Dissertations / Theses on the topic 'Kidney Cancer'

Introduction Chronic kidney disease (CKD) is a common and important public health problem, with significant impact on the person’s quality of life and chances of survival. Cardiovascular disease is major cause of morbidity and mortality among people with CKD. Cancer is also a well-recognised complication in people on dialysis and with kidney transplants, but has not been adequately assessed in people with mild to moderately reduced kidney function. It is uncertain whether the basis of such increased risk in the end-stage kidney and transplant populations is solely related to their immunocompromised health states, or there are plausible biological reasons to explain the association beyond current knowledge. Screening, which allows early detection and subsequent treatment, is effective in reducing cancer-related deaths for common cancer such as breast, colorectal and cervical cancers in the general population. Given the inherent differences in the overall cancer risk and life expectancy among people with CKD, it is plausible that the effects, costs, and harms of routine population cancer screening may be different to the general population. This thesis is presented as published work on the theme of cancer and chronic kidney disease. The first chapter summarises the existing epidemiological evidence of association between cancer and kidney transplantation. The second chapter, uses data from the Blue Mountain Eyes Study cohort and linkage with the New South Wales Central Cancer Registry, explores the hypothesis of increased cancer risk in people with mild to moderately reduced kidney function. The work presented in the last five chapters of this thesis have extrapolated, critically appraised, and synthesized the available evidence for cancer screening in the general, end-stage kidney disease and kidney transplant populations.

Cancer impacts people with kidney failure in multiple ways, however, we still do not fully understand the epidemiology of cancer mortality, feasibility of cancer screening and probability of cancer transmission in organ donation and transplant. This thesis aims to understand the impact of cancer on outcomes for people with kidney failure, utilising existing clinical and health administrative datasets in novel ways. Where existing data is unavailable, it generates new information. Methods: Chapters 2 and 3 estimate cancer mortality in people on dialysis and kidney transplant recipients, compared to the general population, in a bi-national data-linkage study, 1980-2013. Chapters 4 and 5, estimate the prevalence of anal cytological abnormalities and HPV DNA in kidney transplant recipients and, evaluates the acceptability of anal cancer screening intervention, in a cross-sectional study. Chapter 6 and 7 describe a population-based data-linkage study that aims to improve estimates of disease transmission risk in solid organ donation. They explore how real-time data access could support decision making at referral by comparing agreement between suspected and verified risk of melanoma in solid organ donor referrals and tabulated them against donation outcomes, to identify potential missed opportunities for donation. Results: People with on dialysis for kidney failure and kidney transplant recipients experience two- and three-times excess deaths from all-site cancer, respectively, compared to the general population. The relative risk of cancer death was highest for urinary related cancers in people on dialysis and immune related cancers in kidney transplant recipients. Although relative mortality has decreased over time for people on dialysis, this has not reached general population levels. Relative mortality in kidney transplant recipients, remains unchanged. Prevalence of anal cancer precursors in kidney transplant recipients was higher than other immune-compromised populations. An anal cancer screening intervention may be well received in this population. Less than 1% of solid organ donor were suspected of melanoma at referral, however over two-thirds were not verified. Acceptance of these donors would have increased the donor pool by 2%. Conclusion: The impact of cancer in people with kidney failure is reflected in their increased risk of cancer mortality compared to the general population and the limitation of deceased donor kidneys available due to misclassified cancer transmission risk. Concerted efforts at an individual, risk-based approach to cancer prevention, including targeted screening programs, and guideline-based assessment of deceased donor cancers may improve cancer outcomes in this population.

Based on figure from American Association for Cancer Research (2010) & Global Cancer Statistics (2011), Liver cancer (HCC) is the sixth most frequently diagnosed cancer globally and third leading cause of cancer death (Jemal, A. et al., 2011; Jemal, A., Center, M. M., DeSantis, C. et al., 2010). In Hong Kong, Liver Cancer caused 1488 deaths in 2009 in total; it is 2nd and 4th leading killer of cancer death among Hong Kong male and female respectively (Hong Kong Cancer Registry, 2010). However, surgical resection for HCC remains as mainstream treatment modality and extensive studies on post-operative surgical outcomes for different HCC treatment modalities have been published. Nevertheless, the influence of kidney function on surgical outcomes on HCC patient stays novel and it emerges a need to explore on the relation. This study aims to compare the surgical outcomes of post hepatectomy HCC patients between reduced kidney function and normal kidney function in terms of (1) Length of hospital stay, (2) Survival rate, (3) Hospital Mortality and (4) Overall post operative complications. The kidney function can be reflected by the glomerular filtration rate (Thomas, R., Stanley, B. & Datta, S., 2007; Daugirdas, J. T., 2011). The direct measurement of GFR is a complicated and expensive procedure, which is not clinical possible to screen every patient. Thus this study adopted modified Cockcroft- Gault (CG) Formula, one type of creatinine based glomerular filtration rate estimation formulas with normalization to body surface area. Modified CG formula calculate the estimated glomerular filtration rate (eGFR) based on age, body weight, body height, gender and serum creatinine level (Himmelfarb, J. & Sayegh, M. H., 2010; Daugirdas, J. T., 2011; Joanna, Q. H. & Heather A. N., 2011). The eGFR of 452 HCC patients with major hepatectomy was evaluated and categorized into different kidney function groups according to the chronic kidney disease staging system suggested by K/DOQI, National Kidney Foundation. Hence, the surgical outcomes from different kidney function groups are analyzed and compared. Length of hospital stay was analyzed by Kruskal-Wallis Test. Hospital mortality and incidences of post-op complication are analyzed by Chi-square test. Lastly, the survival rate is analyzed by Kaplan-Meier Log rank test; the result is presented in form of survival curve, then 5-year survival rate of different group of samples are obtained and compared. Result of the study shows no evidence that patients with chronic kidney disease will have a longer hospital stay and more prone to surgical complications post operatively. However, it is indicated that the hospital mortality is associated with the severity of kidney function reduction and suggested that patients with chronic kidney disease are at higher risk of post-operative death than those with normal kidney. Patient with severe reduction of kidney function should be aware of high foreseeable chance of death after the surgery and special caution need to be taken. Surprisingly, the result revealed that the overall survival improves with the severity of kidney function reduction and the patients with worse kidney function are more likely to have a better survival. Nevertheless, the result on survival rate suspected to be biased by possible confounders and underlying co-morbidities of samples. In conclusion, eGFR formula is recommended in clinical estimation of kidney function for the patients. Also, it is suggested that HCC patients with reduced kidney function are more susceptible to hospital death after hepatectomy than normal individuals. Thus, cautious consideration and risk analysis before operation is particularly crucial for HCC patient with chronic kidney disease.
published_or_final_version
Medicine
Master
Master of Medical Sciences

Thesis (Ph. D.)--University of Sydney, 2006.
Title from title screen (viewed 21 May 2007). Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the School of Public Health, Faculty of Medicine. Includes bibliographical references. Also available in print form.

Background: Prostate cancer is the most common cancer in Sweden with around 10,000 new cases every year. Kidney and bladder cancer are less common with 1,000 and 2,000 new cases annually, respectively. The incidence of these cancer sites is higher in developed, than in developing countries, suggesting an association between lifestyle and cancer risk. The aims of this thesis were to investigate body mass index (BMI), blood pressure, and blood levels of glucose, total cholesterol, and triglycerides as risk factors for prostate, kidney, and bladder cancer. Furthermore, we aimed at assess probabilities of prostate cancer and competing events, all-cause death, for men with normal and high levels of metabolic factors. Material and methods: This thesis was conducted within the Metabolic Syndrome and Cancer project (Me-Can), a pooled cohort study with data from 578,700 participants from Norway, Sweden, and Austria. Data from metabolic factors were prospectively collected at health examinations and linked to the Cancer and Cause of Death registers in each country.  Results: High levels of metabolic factors were not associated with increased risk of prostate cancer, but high levels of BMI and blood pressure were associated with risk of prostate cancer death. The probability of prostate cancer was higher for men with normal levels of metabolic factors compared to men with high levels, but the probability of all-cause death, was higher for men with high levels than for those with normal levels. For both men and women, high levels of metabolic factors were associated with increased risk of kidney cancer (renal cell carcinoma). Furthermore, blood pressure for men and BMI for women were found as independent risk factors of kidney cancer. High blood pressure was associated with an increased risk of bladder cancer for men. Conclusions: High levels of metabolic factors were associated to risk of kidney and bladder cancer and to death from kidney, bladder, and prostate cancer. Compared to men with normal levels, men with high levels of metabolic factors had a decreased probability of prostate cancer but an increased probability of all-cause death.

