Renal masses in end-stage renal disease patients on dialysis

말기 신부전증으로 투석을 받는 환자에서 발생한 신종괴의 임상적 특징

  • Lee, Mi-Jung (Department of Internal Medicine, Yonsei University College of Medicine) ;
  • Shin, Dong-Ho (Department of Internal Medicine, Yonsei University College of Medicine) ;
  • Kim, Hyun-Min (Department of Internal Medicine, Yonsei University College of Medicine) ;
  • Park, Hyun-Sung (Department of Internal Medicine, Yonsei University College of Medicine) ;
  • Park, Jung-Tak (Department of Internal Medicine, Yonsei University College of Medicine) ;
  • Chang, Tae-Ik (Department of Internal Medicine, Yonsei University College of Medicine) ;
  • Yoo, Tae-Hyun (Department of Internal Medicine, Yonsei University College of Medicine) ;
  • Kang, Shin-Wook (Department of Internal Medicine, Yonsei University College of Medicine) ;
  • Choi, Kyu-Hun (Department of Internal Medicine, Yonsei University College of Medicine)
  • 이미정 (연세대학교 의과대학 내과학교실, 신장내과) ;
  • 신동호 (연세대학교 의과대학 내과학교실, 신장내과) ;
  • 김현민 (연세대학교 의과대학 내과학교실, 신장내과) ;
  • 박현성 (연세대학교 의과대학 내과학교실, 신장내과) ;
  • 박정탁 (연세대학교 의과대학 내과학교실, 신장내과) ;
  • 장태익 (연세대학교 의과대학 내과학교실, 신장내과) ;
  • 유태현 (연세대학교 의과대학 내과학교실, 신장내과) ;
  • 강신욱 (연세대학교 의과대학 내과학교실, 신장내과) ;
  • 최규헌 (연세대학교 의과대학 내과학교실, 신장내과)
  • Received : 2010.06.18
  • Accepted : 2010.07.21
  • Published : 2010.09.01

Abstract

Background/Aims: End-stage renal disease (ESRD) patients are at a higher risk for cancer, especially renal cell carcinoma (RCC). Acquired cystic kidney disease (ACKD) and long duration of dialysis predict RCC in these patients. We explored the cilnical and pathologic characteristics of renal masses and the factors predicting malignant tumors. Methods: The study examined the medical records of 38 ESRD patients who underwent partial/total nephrectomy due to renal masses diagnosed by abdominal ultrasound and computed tomography at YUHS from January 1995 to December 2009. Results: Renal masses were recorded in 38 patients (21 males) with a mean age of $48.3{\pm}13.2$ years. Twenty patients (52.6%) were on hemodialysis and 18 patients (47.4%) were on peritoneal dialysis, for a mean period of $106.4{\pm}62.5$ months. ACKD was reported in 23 patients (67.6%). Of the 38 renal masses, 23 (60.5%) were diagnosed as malignant tumors and 15 (39.5%) were benign tumors. Clear cell RCC (n=16) and hematoma (n=6) was the predominant respective types. The patients with malignant tumors had a significantly longer duration of dialysis ($122.3{\pm}61.8$ vs. $81.1{\pm}56.7$ months, p<0.05) and a higher prevalence of ACKD (87.0 vs. 46.7%, p<0.01) compared to the patients with benign tumors. Conclusions: The most common renal mass in ESRD patients was RCC. Malignant tumors were significantly associated with a longer duration of dialysis and ACKD. Therefore, early evaluation and treatment of RCC are mandatory in long-term dialysis patients with ACKD.

