1230 CLINICAL REPORT
ActaDV ActaDV Advances in dermatology and venereology Acta Dermato-Venereologica
Risk of Non-melanoma Skin Cancer in Patients with Chronic Kidney Disease and its Relationship to Uraemic Pruritus
Chia-Chen WANG 1, 2, Chao-Hsiun TANG 3, Siao-Yuan HUANG 3, Kuan-Chih HUANG 3 and Yuh-Mou SUE 4, 5
1
Departments of Dermatology and Medical Research, Cardinal Tien Hospital, New Taipei City, 2 School of Medicine, Fu-Jen Catholic University, New Taipei City, 3 School of Health Care Administration, College of Management, Taipei Medical University, 4 Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, and 5 Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
This study investigated the risk of non-melanoma skin cancer( NMSC) in pre-dialysis patients with chronic kidney disease( CKD) and explored associated risk factors. A population-based cohort of 1,515,858 Taiwanese CKD patients was included. The standardized incidence ratio( SIR) for incident NMSC was determined. Compared with the general population, a 1.14- fold risk of NMSC was found in the CKD cohort. NMSC risk was significant in patients with pre-dialysis stage 5 CKD and anaemia( 1.48-fold), and in those with uraemic pruritus after long-term antihistamine treatment( 1.38-fold). A higher SIR for NMSC was found in younger patients with CKD( age < 70 years, 1.34-fold; age 20 – 39 years, 1.63-fold), stage 5 CKD with anaemia( age < 70 years, 2.09-fold), and uraemic pruritus( age < 70 years, 2.22-fold). Pre-dialysis patients with CKD are at higher risk of NMSC, especially those with advanced-stage CKD, and those with uraemic pruritus.
Key words: non-melanoma skin cancer; chronic kidney disease; uraemic pruritus; epidemiology.
Accepted Aug 9, 2017; Epub ahead of print Aug 10, 2017 Acta Derm Venereol 2017; 97: 1230 – 1234.
Corr: Yuh-Mou Sue, Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, 5 th Floor, No. 111, Section 3, Xing Long Road, Taipei 116, Taiwan. E-mail: sueym @ tmu. edu. tw
Chronic kidney disease( CKD) is classified into 5 stages, mainly in accordance with measured or estimated glomerular filtration rate( GFR). Stage 5 CKD is defined as GFR < 15 ml / min / 1.73 m 2. Owing to decreased erythropoietin synthesis, patients with stage 5 CKD are usually anaemic, and typically eventually require renal replacement therapy( 1). Pre-dialysis patients with CKD have demonstrated a higher incidence of kidney and urinary tract cancer than the general population( 2 – 4), with the hazard ratios( HR) being maximum at the stage of needing chronic dialysis( 5, 6). Jensen et al.( 7) reported that the standardized incidence ratio( SIR) for squamous cell carcinoma was 4.8 among Denmark CKD patients, but was not elevated for basal cell carcinoma and melanoma; however, the study participants were confined to those aged < 70 years who were hospitalized for CKD. The risk of skin cancer in the total cohort of CKD patients remains unclear.
Our previous study showed that chronic haemodialysis( HD) patients are at 1.58-fold higher risk of developing non-melanoma skin cancer( NMSC) compared with the general population( 8), and that this risk is presumably related to chronic inflammation of uraemia. Uraemic pruritus( UP) is a manifestation of chronic systemic inflammation( 9, 10) and its prevalence is approximately 42 % in HD patients( 11). The prevalence rate of UP in pre-dialysis CKD patients is positively associated with the progression of CKD( 18 % and 42 % in stages 3 and 5 CKD, respectively)( 12). HD patients with UP are at a 1.53-fold higher risk of NMSC compared with those without UP( 8). In pre-dialysis CKD patients, the association between UP and NMSC has not been investigated.
Taiwan has the highest incidence and prevalence of CKD in the world( 13). In 1995, the government of Taiwan established the National Health Insurance( NHI) programme, which includes 99 % of Taiwanese residents. Using the National Health Insurance Research Database( NHIRD), we conducted a population-based study to investigate the risk and possible risk factors of NMSC in pre-dialysis patients with CKD.
MATERIALS AND METHODS Data source and study participants
In this study, we obtained data recorded between 1999 and 2013 from the NHIRD, which contains healthcare data for 99 % of the entire population of Taiwan( 23.74 million people). All data are delinked information. We used the International Classification of Diseases, 9 th revision, clinical modification( ICD-9-CM) for diagnostic codes. This study was conducted with prior approval from the Ethics Committee and Human Subjects Institutional Review Board of Cardinal Tien Hospital.
We identified a CKD cohort comprised of patients newly diagnosed with CKD( who presented with at least one inpatient discharge diagnosis or 3 outpatient diagnoses codes of the following: ICD-9-CM 250.4, 274.1, 283.11, 403, 404, 440.1, 442.1, 447.3, 572.4, and 580 – 588( which includes diabetes nephropathy, gouty nephropathy, hypertensive nephropathy, atherosclerosis / aneurysm / hyperplasia of renal artery, haemolytic uraemic syndrome, hepatorenal syndrome, nephrotic syndrome, glomerulonephritis and other nephritis, renal failure and renal sclerosis)( 14) and had not commenced yet dialysis or renal transplantation), from 1 January 2000 to 31 December 2007( enrolment period). Patients who had missing data, those aged < 20 years, those who had NMSC within 12 months before CKD diagnosis, and those who were followed up for less than 3 months were excluded from this study. The CKD index date was defined as the first date of CKD diagnosis. doi: 10.2340 / 00015555-2762 Acta Derm Venereol 2017; 97: 1230 – 1234
This is an open access article under the CC BY-NC license. www. medicaljournals. se / acta Journal Compilation © 2017 Acta Dermato-Venereologica.