Ytterligare forskningsfinansiärer: World Cancer Research Fund (2007/09) och Wereld Kanker Onderzoek Fonds (R2010/247)

Me-Can

Les progrès thérapeutiques ont conduit à une augmentation de la survie à 5 ans des enfants traités pour un un cancer et qui dépasse actuellement 80%. En France il a été estimé que 50 000 adultes guéris d’un cancer pédiatrique, mais la prévalence des complications à long terme causées par la maladie et par ses traitement dépasse 60% après un suivi de 30 ans. L’objectif général de cette thèse était de faire avancer les connaissances actuelles sur la mortalité et la morbidité à long terme liées aux cancers pédiatriques.Avec les données de la cohorte FCCSS (French Childhood Cancer Survivor Study) qui inclut des sujets ayant été traités pour entre 1946 et 2000 pour un cancer pédiatrique solide, nous avons observé que le risque de mortalité chez ces patients demeure plus élevé que la population générale même à plus de 40 ans après le diagnostic de leur premier cancer. D’autre part, la mortalité liée plus aux effets à long terme des traitements anticancéreux, plus spécifiquement les seconds cancers et maladies circulatoires, a significativement baissé parmi les sujets traités plus récemment.Par ailleurs, nous avons aussi confirmé le rôle des anthracyclines dans la survenue de l’insuffisance cardiaque et montré que la fraction du volume médian du cœur ayant reçu 30 Gray était beaucoup plus élevés chez les sujets ayant développé une insuffisance cardiaque par rapport aux autres. Nous avons aussi observé que des faibles volumes du cœur (10% du volume du ventricule gauche) ayant reçus ≥30 Gy sont associés à un risque élevé de développer une insuffisance cardiaque. Cette étude est la première à rapporter une relation dose-effet basée sur des indicateurs dose-volume et ces résultats peuvent être utilisés dans la pratique clinique couranteNos travaux ont aussi montré que les patients ayant subi une néphrectomie unilatérale étaient à risque de développer une maladie rénale chronique à très long terme. L’effet de la dose de radiation reçue aux reins différait selon si les patients ayant subi une néphrectomie unilatérale ou non . En effet, une dose au seul rein même <5Gy était associée à un risque élevé de dysfonctionnement rénal. Par ailleurs, grâce aux données du registre REIN, nous avons pu montrer que l’incidence de l’insuffisance rénale terminale liée aux anticancéreux était en train d’augmenter au fil des années. Cependant ces patients étaient moins inscrits en liste d'attente comparés à d’autres malades rénaux et avaient par conséquent un accès très limité à la transplantation rénale.En conclusion, le travail effectué courant cette thèse pourrait aider à identifier les patients à risque accru de complications tardives majeures liées aux traitements anticancéreux. Nos résultats pourraient être utilisés dans la pratique clinique courante pour l’adaptation de la prise en charge thérapeutique des enfants atteints de cancer et pour les recommandations de leurs suivi à long terme
Advances in treatment have increased the overall 5-year survival rate for childhood cancers to approximately 80%. In France, it estimated that about 50,000 adults have survived childhood cancer. However, previous studies have demonstrated that by the second decade of life, more than 60% of survivor of childhood malignancies (CCS) will suffer from at least one chronic disease related to the treatment they have received.The general objective of this thesis was to advance knowledge about the very long morbidity associated with childhood cancer, with the ultimate target to improve both the long term outcome and quality of life of survivors.Using data from the French Childhood Cancer Survivor Study (FCCSS) cohort, which includes patients treated for a solid pediatric malignancy between 1942 and 2000, we found that that mortality among CCS remained higher than the general population even after more than 40 years of the primary cancer diagnosis. A major finding of this study was that mortality attributed to adverse effects of cancer treatments (secondary primary neoplasm and circulatory disease) declined among patients treated in more recent treatment periods. We also conducted a case control study nested in the FCCSS cohort and further affirmed the role of anthracycline in the occurrence of heart failure. We demonstrated that the median heart volume that received at least 30Gy was higher among heart failure cases and that exposing small volumes of the heart (10% of the volume of the left ventricle) to at least 30Gy was associated with an elevated risk of cardiac failure. This study was the first to derive a dose response relationship based on dose-volume metrics which can be used in current clinical practice.Our results also showed that unilateral nephrectomy was associated with a high risk of renal impairment. The effect of radiation dose to the kidneys was also different among nephrectomized patients for whom any exposure to radiation was associated with an elevated risk of chronic kidney disease even at doses less than 5 Gy.Furthermore, data from the renal epidemiology and information network (REIN) registry allowed us to investigated ESKD (end stage kidney disease) related to nephrotoxic chemotherapy and/or radiation. Our registry-based study showed that ESKD related to nephrotoxic cancer treatment has been steadily increasing over the past decade in the French population. These patients experienced a much lower rate of wait-listing than matched controls with other causes of ESKD, despite similar survival on dialysis.To conclude the results of this thesis are useful to identify survivors of childhood malignancies who are at risk of developing severe long term adverse effects related to the treatment of their primary cancer. Our results could be applied in current clinical practice to help adapt current treatment strategies and improve the long-term follow-up recommendations of childhood cancer survivors