목적: 말기 신부전증으로 혈액 투석이나 복막 투석을 받고 있는 환자에서 악성 종양, 특히 신세포암의 발생 빈도는 정상인에 비해 높은 것으로 알려져 있다. 그러나 국내의 말기 신부전증 환자를 대상으로 한 신세포암의 임상적 특성에 관한 연구는 미미한 실정이며, 신세포암 이외의 양성 신종괴에 대한 연구는 보고된 바가 없다. 이에 본 연구에서는 말기 신부전증으로 투석을 받고 있는 환자에서 발생한 신종괴의 임상적 특성을 규명하고자 하였다. 방법: 1995년 1월부터 2009년 12월까지 연세대학교 의과대학 세브란스 병원에서 말기 신부전증으로 투석을 받고 있는 환자에서 복부 초음파 또는 복부 전산화단층촬영을 통해 신종괴가 발견되어 전 혹은 부분 신적출술을 시행 받은 186명 중, 투석전에 신종괴가 발견되었거나 신장 이식을 받은 환자를 제외한 총 38명의 환자를 대상으로 임상적 특성과 신종괴의 조직학 소견을 후향적으로 분석하였다. 결과: 대상 환자의 평균 연령은 $48.3{\pm}13.2$세였고, 남자가 21명, 여자가 17명이었다. 원인 신질환으로는 만성 사구체 신염과 고혈압이 각각 13명(34.2%)으로 가장 흔했고, 역류성 신질환이 5명(13.2%), 상염색체 우성 다낭신이 4명(10.5%)이었다. 혈액 투석 환자가 20명(52.6%), 복막 투석 환자가 18명(47.4%)이었고, 평균 투석 기간은 $106.4{\pm}62.5$개월이었다. 신종괴는 대부분(36예, 91.3%) 한쪽 신장에 국한되어 있었으나, 2예(8.7%)에서는 양쪽 신장 모두에서 발견되었다. 28예(73.7%)는 단일 병변이었으나, 다수의 병변도 8예(26.3%)에서 관찰되었다. 종괴의 크기는 평균 $3.4{\pm}2.3$ cm였다. 상 염색체 우성 다낭신을 제외하고도 23예(67.6%)의 환자에서 다수의 후천성 낭종이 관찰되었다. 종괴의 조직학적 검사상 23예(60.5%)에서 악성 종양이 관찰되었는데, 이 중 21예(91.3%)는 신세포암이었고, 조직학적 형태는 투명 세포형이 16예(76.2%)로 가장 흔하였고, 유두상형이 3예(14.3%), 그리고 투명 세포형과 유두상형이 혼합된 경우와 다방 낭성형이 각각 1예(4.7%)였다. 반면, 15예(39.5%)에서는 양성 종양이 확인되었는데, 혈종이 6예(40.0%), 농양이 2예(26.7%), 혈관 근육 지방종과 전암 병변이 각각 2예(13.3%)였고, 합병낭종이 1예(6.7%) 관찰되었다. 악성 종양과 양성 종양 두 군으로 나누어 임상적 특성 및 조직소견을 비교한 결과, 악성 종양군에서 유의하게 투석기간($122.3{\pm}61.8$개월: $81.1{\pm}56.7$개월, p<0.05)이 길었고, 후천성 신낭종(87.0%: 46.7%, p<0.01)을 동반한 경우가 의미있게 많았다. 결론: 말기 신부전증으로 투석을 받고 있는 환자에서 신적출술로 확인된 신종괴의 대부분은 신세포암이었으며, 양성 종양에 비해 긴 투석 기간과 후천성 신낭종의 동반과 연관되어 있었다.

