Should screening for renal cell carcinoma in patients with end-stage renal disease (ESRD) be reserved for those with specific risk factors?

Screening for Renal Cell Carcinoma in End-Stage Renal Disease Patients

Screening for renal cell carcinoma in patients with end-stage renal disease should be reserved for patients who have been on long-term dialysis (>10 years), those with acquired renal cystic disease, and those who have had kidney transplantation. 1

Risk Factors for RCC in ESRD Patients

End-stage renal disease significantly increases the risk of developing renal cell carcinoma compared to the general population:

• Patients with ESRD have a 4.5-times increased risk for RCC compared to matched controls 2
• The risk increases with duration of ESRD, with patients having ESRD for >9 years showing a 10.2-fold increased risk 2
• ESRD patients commonly develop acquired cystic kidney disease (ACKD), which further increases RCC risk 3
• Kidney transplant recipients have an elevated risk of RCC development 1
• Long-term hemodialysis (>10 years) is particularly associated with acquired cystic disease-associated RCC 3

Unique Characteristics of RCC in ESRD Patients

RCC in ESRD patients differs from RCC in the general population in several important ways:

• Tumors tend to be smaller in size at diagnosis 2, 4
• Lower tumor stage at presentation (more likely to be confined to the kidney) 2, 4
• Different histological pattern with higher incidence of papillary and chromophobe RCC subtypes 2
• Acquired cystic disease-associated RCC occurs almost exclusively in patients on hemodialysis 3
• Clear cell papillary renal cell carcinoma is also common in ESRD patients 3, 4

Screening Recommendations

Based on the evidence, targeted screening should be implemented for:

• Patients on long-term dialysis, especially those exceeding 10 years 3, 2
• Patients with acquired cystic kidney disease 3, 4
• Kidney transplant recipients 1
• Patients with tuberous sclerosis syndrome 1

Screening Modalities

• Ultrasonography is the initial imaging modality of choice for screening 1
• CT scan with contrast (if not contraindicated) should be used for further investigation of suspicious findings 1
• MRI may provide additional information when intravenous contrast cannot be used 1

Clinical Outcomes

Despite having more favorable tumor characteristics at diagnosis, ESRD patients with RCC require careful monitoring:

• 5-year overall survival is lower in ESRD-RCC patients (50%) compared to RCC-only patients (63%) 2
• Most RCCs in ESRD patients have an indolent clinical course, except those with sarcomatoid components 3
• Long-term hemodialysis may worsen prognosis regardless of histological subtype 3

Important Considerations

• Younger age at diagnosis should raise suspicion for hereditary RCC syndromes 1
• The median age of diagnosis for hereditary RCC is 37 years, compared to 64 years for sporadic cases 1
• Genetic testing should be considered for patients with bilateral or multifocal disease 5
• Regular surveillance is essential as ESRD patients have ongoing risk for developing RCC 1, 2

By focusing screening efforts on these high-risk ESRD patients, clinicians can detect RCC at earlier stages when treatment outcomes are more favorable, while avoiding unnecessary imaging in lower-risk individuals.