Introduction Kidney transplantation confers both survival and quality of life advantages over dialysis for most people with end-stage kidney disease (ESKD). The mortality rate on dialysis is 10-15% per year, compared with 2-4% per year post-transplantation. Short-term graft survival is related to control of the acute rejection process, requiring on-going immunosuppression. Most current immunosuppressive algorithms include one of the calcineurin inhibitors (CNI: cyclosporin or tacrolimus), an anti-metabolite (azathioprine or mycophenolate) and corticosteroids, with or without antibody induction agents (Ab) given briefly peri-transplantation. Despite this approach, between 15-35% of recipients undergo treatment for an episode of acute rejection (AR) within one year of transplantation. Transplantation is not without risk, and relative mortality rates for kidney recipients after the first post-transplant year remain 4-6 times that of the general population. Longer-term transplant and recipient survival are related to control of chronic allograft nephropathy (rooted in the interplay of AR, non-immunological factors, and the chronic nephrotoxicity of CNI) and limitation of the complications of chronic ESKD and long-term immunosuppression: cardiovascular disease, cancer and infection, which are responsible for 22%, 39% and 21% of deaths respectively. This thesis is presented as published works on the theme of immunosuppression and cancer after kidney transplantation. The work presented in the first chapters of this thesis has striven to identify, evaluate, synthesise and distil the entirety of evidence available of new and established immunosuppressive drug agents through systematic review of randomised trial data, with particular emphasis on quantifying harms of treatment. The final chapters use inception cohort data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), which is first validated then used to explore the risk of cancer in more detail than was possible from trial data alone. Interleukin 2 receptor antagonists Interleukin-2 receptor antagonists (IL2Ra, commercially available as basiliximab and daclizumab) are humanised or chimeric IgG monoclonal antibodies to the alpha subunit of the IL2 receptor present only on activated T lymphocytes, and the rationale for their use has been as induction agents peri-transplantation. Introduced in the mid-1990s, IL2Ra use has increased globally, and by 2003 38% of new kidney transplant recipients in the United States and 25% in Australasia received an IL2Ra. This study aimed to systematically identify and synthesise the evidence of effects of IL2Ra as an addition to standard therapy, or as an alternative to other induction agents. We identified 117 reports from 38 randomised trials involving 4893 participants. Where IL2Ra were compared with placebo (17 trials; 2786 patients), graft loss was not different at one (Relative Risk -RR 0.84; 0.64 to 1.10) or 3 years (RR 1.08; 0.71 to1.64). AR was reduced at 6 months (RR 0.66; 0.59 to 0.74) and at 1 year (RR 0.66; 0.59 to 0.74) but cytomegalovirus (CMV) disease (RR 0.82; CI 0.65 to 1.03) and malignancy (RR 0.67; 0.33 to1.36) were not different. Where IL2Ra were compared with other antibody therapy no significant differences in treatment effects were demonstrated, but IL2Ra had significantly fewer side effects. Given a 40% risk of rejection, 7 patients would need treatment with IL2Ra in addition to standard therapy, to prevent 1 patient having rejection, with no definite improvement in graft or patient survival. There was no apparent difference between basiliximab and daclizumab. Tacrolimus versus cyclosporin for primary immunosuppression There are pronounced global differences in CNI use; 63% of new kidney transplant recipients in the USA but only 22% in Australia receive tacrolimus as part of the initial immunosuppressive regimen. The side effects of CNI differ: tacrolimus is associated more with diabetes and neurotoxicity, but less with hypertension and dyslipidaemia than cyclosporin, with uncertainty about equivalence of nephrotoxicity or how these relate to patient and graft survival, or impact on patient compliance and quality of life. This study aimed to systematically review and synthesise the positive and negative effects of tacrolimus and cyclosporin as initial therapy for renal transplant recipients. We identified 123 reports from 30 randomised trials involving 4102 participants. At 6 months graft loss was reduced in tacrolimus-treated recipients (RR 0•56; 0•36 to 0•86), and this effect persisted for 3 years. The relative reduction in graft loss with tacrolimus diminished with higher levels of tacrolimus (P=0.04), but did not vary with cyclosporin formulation (P=0.97) or cyclosporin level (P=0.38). At 1 year, tacrolimus patients suffered less AR (RR 0•69; 0•60 to 0•79), and less steroid-resistant AR (RR 0•49; 0•37 to 0•64), but more insulin-requiring diabetes (RR 1•86; 1•11 to 3•09), tremor, headache, diarrhoea, dyspepsia and vomiting. The relative excess in diabetes increased with higher levels of tacrolimus (P=0.003). Cyclosporin-treated recipients experienced significantly more constipation and cosmetic side-effects. We demonstrated no differences in infection or malignancy. Treating 100 recipients with tacrolimus instead of cyclosporin for the 1st year post-transplantation avoids 12 suffering acute rejection and 2 losing their graft but causes an extra 5 to become insulin dependent diabetics, thus optimal drug choice may vary among patients. Target of rapamycin inhibitors for primary immunosuppression Target of rapamycin inhibitors (TOR-I) are among the newest immunosuppressive agents and have a novel mode of action but uncertain clinical role. Sirolimus is a macrocyclic lactone antibiotic and everolimus is a derivative of sirolimus. Both prevent DNA synthesis resulting in arrest of the cell cycle. Animal models suggested TOR-I would provide synergistic immunosuppression when combined with CNI, but early clinical studies demonstrated synergistic nephrotoxicity. Since then diverse trials have explored strategies that avoid this interaction and investigated other potential benefits. The aim of this study was to systematically identify and synthesise available evidence of sirolimus and everolimus when used in initial immunosuppressive regimens for kidney recipients. We identified 142 reports from 33 randomised trials involving 7114 participants, with TOR-I evaluated in four different primary immunosuppressive algorithms: as replacement for CNI, as replacement for antimetabolites, in combination with CNI at low and high dose, and with variable dose of CNI. When TOR-I replaced CNI (8 trials, 750 participants), there was no difference in AR (RR 1.03; 0.74 to 1.44), but creatinine was lower (WMD -18.31 umol/l; -30.96 to -5.67), and bone marrow more suppressed (leucopoenia RR 2.02; 1.12 to 3.66, thrombocytopenia RR 6.97; 2.97 to 16.36, anaemia RR 1.67; 1.27 to 2.20). When TOR-I replaced antimetabolites (11 trials, 3966 participants), AR and CMV were reduced (RR 0.84; 0.71 to 0.99 and RR 0.49; 0.37 to 0.65) but hypercholesterolaemia was increased (RR 1.65; 1.32 to 2.06). When low was compared to high-dose TOR-I, with equal CNI dose (10 trials, 3175 participants), AR was increased (RR 1.23; 1.06 to 1.43) but GFR higher (WMD 4.27 ml/min; 1.12 to 7.41). When low-dose TOR-I and standard-dose CNI were compared to higher-dose TOR-I and reduced CNI AR was reduced (RR 0.67; 0.52 to 0.88), but GFR also reduced (WMD -9.46 ml/min; -12.16 to -6.76). There was no significant difference in mortality, graft loss or malignancy risk demonstrated for TOR-I in any comparison. Generally surrogate endpoints for graft survival favoured TOR-I (lower risk of acute rejection and higher GFR) and surrogate endpoints for patient outcomes were worsened by TOR-I (bone marrow suppression, lipid disturbance). Long-term hard-endpoint data from methodologically robust randomised trials are still needed. Monoclonal and polyclonal antibody therapy for treating acute rejection Strategies for treating AR include pulsed steroids, an antibody (Ab) preparation, the alteration of background immunosuppression, or combinations of these options. In 2002, in the USA 61.4% of patients with AR received steroids, 20.4% received Ab and 18.2% received both. The Ab available for AR are not new: horse and rabbit derived polyclonal antibodies (ATG and ALG) have been used for 35 years, and a mouse monoclonal antibody (muromonab-CD3) became available in the late 1980s. These preparations remove the functional T-cell population from circulation, producing powerful saturation immunosuppression which is useful for AR but which may be complicated by immediate toxicity and higher rates of infection and malignancy. The aim of this study was to systematically evaluate and synthesise all evidence available to clinicians for treating AR in kidney recipients. We identified 49 reports from 21 randomised trials involving 1394 participants. Outcome measures were inconsistent and incompletely defined across trials. Fourteen trials (965 patients) compared therapies for 1st AR episodes (8 Ab versus steroid, 2 Ab versus another Ab, 4 other comparisons). In treating first rejection, Ab was better than steroid in reversing AR (RR 0.57; CI 0.38 to 0.87) and preventing graft loss (RR 0.74; CI 0.58 to 0.95) but there was no difference in preventing subsequent rejection (RR 0.67; CI 0.43 to 1.04) or death (RR 1.16; CI 0.57 to 2.33) at 1 year. Seven trials (422 patients) investigated Ab treatment of steroid-resistant rejection (4 Ab vs another Ab, 1 different doses Ab, 1 different formulation Ab, 2 other comparisons). There was no benefit of muromonab-CD3 over ATG or ALG in reversing rejection (RR 1.32; CI 0.33 to 5.28), preventing subsequent rejection (RR 0.99; CI 0.61 to 1.59), graft loss (RR 1.80; CI 0.29 to 11.23) or death (RR 0.39; CI 0.09 to 1.65). Given the clinical problem caused by AR, comparable data are sparse, and clinically important differences in outcomes between widely used interventions have not been excluded. Standardised reproducible outcome criteria are needed. Validity of cancer data in an end stage kidney disease registry Registries vary in whether the data they collect are given voluntarily or as a requirement of law, the completeness of population coverage, the breadth of data collected and whether data are assembled directly or indirectly through linkage to other databases. Data quality is crucial but difficult to measure objectively. Formal audit of ANZDATA cancer records has not previously taken place. The aim of this study was to assess agreement of records of incident cancer diagnoses held in ANZDATA (voluntary reporting system) with those reported under statute to the New South Wales (NSW) state Central Cancer Registry (CCR), to explore the strengths and weaknesses of both reporting systems, and to measure the impact of any disagreement on results of cancer analyses. From 1980-2001, 9453 residents received dialysis or transplantation in NSW. Records from ANZDATA registrants were linked to CCR using probabilistic matching and agreement between registries for patients with 1 or more cancers, all cancers and site-specific cancer was estimated using the kappa-statistic (κ). ANZDATA recorded 867 cancers in 779 (8.2%) registrants; CCR 867 cancers in 788 (8.3%), with κ =0.76. ANZDATA had sensitivity 77.3% (CI 74.2 to 80.2), specificity 98.1% (CI 97.7 to 98.3) if CCR records were regarded as the reference standard. Agreement was similar for diagnoses whilst receiving dialysis (κ =0.78) or after transplantation (κ =0.79), but varied by cancer type. Melanoma (κ =0.61) and myeloma (κ =0.47) were less good; lymphoma (κ =0.80), leukaemia (κ =0.86) and breast cancer (κ =0.85) were very good. Artefact accounted for 20.8% non-concordance but error and misclassification did occur in both registries. Cancer risk did not differ in any important way whether estimated using ANZDATA or CCR records. Quality of cancer records in ANZDATA are high, differences largely explicable, and seem unlikely to alter results of analyses. Risk of cancer after kidney transplantation Existing data on the magnitude of excess risk of cancer across different kidney recipient groups are sparse. Quantifying an individual transplant candidate’s cancer risk informs both pre-transplant counselling, treatment decisions and has implications for monitoring, screening and follow-up after transplantation. The aims of this study were firstly to establish the risk of cancer in the post-transplant population compared to that experienced by the general population, and secondly to quantify how excess risk varied within the transplanted population, seeking to establish meaningful absolute risk estimates for post-transplant cancer based on unalterable recipient characteristics known a priori at the time of transplantation. 15,183 residents of Australia and New Zealand had a transplant between 1963 and 2004, and were followed for a median of 7.2 years (130,186 person-years), with 1642 (10.8%) developing cancer. Overall, kidney recipients had 3 times the cancer risk, with risk inversely related to age (Standardised Incidence Ratio of 15 to 30 in children reducing to 2 in people > 65 years). Female recipients aged 25 -29 had rates of cancer (779.2/100,000) equivalent to women aged 55 - 59 from the general population. The risk pattern of lymphoma, colorectal and breast cancer was similar to the overall age trend, melanoma showed less variability across ages and prostate cancer showed no risk increase. Within the transplanted population cancer risk was affected by age differently for each sex (P=0.007), and was elevated for recipients with prior non-skin malignancy (Hazard Ratio: HR 1.40; 1.03 to 1.89), of white race (HR 1.36; 1.12 to 1.89), but reduced for those with diabetic ESKD (HR 0.67; 0.50 to 0.89) Rates of cancer in kidney recipients were similar to non-transplanted people 20 -30 years older, but risk differed across patient groups. Men aged 45 - 54 at transplantation with graft function at 10 years had a risk of cancer that varied from 1 in 13 (non-white, diabetic ESKD, no prior cancer) to 1 in 5 (white, prior cancer, ESKD from other causes).