Keywords

References

  1. Penn I. Occurrence of cancers in immunosuppressed organ transplant recipients. Clin Transpl 99-109, 1994
  2. Matas AJ, Simmons RL, Kjellstrand CM, Buselmeier TJ, Najarian JS. Increased incidence of malignancy during chronic renal failure. Lancet 1:883-886, 1975
  3. Bush A, Gabriel R. Cancer and patients with end-stage renal failure. Br Med J (Clin Res ed) 284:667, 1982
  4. Stewart JH, Buccianti G, Agodoa L, Gellert R, McCredie MR, Lowenfels AB, Disney AP, Wolfe RA, Boyle P, Maisonneuve P. Cancers of the kidney and urinary tract in patients on dialysis for end-stage renal disease: analysis of data from the United States, Europe, and Australia and New Zealand. J Am Soc Nephrol 14:197-207, 2003 https://doi.org/10.1097/01.ASN.0000039608.81046.81
  5. Cuckovic C, Djukanovic L, Jankovic S, Stanojcic A, Dragicevic P, Radmilovic A, Lambic L, Stojanovic M, Milic M, Bakovic J, Radovic M, Labudovic M. Malignant tumors in hemodialysis patients. Nephron 73:710-712, 1996 https://doi.org/10.1159/000189167
  6. Lee JE, Han SH, Cho BC, Park JT, Yoo TH, Kim BS, Park HC, Kang SW, Lee HY, Han DS, Ha SK, Choi KH. Cancer in patients on chronic dialysis in Korea. J Korean Med Sci 24(Suppl 3):S95-S101, 2009
  7. Schollmeyer P, Bozkurt F. The immune status of the uremic patient: hemodialysis vs CAPD. Clin Nephrol 30(Suppl 1):S37-S40, 1988
  8. Bonomini M, Forster S, De Risio F, Rychly J, Nebe B, Manfrini V, Klinkmann H, Albertazzi A. Effects of selenium supplementation on immune parameters in chronic uraemic patients on haemodialysis. Nephrol Dial Transplant 10:1654-1661, 1995
  9. Fabrizi F, Marcelli D, Bacchini G, Guarnori I, Erba G, Locatelli F. Antibodies to hepatitis C virus (HCV) in chronic renal failure (CRF) patients on conservative therapy: prevalence, risk factors and relationship to liver disease. Nephrol Dial Transplant 9:780-784, 1994
  10. Yanagisawa H, Manabe S, Kanai Y, Wada O. Carcinogenic glutamic acid pyrolysis product in the dialysate of uremic patients treated by continuous ambulatory peritoneal dialysis. Clin Nephrol 30:73-78, 1988
  11. Akizawa T, Kinugasa E, Koshikawa S. Increased risk of malignancy and blood-membrane interactions in uraemic patients. Nephrol Dial Transplant 9(Suppl 2):S162-S164, 1994
  12. Gehrig JR, Gottheiner TI, Swenson RS. Acquired cystic disease of the end-stage kidney. Am J Med 79:609-620, 1985 https://doi.org/10.1016/0002-9343(85)90059-2
  13. Kim YO, Han CH, Shin OR, Yoon JM, Shin SJ, Chang YK, Yoon SA, Yang CW, Jin DC, Kim YS, Chang YS, Bang BK. Clinical characteristics of renal cell carcinoma in dialysis patients. Korean J Nephrol 22:559-564, 2003
  14. Park YH, Chang KS, Yoon JY, Hwang TK, Kim JC. Three cases of renal cell carcinomas in dialyzed patients. Korean J Urol 39:278-282, 1998
  15. Moch H, Artibani W, Delahunt B, Ficarra V, Knuechel R, Montorsi F, Patard JJ, Stief CG, Sulser T, Wild PJ. Reassessing the current UICC/AJCC TNM staging for renal cell carcinoma. Eur Urol 56:636-643, 2009 https://doi.org/10.1016/j.eururo.2009.06.036
  16. Satoh S, Tsuchiya N, Habuchi T, Ishiyama T, Seimo K, Kato T. Renal cell and transitional cell carcinoma in a Japanese population undergoing maintenance dialysis. J urol 174:1749-1753, 2005 https://doi.org/10.1097/01.ju.0000177489.98031.54
  17. Dunnill MS, Millard PR, Oliver D. Acquired cystic disease of the kidneys: a hazard of long-term intermittent maintenance haemodialysis. J Clin Pathol 30:868-877, 1977 https://doi.org/10.1136/jcp.30.9.868
  18. Matson MA, Cohen EP. Acquired cystic kidney disease: occurrence, prevalence, and renal cancers. Medicine (Baltimore) 69:217-226, 1990
  19. Herrera GA. C-erb B-2 amplification in cystic renal disease. Kidney Int 40:509-513, 1991 https://doi.org/10.1038/ki.1991.239
  20. Sule N, Yakupoglu U, Shen SS, Krishnan B, Yang G, Lerner S, Sheikh-Hamad D, Truong LD. Calcium oxalate deposition in renal cell carcinoma associated with acquired cystic kidney disease: a comprehensive study. Am J Surg Pathol 29:443-451, 2005 https://doi.org/10.1097/01.pas.0000152131.58492.97
  21. Oya M, Mikami S, Mizuno R, Marumo K, Mukai M, Murai M. C-jun activation in acquired cystic kidney disease and renal cell carcinoma. J Urol 174:726, 2005 https://doi.org/10.1097/01.ju.0000164656.99251.77
  22. Tickoo SK, dePeralta-Venturina MN, Harik LR, Worcester HD, Salama ME, Young AN, Moch H, Amin MB. Spectrum of epithelial neoplasms in end-stage renal disease: an experience from 66 tumor-bearing kidneys with emphasis on histologic patterns distinct from those in sporadic adult renal neoplasia. Am J Surg Pathol 30:141-153, 2006 https://doi.org/10.1097/01.pas.0000185382.80844.b1
  23. Antopol W, Goldman L. Subepithelial hemorrhage of renal pelvis simulating neoplasm. Urol Cutaneous Rev 52:189-195, 1948
  24. Eccher A, Brunelli M, Gobbo S, Ghimenton C, Grosso G, Iannucci A, Dalla Palma P, Menestrina F, Martignoni G. Subepithelial pelvic hematoma (Antopol-Goldman lesion) simulating renal neoplasm: report of a case and review of the literature. Int J Surg Pathol 17:264-267, 2009 https://doi.org/10.1177/1066896908330482
  25. Murphy AM, Buck AM, Benson MC, McKiernan JM. Increasing detection rate of benign renal tumors: evaluation of factors predicting for benign tumor histologic features during past two decades. Urology 73:1293-1297, 2009 https://doi.org/10.1016/j.urology.2008.12.072
  26. Snyder ME, Bach A, Kattan MW, Raj GV, Reuter VE, Russo P. Incidence of benign lesions for clinically localized renal masses smaller than 7 cm in radiological diameter: influence of sex. J Urol 176:2391-2395, 2006 https://doi.org/10.1016/j.juro.2006.08.013
  27. Pierorazio PM, Murphy AM, Benson MC, McKiernan JM. Gender discrepancies in the diagnosis of renal cortical tumors. World J Urol 25:81-85, 2007 https://doi.org/10.1007/s00345-006-0124-9