待，而对于已接受症状性 RCC 治疗或有大或侵袭性肿瘤的患者的建议则存在争议。即使是最近关注有恶性肿瘤既往史的肾移植受者的癌症风险的研究也报告了有争议的结果，这无助于澄清日常临床实践中出现的疑问。目前有几种工具，包括综合评分系统，可用于评估有既往 RCC 病史患者的预后，尽管它们尚未在接受长期免疫抑制药物治疗的患者中得到验证，但可用于识别适合列入移植名单的患者。其中， Leibovich 评分目前应用最广泛，因为它简单可靠，有助于对肾移植候选者进行分类。根据该系统，评分在 0 到 2 之间的患者风险较低，可以立即列入名单，而评分在 6 或更高的患者应排除在移植之外。此外，其他因素具有明确的预后价值，包括嫌色细胞或透明细胞乳头状肿瘤或 G1 级癌症；相反，组织学检查显示有髓质或 Bellini 导管癌或肉瘤样去分化的患者应排除在外。所有其他患者最好在由肿瘤学家进行仔细的个体评估后再列入肾移植名单，等待专门针对已接受恶性肿瘤治疗并接受长期免疫抑制治疗的人群进行癌症风险评估的研究。