PhD
Introduction Kidney transplantation confers both survival and quality of life advantages over dialysis for most people with end-stage kidney disease (ESKD). The mortality rate on dialysis is 10-15% per year, compared with 2-4% per year post-transplantation. Short-term graft survival is related to control of the acute rejection process, requiring on-going immunosuppression. Most current immunosuppressive algorithms include one of the calcineurin inhibitors (CNI: cyclosporin or tacrolimus), an anti-metabolite (azathioprine or mycophenolate) and corticosteroids, with or without antibody induction agents (Ab) given briefly peri-transplantation. Despite this approach, between 15-35% of recipients undergo treatment for an episode of acute rejection (AR) within one year of transplantation. Transplantation is not without risk, and relative mortality rates for kidney recipients after the first post-transplant year remain 4-6 times that of the general population. Longer-term transplant and recipient survival are related to control of chronic allograft nephropathy (rooted in the interplay of AR, non-immunological factors, and the chronic nephrotoxicity of CNI) and limitation of the complications of chronic ESKD and long-term immunosuppression: cardiovascular disease, cancer and infection, which are responsible for 22%, 39% and 21% of deaths respectively. This thesis is presented as published works on the theme of immunosuppression and cancer after kidney transplantation. The work presented in the first chapters of this thesis has striven to identify, evaluate, synthesise and distil the entirety of evidence available of new and established immunosuppressive drug agents through systematic review of randomised trial data, with particular emphasis on quantifying harms of treatment. The final chapters use inception cohort data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), which is first validated then used to explore the risk of cancer in more detail than was possible from trial data alone. Interleukin 2 receptor antagonists Interleukin-2 receptor antagonists (IL2Ra, commercially available as basiliximab and daclizumab) are humanised or chimeric IgG monoclonal antibodies to the alpha subunit of the IL2 receptor present only on activated T lymphocytes, and the rationale for their use has been as induction agents peri-transplantation. Introduced in the mid-1990s, IL2Ra use has increased globally, and by 2003 38% of new kidney transplant recipients in the United States and 25% in Australasia received an IL2Ra. This study aimed to systematically identify and synthesise the evidence of effects of IL2Ra as an addition to standard therapy, or as an alternative to other induction agents. We identified 117 reports from 38 randomised trials involving 4893 participants. Where IL2Ra were compared with placebo (17 trials; 2786 patients), graft loss was not different at one (Relative Risk -RR 0.84; 0.64 to 1.10) or 3 years (RR 1.08; 0.71 to1.64). AR was reduced at 6 months (RR 0.66; 0.59 to 0.74) and at 1 year (RR 0.66; 0.59 to 0.74) but cytomegalovirus (CMV) disease (RR 0.82; CI 0.65 to 1.03) and malignancy (RR 0.67; 0.33 to1.36) were not different. Where IL2Ra were compared with other antibody therapy no significant differences in treatment effects were demonstrated, but IL2Ra had significantly fewer side effects. Given a 40% risk of rejection, 7 patients would need treatment with IL2Ra in addition to standard therapy, to prevent 1 patient having rejection, with no definite improvement in graft or patient survival. There was no apparent difference between basiliximab and daclizumab. Tacrolimus versus cyclosporin for primary immunosuppression There are pronounced global differences in CNI use; 63% of new kidney transplant recipients in the USA but only 22% in Australia receive tacrolimus as part of the initial immunosuppressive regimen. The side effects of CNI differ: tacrolimus is associated more with diabetes and neurotoxicity, but less with hypertension and dyslipidaemia than cyclosporin, with uncertainty about equivalence of nephrotoxicity or how these relate to patient and graft survival, or impact on patient compliance and quality of life. This study aimed to systematically review and synthesise the positive and negative effects of tacrolimus and cyclosporin as initial therapy for renal transplant recipients. We identified 123 reports from 30 randomised trials involving 4102 participants. At 6 months graft loss was reduced in tacrolimus-treated recipients (RR 0•56; 0•36 to 0•86), and this effect persisted for 3 years. The relative reduction in graft loss with tacrolimus diminished with higher levels of tacrolimus (P=0.04), but did not vary with cyclosporin formulation (P=0.97) or cyclosporin level (P=0.38). At 1 year, tacrolimus patients suffered less AR (RR 0•69; 0•60 to 0•79), and less steroid-resistant AR (RR 0•49; 0•37 to 0•64), but more insulin-requiring diabetes (RR 1•86; 1•11 to 3•09), tremor, headache, diarrhoea, dyspepsia and vomiting. The relative excess in diabetes increased with higher levels of tacrolimus (P=0.003). Cyclosporin-treated recipients experienced significantly more constipation and cosmetic side-effects. We demonstrated no differences in infection or malignancy. Treating 100 recipients with tacrolimus instead of cyclosporin for the 1st year post-transplantation avoids 12 suffering acute rejection and 2 losing their graft but causes an extra 5 to become insulin dependent diabetics, thus optimal drug choice may vary among patients. Target of rapamycin inhibitors for primary immunosuppression Target of rapamycin inhibitors (TOR-I) are among the newest immunosuppressive agents and have a novel mode of action but uncertain clinical role. Sirolimus is a macrocyclic lactone antibiotic and everolimus is a derivative of sirolimus. Both prevent DNA synthesis resulting in arrest of the cell cycle. Animal models suggested TOR-I would provide synergistic immunosuppression when combined with CNI, but early clinical studies demonstrated synergistic nephrotoxicity. Since then diverse trials have explored strategies that avoid this interaction and investigated other potential benefits. The aim of this study was to systematically identify and synthesise available evidence of sirolimus and everolimus when used in initial immunosuppressive regimens for kidney recipients. We identified 142 reports from 33 randomised trials involving 7114 participants, with TOR-I evaluated in four different primary immunosuppressive algorithms: as replacement for CNI, as replacement for antimetabolites, in combination with CNI at low and high dose, and with variable dose of CNI. When TOR-I replaced CNI (8 trials, 750 participants), there was no difference in AR (RR 1.03; 0.74 to 1.44), but creatinine was lower (WMD -18.31 umol/l; -30.96 to -5.67), and bone marrow more suppressed (leucopoenia RR 2.02; 1.12 to 3.66, thrombocytopenia RR 6.97; 2.97 to 16.36, anaemia RR 1.67; 1.27 to 2.20). When TOR-I replaced antimetabolites (11 trials, 3966 participants), AR and CMV were reduced (RR 0.84; 0.71 to 0.99 and RR 0.49; 0.37 to 0.65) but hypercholesterolaemia was increased (RR 1.65; 1.32 to 2.06). When low was compared to high-dose TOR-I, with equal CNI dose (10 trials, 3175 participants), AR was increased (RR 1.23; 1.06 to 1.43) but GFR higher (WMD 4.27 ml/min; 1.12 to 7.41). When low-dose TOR-I and standard-dose CNI were compared to higher-dose TOR-I and reduced CNI AR was reduced (RR 0.67; 0.52 to 0.88), but GFR also reduced (WMD -9.46 ml/min; -12.16 to -6.76). There was no significant difference in mortality, graft loss or malignancy risk demonstrated for TOR-I in any comparison. Generally surrogate endpoints for graft survival favoured TOR-I (lower risk of acute rejection and higher GFR) and surrogate endpoints for patient outcomes were worsened by TOR-I (bone marrow suppression, lipid disturbance). Long-term hard-endpoint data from methodologically robust randomised trials are still needed. Monoclonal and polyclonal antibody therapy for treating acute rejection Strategies for treating AR include pulsed steroids, an antibody (Ab) preparation, the alteration of background immunosuppression, or combinations of these options. In 2002, in the USA 61.4% of patients with AR received steroids, 20.4% received Ab and 18.2% received both. The Ab available for AR are not new: horse and rabbit derived polyclonal antibodies (ATG and ALG) have been used for 35 years, and a mouse monoclonal antibody (muromonab-CD3) became available in the late 1980s. These preparations remove the functional T-cell population from circulation, producing powerful saturation immunosuppression which is useful for AR but which may be complicated by immediate toxicity and higher rates of infection and malignancy. The aim of this study was to systematically evaluate and synthesise all evidence available to clinicians for treating AR in kidney recipients. We identified 49 reports from 21 randomised trials involving 1394 participants. Outcome measures were inconsistent and incompletely defined across trials. Fourteen trials (965 patients) compared therapies for 1st AR episodes (8 Ab versus steroid, 2 Ab versus another Ab, 4 other comparisons). In treating first rejection, Ab was better than steroid in reversing AR (RR 0.57; CI 0.38 to 0.87) and preventing graft loss (RR 0.74; CI 0.58 to 0.95) but there was no difference in preventing subsequent rejection (RR 0.67; CI 0.43 to 1.04) or death (RR 1.16; CI 0.57 to 2.33) at 1 year. Seven trials (422 patients) investigated Ab treatment of steroid-resistant rejection (4 Ab vs another Ab, 1 different doses Ab, 1 different formulation Ab, 2 other comparisons). There was no benefit of muromonab-CD3 over ATG or ALG in reversing rejection (RR 1.32; CI 0.33 to 5.28), preventing subsequent rejection (RR 0.99; CI 0.61 to 1.59), graft loss (RR 1.80; CI 0.29 to 11.23) or death (RR 0.39; CI 0.09 to 1.65). Given the clinical problem caused by AR, comparable data are sparse, and clinically important differences in outcomes between widely used interventions have not been excluded. Standardised reproducible outcome criteria are needed. Validity of cancer data in an end stage kidney disease registry Registries vary in whether the data they collect are given voluntarily or as a requirement of law, the completeness of population coverage, the breadth of data collected and whether data are assembled directly or indirectly through linkage to other databases. Data quality is crucial but difficult to measure objectively. Formal audit of ANZDATA cancer records has not previously taken place. The aim of this study was to assess agreement of records of incident cancer diagnoses held in ANZDATA (voluntary reporting system) with those reported under statute to the New South Wales (NSW) state Central Cancer Registry (CCR), to explore the strengths and weaknesses of both reporting systems, and to measure the impact of any disagreement on results of cancer analyses. From 1980-2001, 9453 residents received dialysis or transplantation in NSW. Records from ANZDATA registrants were linked to CCR using probabilistic matching and agreement between registries for patients with 1 or more cancers, all cancers and site-specific cancer was estimated using the kappa-statistic (κ). ANZDATA recorded 867 cancers in 779 (8.2%) registrants; CCR 867 cancers in 788 (8.3%), with κ =0.76. ANZDATA had sensitivity 77.3% (CI 74.2 to 80.2), specificity 98.1% (CI 97.7 to 98.3) if CCR records were regarded as the reference standard. Agreement was similar for diagnoses whilst receiving dialysis (κ =0.78) or after transplantation (κ =0.79), but varied by cancer type. Melanoma (κ =0.61) and myeloma (κ =0.47) were less good; lymphoma (κ =0.80), leukaemia (κ =0.86) and breast cancer (κ =0.85) were very good. Artefact accounted for 20.8% non-concordance but error and misclassification did occur in both registries. Cancer risk did not differ in any important way whether estimated using ANZDATA or CCR records. Quality of cancer records in ANZDATA are high, differences largely explicable, and seem unlikely to alter results of analyses. Risk of cancer after kidney transplantation Existing data on the magnitude of excess risk of cancer across different kidney recipient groups are sparse. Quantifying an individual transplant candidate’s cancer risk informs both pre-transplant counselling, treatment decisions and has implications for monitoring, screening and follow-up after transplantation. The aims of this study were firstly to establish the risk of cancer in the post-transplant population compared to that experienced by the general population, and secondly to quantify how excess risk varied within the transplanted population, seeking to establish meaningful absolute risk estimates for post-transplant cancer based on unalterable recipient characteristics known a priori at the time of transplantation. 15,183 residents of Australia and New Zealand had a transplant between 1963 and 2004, and were followed for a median of 7.2 years (130,186 person-years), with 1642 (10.8%) developing cancer. Overall, kidney recipients had 3 times the cancer risk, with risk inversely related to age (Standardised Incidence Ratio of 15 to 30 in children reducing to 2 in people > 65 years). Female recipients aged 25 -29 had rates of cancer (779.2/100,000) equivalent to women aged 55 - 59 from the general population. The risk pattern of lymphoma, colorectal and breast cancer was similar to the overall age trend, melanoma showed less variability across ages and prostate cancer showed no risk increase. Within the transplanted population cancer risk was affected by age differently for each sex (P=0.007), and was elevated for recipients with prior non-skin malignancy (Hazard Ratio: HR 1.40; 1.03 to 1.89), of white race (HR 1.36; 1.12 to 1.89), but reduced for those with diabetic ESKD (HR 0.67; 0.50 to 0.89) Rates of cancer in kidney recipients were similar to non-transplanted people 20 -30 years older, but risk differed across patient groups. Men aged 45 - 54 at transplantation with graft function at 10 years had a risk of cancer that varied from 1 in 13 (non-white, diabetic ESKD, no prior cancer) to 1 in 5 (white, prior cancer, ESKD from other causes).

