PRE-TRANSPLANT immunosuppression in the treatment of glomerulonephritis may increase the risk of developing a malignancy post-kidney transplantation, according to new data. Treatment prior to transplant is an often overlooked but important contributor to immunosuppressive burden in patients receiving a kidney transplant, said author David Massicotte-Azarniouch, University of North Carolina at Chapel Hill, USA. A variety of immunosuppressant agents, as well as a combination of these agents and long-lasting treatment with these agents, including corticosteroids, cytotoxic therapies, calcineurin inhibitors, anti-CD20 therapy, and anti-proliferative antimetabolites, are given to patients with glomerulonephritis.
The retrospective study included recipients of kidney transplants attending the team’s centre from 2005 to May 2020. Out of the participants, 579 patients had non-diabetic end-stage kidney disease without exposure to immunosuppressants pre-transplant, and 184 patients had glomerulonephritis that was treated with pre-transplant immunosuppression. Of those having received pre-transplant immunosuppression, 16.9% had received rituximab, 44.0% cyclophosphamide, 9.8% azathioprine, 45.1% mycophenolate mofetil, 92.4% high-dose prednisone, and 32.6% calcineurin inhibitor. Median follow-up was of 5.7 years, during which a larger proportion of patients with pre-transplant immunosuppression experienced a first hematologic or solid malignancy, compared to those not having received immunosuppression (13.0% versus 9.7%).
The overall risk for malignancy was increased 1.8-fold with pre-transplant immunosuppression, while the use of pre-transplant cyclophosphamide and rituximab led to a 2.6- and 3.8-fold increase for malignancy, respectively. The risk of malignancy was not increased in patients having used mycophenolate mofetil or calcineurin inhibitors. Interestingly, the risks of post-transplant lymphoproliferative disorder and non-melanoma skin cancer was not increased in patients who received pre-transplant immunosuppression.
The team concluded: “Patients with significant receipt of any type of immunosuppression pre-transplant should also be counselled on the importance of post-transplant monitoring for malignancy,” and clinicians need to stay mindful of the risks when prescribing immunosuppression in patients with long-standing impaired kidney function or marked chronicity and fibrosis.