For patients with end-stage kidney disease, kidney transplantation generally offers the best survival and quality of life. Complications such as cancer and cardiovascular disease are now the most important causes of morbidity and mortality in kidney transplant recipients past the initial post-transplant period. The overarching aim of this thesis was to improve our understanding of cancer in people after kidney transplantation. Chapter 2 provides a comprehensive literature review of the topic of cancer and kidney transplantation. Chapter 3 provides a review of the process of creating a risk prediction model, including an illustrative example. Prediction models may be applied to transplant recipients to predict the risk of experiencing an outcome, such as cancer. Chapters 4 and 5 were population-based registry studies using data from the Australia and New Zealand Dialysis and Transplant Registry. Chapter 4 demonstrated the greatly increased risk of cancer mortality in kidney transplant recipients, particularly in de novo cancers that arise after kidney transplantation. Chapter 5 explored the changes in cancer risk as patients progress through different treatment modalities for end-stage kidney disease, from dialysis to kidney transplantation to graft loss to subsequent kidney transplantation, and demonstrated increased risk of cancer after kidney transplantation, and reduction in cancer risk after loss of the first kidney transplant. In Chapter 6, data from the DETECT study was analysed and novel risk factors for advanced colorectal neoplasia in patients with chronic kidney disease, including patients on dialysis and kidney transplant recipients, were identified. Chapter 7 was a systematic review of trial registrations which demonstrated that cancer is an infrequently reported outcome and is inconsistently defined in trials of kidney transplant recipients, despite the importance of cancer as an outcome to kidney transplant recipients and other stakeholders.

The PAX gene family of transcription factors plays a prominent role during embryogenesis however can be aberrantly re-activated during tumorigenesis and contributes to the malignant phenotype.
During embryonic kidney development, PAX2 exerts an anti-apoptotic function however its expression typically attenuates during the post-natal period. On the other hand, PAX2 aberrant expression is observed in the majority of Renal Cell Carcinomas (RCC). RCC is resistant to chemotherapy; up-regulation of anti-apoptotic genes is recognized to contribute to tumor resistance to chemotherapy. We hypothesized that the anti-apoptotic effect of the PAX2 gene that is expressed in RCC cells contributes to RCC and their resistance to chemotherapy-induced cell death.
Human embryonic kidney (HEK293) cells transfected with a PAX2 expression vector and exposed to cisplatin, were protected from apoptosis compared to control cells. Conversely, murine collecting duct cells stably transfected with PAX2 antisense cDNA had twofold increases in cisplatin-induced apoptosis. Similarly, PAX2 knockdown using PAX2 siRNA in RCC cells CAKI-1 and ACHN enhances cisplatin-induced apoptosis in vitro.
To test the combination of PAX2 expression silencing and cisplatin treatment in vivo we developed a model of renal tumors by injecting ACHN cells as a xenograft under the skin of nude mice. I showed that a PAX2 shRNA successfully knocks down PAX2 mRNA and protein levels in a RCC cell line (ACHN). ACHN cells stably transfected with shRNAs targeted against the PAX2 homeodomain, are more susceptible to cisplatin-induced caspase-3 activation than the control ACHN cell line. Furthermore, growth of subcutaneous ACHN/shPAX2 xenografts in nude mice is significantly more responsive to cisplatin therapy than control of ACHN cell tumors. This work proposes PAX2 as a potential therapeutic gene target in metastatic renal cell carcinoma and suggests that adjunctive PAX2 knockdown may enhance the efficacy of chemotherapeutic agents such as cisplatin.
Wilms tumor, the most common pediatric renal cancer, is thought to arise from a progenitor cell of the metanephric mesenchyme that fails to complete nephrogenesis. In addition to its characteristic triphasic histology, WT can exhibit myogenic differentiation. Myogenic programming during muscle development is controlled by a PAX3 transcription factor determinant for muscle development; unexpectedly PAX3 transcriptional activity has been recently identified in the embryonic mouse kidney. These observations led us to hypothesize that PAX3 plays a role during kidney development. Furthermore, we predict that if PAX3 expression is verified during renal development, PAX3 may also be expressed in Wilms tumor with a myogenic component.
I showed that PAX3 is expressed in the metanephric mesenchyme and stromal compartment of the developing mouse kidney. In a panel of 20 Wilms tumors, PAX3 was identified in tumor samples with myogenic histopathology. Furthermore, mutations of WT1 were consistently associated with PAX3 expression in Wilms tumors and modulation of WT1 expression in HEK293 cells was inversely correlated with the level of endogenous PAX3 protein.
This work supports a novel model of normal renal development in which progenitor cells of the metanephric blastema express PAX3 when targeted toward the stromal cell fate. Suppression of PAX3 is integral to the mesenchyme-to-epithelium transition, which defines the nephrogenic cell fate and may be accomplished, in part, by WT1. Conversely, failure to suppress PAX3 may account for the myogenic phenotype in a subset of WT1-negative Wilms tumors.

Chronic kidney disease (CKD) is a leading public health problem affecting almost 700 million people globally and is the 12th leading cause of death worldwide.1 The increasing burden of CKD across the globe parallels the increase in ageing populations and the growing prevalence of vascular comorbid conditions like diabetes and hypertension. CKD is associated with increased morbidity and mortality, with patients experiencing an increased risk of death from related conditions such as heart disease and cancers. In 2017, CKD alone resulted in 1.2 million deaths universally.1 Additionally, 1.4 million deaths from cardiovascular disease were attributed to impaired kidney function. CKD is associated with multiple comorbidities which adversely impacts on the life of affected persons and results in reduced quality of life (QoL) compared to the general population,2 with a trend for the lowest QoL experienced by those with kidney failure requiring dialysis.3 Utilities are the numerical value attached to the strength of an individual's preference for specific health-related outcomes. Utility is measured on a 0 to 1 scale, where 0 represents death and 1 represents full health.3 While previous studies have assessed QoL measures in CKD, few have examined domain-specific data in detail across a wide spectrum of CKD stages. Knowledge of factors that negatively affect QoL in CKD may help inform the development of targeted interventions and health policies to help improve QoL in this population. Impaired kidney function is an independent risk factor for cardiovascular disease and all cause mortality, particularly in those with kidney failure requiring dialysis. Kidney transplantation remains the treatment of choice for most patients with kidney failure and is associated with improved survival and QoL compared with treatment with dialysis. However, kidney transplantation is associated with an increased risk of multiple complications through exposure to chronic immunosuppression, with cancer now the leading cause of death in this population.4 Although clinical practice guidelines recommend age and sex-specific screening for potential kidney transplant recipients, cancers ensuing early post-transplant may occur. The incidence and clinical outcomes of these cancers remain uncertain. Knowledge of the epidemiology of these cancers and their risk factors for adverse outcomes will help identify those patients at high risk for developing early cancers post-transplant and facilitate appropriate interventions such as targeted cancer screening in this at-risk population. The aims of this thesis are two-fold. Firstly, we aimed to compare the overall and domain specific QoL in a large cohort of patients with different stages of CKD (stage 3-5, dialysis and kidney transplant recipients) and determine the factors associated with reduced QoL. Secondly, we aimed to compare the burden, frequency, type, stages of cancers and risk of mortality with cancer that occurred early (<12 months) compared to those that occurred late (>12 months) after kidney transplantation. Chapter 1 describes and quantifies the disease burden of patients with kidney disease. Chapter 2 reports the QoL experienced by people with CKD, across a broad spectrum of CKD stages and explores overall and domain-specific QoL measures and factors associated with decrements in QoL. Chapter 3 reports the burden of early cancers (occurring <12 months) after kidney transplantation and describes the types, stages, frequency of these cancers, explores mortality associated with early cancers and factors associated with mortality from these cancers. Chapter 4 focusses on discussions related to quality of life in CKD and early posttransplant cancers and future steps on improving care for this group of patients. This thesis generated original insights into the QoL experienced by patients across a broad spectrum of CKD, the factors associated with poor QoL and highlights the need for novel social and medical interventions to support this vulnerable group. This work also provides insight into the burden of early cancers experienced by kidney transplant recipients, which in turn leads to increased morbidity and mortality and emphasizes the need for development of screening and treatment approaches to help improve outcomes in this population.

Patients with chronic kidney disease (CKD) have an increased risk of cancer and a substantially higher risk of cancer-specific mortality compared with the general population. Early detection and intervention through cancer screening is one of the many effective strategies for reducing cancer specific mortality in the general population. However, cancer screening in people with CKD is complex, and little is known about how CKD and related comorbidities influence screening decisions among patients, clinicians and other health professionals. Further, there is a lack of robust evidence regarding the benefits and harms, treatment effectiveness and cancer-related prognosis to support cancer screening. There is also concern that not all patients with CKD will enjoy the benefits of screening because of the shorter life expectancy and competing risks of death from causes such as cardiovascular disease, and may also induce harms through subsequent interventions, overdiagnoses and overtreatment. Although there is an increased incidence of cancer and cancer-related death as well as increased risk of overdiagnosis compared to the age and sex matched general population, the benefits and harms of screening for bowel, skin and prostate cancer in patients with CKD remain largely unknown. Current recommendations specific to the CKD population suggest for a shared decision-making approach between clinicians and patients to ensure an informed decision is made based on patients priorities and values. Despite this, little is known about patient’s and clinician’s preferences and attitudes to cancer screening and how cancer screening is prioritised in relation to CKD and current health priorities. Understanding the preferences and attitudes of patients and clinicians to cancer screening will better inform and guide shared decision-making and improve patient-centred care and outcomes.

Thesis (Ph.D. in Human Medical Genetics) -- University of Colorado Denver, 2007.
Typescript. Includes bibliographical references (leaves 117-126). Free to UCD affiliates. Online version available via ProQuest Digital Dissertations;

The incidence of venous and arterial thromboembolic events (VTEs/ATEs) varies greatly by cancer type and age, with increased risk in the elderly. Very little research has been reported specific to elderly kidney cancer patients. Retrospective cohort analyses of Medicare patients, 11,463 with and 11,463 without kidney cancer, between 2003 and 2010 were conducted to compare incidence rates of VTEs/ATEs in cancer patients with matched noncancer patients and to assess independent risk factors for VTEs in cancer patients. The advanced epidemiology triangle was the theoretical framework used to interpret the association between incident events and other factors. Using Cox proportional hazard regression, the first 2 research questions examined whether the incidence rates of VTEs/ATEs were higher in kidney cancer patients than noncancer patients; the third research question assessed which factors were associated with VTEs after kidney cancer diagnosis. In the year prior to index date, cancer patients had higher incidence rates of VTEs than noncancer patients; the incidence rate of myocardial infarction was higher in cancer patients than noncancer patients for patients with a history of cardiovascular disease. Elderly kidney cancer patients with transitional cell tumors had lower rates of pulmonary embolism and ischemic stroke compared to patients with clear cell tumors. Recent history of VTE and Charlson comorbidity score were strong predictors of VTE after cancer diagnosis. These results can lead to positive social change by helping healthcare providers to determine who may benefit from closer observation or prophylaxis to prevent or minimize morbidity from these thromboembolic events, thus improving health and quality of life for elderly kidney cancer patients.

Beckwith Wiedemann syndrome (BWS) and Birt-Hogg-Dube syndrome (BHD) are two examples of genetic conditions that are associated with an increased risk of renal neoplasia (Wilms tumour and renal cell carcinoma (RCC) respectively). BWS is a model imprinting disorder characterised by overgrowth, developmental defects, predisposition to embryonal tumours and results from disordered expression of imprinted genes on chromosome 11p15.5. There is an association between the use of assisted reproductive technologies (ART) and BWS. BHD is an autosomal dominantly inherited condition characterised by cutaneous fibrofolliculomas, lung cysts predisposing to spontaneous pneumothorax and an increased lifetime risk of RCC and is caused by germline mutations in the FLCN gene. Both BWS and BHD show phenotypic variation in their manifestation. The clinical and molecular genetic investigations described in this thesis aimed to uncover factors influencing variation in phenotypic expression in these two conditions. Conclusions: Phenotypic variation in BWS can result from locus heterogeneity, epigenetic and environmental modifiers. Phenotypic variation in BHD may reflect allelic heterogeneity and the presence of genetic modifiers.

Organoide aus adulten Mäusen sind vielversprechende Modelle für die Nierenforschung. Ihre Charakterisierung wurde jedoch nicht auf ein zufriedenstellendes Niveau gebracht. Hier habe ich ein langfristiges 3D-Maus-Organoid (Tubuloid)-Modell etabliert und charakterisiert, das die Erneuerung und die Reparatur sowie die Architektur und die Funktionalität der adulten tubulären Epithelien rekapituliert. In der Zukunft wird das Modell detaillierte Untersuchungen der Trajektorien selbsterneuernder Zellen sowohl zur teilweisen Wiederherstellung der Niere als auch zur malignen Transformation der Niere ermöglichen. Das klarzellige Nierenzellkarzinom (ccRCC) ist der häufigste und aggressivste Nierenkrebs. Die Inaktivierung des Tumorsuppressorgens Von Hippel-Lindau (VHL) ist der Haupttreiber des ccRCCs. Zuvor hatten wir die Hochregulation der Wnt- und Notch-Signalübertragung in den CXCR4+MET+CD44+-Krebsstammzellen (CSC) aus primären humanen ccRCC-Tumoren identifiziert. Das Blockieren von Wnt und Notch in von Patienten stammenden Xenotransplantaten, Organoiden und nicht-anhaftenden Sphären unter Verwendung von niedermolekularen Inhibitoren beeinträchtigte die Selbsterneuerung der CSC und das Tumorwachstum. Um CSC-gesteuertes humanes ccRCC in genetischen Mausmodellen nachzuahmen, begann ich mit der Erzeugung von zwei Doppelmausmutanten; β-Catenin-GOF; Notch-GOF und Vhl-LOF; β-Catenin-GOF. Sowohl die β-Catenin-GOF; Notch-GOF Mausmutante als auch die Vhl-LOF; β-Catenin-GOF Mausmutante entwickelten innerhalb einiger Monate schwere Krankheitssymptome. Überraschenderweise beobachtete ich weder Tumore oder Tumorvorläuferläsionen noch höhere Zellproliferationsraten in den mutierten Nieren. Weitere Analysen ergaben, dass die Mausmutanten Merkmale chronischer Nierenerkrankung (CKD) aufwiesen.
Adult mouse organoids are promising models for kidney research. However, their characterization has not been pushed forward to a satisfying level. Here, I have generated and characterized a long-term 3D mouse organoid (tubuloid) model, which recapitulates renewal and repair, and the architecture and functionality of the adult tubular epithelia. In the future, the model will allow detailed investigations of trajectories of self-renewing cells towards both the partial recreation and malignant transformation of the kidney. Clear cell renal cell carcinoma (ccRCC) is the most common and aggressive kidney cancer. Inactivation of the Von Hippel-Lindau (VHL) tumor suppressor gene is the major driver of ccRCC. Earlier, we identified the upregulation of Wnt and Notch signaling in CXCR4+MET+CD44+ cancer stem cells (CSCs) from primary human ccRCCs. Blocking Wnt and Notch in patient-derived xenografts, organoids and non-adherent spheres using small-molecule inhibitors impaired self-renewal of CSCs and tumor growth. To mimic CSC-governed human ccRCC in genetic mouse models, I started from the generation of two double mouse mutants; β-catenin-GOF; Notch-GOF and Vhl-LOF; β-catenin-GOF. Surprizingly, I observed neither tumors or tumor precursor lesions nor higher cell proliferation rates in the mutant kidneys. Further analyses revealed that the mutant mice displayed features of chronic kidney disease (CKD). Thus, β-catenin-GOF; Notch-GOF and Vhl-LOF; β-catenin-GOF mouse mutants did not develop kidney tumors under the given experimental conditions.

Das Nierenzellkarzinom ist in Europa die 10. häufigste Tumorerkrankung [1]. Da das Prädi- lektionsalter bei 62 Jahren liegt [2] und die Inzidenz mit steigendem Alter zunimmt, geht die Erkrankung häufig mit einer Vielzahl an Komorbiditäten einher. Dies fordert eine Auseinan- dersetzung mit der Anwendung minimal invasiver Methoden, die das operative Risiko mini- mieren. Immernoch wird die Therapie durch radikale Nephrektomie favorisiert. Ziel der Stu- die war es deshalb Entscheidungshilfen für die Anwendung der Radiofrequenzablation (RFA) zu liefern. Daher untersuchten wir an Hausschweinen technische Einflussgrößen auf Behandlungszeit, Ablationsvolumen und Läsionsform bei bipolarer und multipolarer RFA im Vergleich. Dabei ergaben sich nach 3-D-Rekonstruktion größere Ablationsvolumina im mul- tipolaren Modus, wobei sich signifikante Formunterschiede in beiden Anwendungen heraus- kristallisierten. Bei multipolarer RFA ergaben sich größere Inhomogenitäten. Die Ablation kleinerer Tumorgrößen unter 2 cm erscheint mit bipolarer RFA sicher. Patienten mit Tumo- ren bis zu 3 cm profitieren von mutipolarer Radiofrequenzablation. Die Anwendung multi- polarer RFA bei Tumoren größer 3 cm gestaltet sich durch die inhomogene Ablation schwie- rig und bietet ein schwer kalkulierbares Risiko für die Patienten. Es konnte kein Vorteil durch Steigerung des Energietransfers innerhalb eines Modus nachgewiesen werden, da dies mit einer längeren Behandlungszeit einherging, jedoch nicht mit einer Zunahme der Läsiongröße korrelierte. Bei Patienten mit Niereninsuffizienz, Einzelnieren oder bilateralen Tumoren liegt ein Hauptaugenmerk der Therapie auf dem Erhalt der Nierenfunktion. Um eine mögliche Schädigung von gesundem Nierengewebe durch die RFA zu detektieren, färbten wir die Mar- kerproteine aktivierte Caspase3 und HSP70 immunohistochemisch an. Bei Ablation nahe des Nierenbeckenkelchsystems konnten beide Proteine sowohl im System des distalen Sammel- rohrs, als auch im Nierenmark gefunden werden. Hauptsächlich war das Auftreten jedoch auf die Randgebiete der zentralen Koagulationszone begrenzt. Die Radiofrequenzablation scheint daher ein sicheres Verfahren für die Therapie von Tumoren ≤ 3 cm zu sein.

La prise en charge thérapeutique des tumeurs rénales a considérablement évolué ces dernières années avec l’avènement de traitements mini-invasifs (comme la radiofréquence percutanée) qui optimisent l’épargne néphronique, améliore le confort du patient avec une efficacité oncologique comparable aux traitements chirurgicaux de référence. La prochaine étape serait de proposer des traitements transcutanés aussi performants avec une morbi-mortalité optimisée. L’objectif des travaux réalisés au LIIE du CERIMED (AMU) et au CRCHUM (Université de Montréal) était de développer une alternative à la radiofréquence rénale percutanée que nous utilisons en pratique clinique à Marseille depuis plus de 10 ans et qui a fait ses preuves. Cette alternative doit permettre de traiter des masses rénales avec un niveau d’efficacité et un taux de complications au minimum identique à la RFA, par application transcutanée d’agents physiques sans abord percutané (projet KiTT). Cela passe par la mise au point d’une technique de détection en temps réel de la masse rénale. Nous avons pu développer un algorithme de repérage fiable qui doit encore être optimisé (rapidité de calcul) et être validé sur un modèle qui n’est pas encore disponible. Les travaux d’optimisation et de validation des algorithmes de segmentation, de fonction de mérite de corrélation croisée associée à la fonction d’optimisation Simplex, sont en cours dans le cadre d’une collaboration internationale franco-canadienne au LIIE et au LIO. Même si nous n’avons pas encore la possibilité de proposer ce type de traitement, nos travaux permettent de s’en approcher pour pouvoir les proposer dans les prochaines années
The therapeutic management of renal tumors has changed considerably in recent years with the advent of minimally invasive therapies (such as percutaneous radiofrequency) that maximize nephron savings, improves patient comfort with efficiency comparable to surgical oncology treatments reference. The next step would be to propose transcutaneous treatment (HIFU, stereotactic radiotherapy ...) as efficient with optimized morbidity and mortality.The objective of this work in the context of the LIIE of CERIMED (Aix-Marseille Université) and CRCHUM (Université de Montréal) was to develop an alternative to percutaneous renal radiofrequency we use in clinical practice Marseille for over 10 years and has proved its worth. This alternative must be capable of treating renal masses with a level of effectiveness and complication rates at least equal to the RFA, by applying transcutaneous physical agents without percutaneous approach (project KITT (Kidney Tracking Tumor)). This requires the design of technical point detection in real time of the renal tumor.We were able to develop a reliable identification algorithm that has yet to be optimized (speed of calculation) and be validated on a model that is not yet available. Work optimization and validation of segmentation algorithms, cross correlation merit function associated with Simplex optimization function, are underway as part of an international collaboration to French-Canadian LIIE and LIO.Even if we have not the opportunity to offer this type of treatment, our work allows to approach in order to offer them in the coming years

Aim of this study was to evaluate the association between cancer occurrence and risk of graft failure in kidney transplant recipients. From 1998 to 2013, 672 adults receiving their first kidney transplant from a deceased donor, with at least six months of follow-up, were included in the study. To illustrate the effect of tumors incidence on graft failure risk, a modified Kaplan-Meier method was used. To quantify the tumor effect as hazard ratio, multivariable adjusted Cox models were fitted considering the diagnosis of non-cutaneous malignancies (NCM) and non-melanoma skin cancer (NMSC) as a time-dependent covariates. The 5-year cumulative incidence of graft failure was 7.5% (95%CI: 5.3-10.0), with 59 events (39 due to chronic rejection and 20 for other causes). Forty patients developed a NCM (5-yrs cumulative incidence: 5.6%), and 47 developed a NMSC (5-yrs cumulative incidence: 6.5%). From the multivariable Cox model, the adjusted hazard ratio of graft failure associated with NCM was 3.27 (95%CI=1.44-7.44, p=0.005). The occurrence of a NMSC was not associated with graft failure (HR = 0.80; 95% CI = 0.30-2.14, p = 0.66). The model validation procedure (a leave-one out cross validation) showed a C-statistics of 0.80 (95%CI: 0.72-0.88) for the cross-validated cohort, ruling out model overfitting and validating its predictive ability. Investigating the effects of NCM on cause-specific graft failure, an NCM diagnosis seemed to have a different association (P = 0.002) when considering graft failed due to chronic rejection (HR 0.55, 95% CI: 0.07-4.08) or for other causes (HR 15.59, 95% CI 5.43-44.76). The reduction of the immunosuppression after NCM was not associated with a greater risk of graft failure. In conclusion, our data suggest that post-transplant NCM may be a strong risk factor for graft failure, particularly for causes other than chronic rejection, and more efforts should be addressed to improve graft outcomes acting on malignancy-associated nephropathies.

Le cancer du rein se situe au 7ème rang des tumeurs solides de l'adulte et son incidence est en forte augmentation. L'objet de nos recherches a été d'étudier la carcinogénèse rénale et d'identifier des marqueurs pronostiques.Nous avons utilisé le marquage isobarique iTRAQ® pour réaliser une quantification relative des protéines de tumeurs rénales. Nous avons identifié 928 protéines, dont 346 avaient des expressions modifiées en fonction du profil d'agressivité des tumeurs. L'analyse des voies métaboliques impliquées a mis en évidence une amplification du métabolisme préférentiel du glucose en lactate et une diminution du métabolisme oxydatif dans les carcinomes agressifs. Quatorze protéines ont été sélectionnées comme étant de possibles biomarqueurs. Parmi ces protéines, nous avons pu confirmer que l'expression des tumeurs en TGFBI était un marqueur de mauvais pronostique.Pour appréhender la carcinogénèse rénale, nous avons étudié le locus de prédisposition au cancer du rein 12p11.23. La première étape de ce travail a été de confirmer par une étude de réplication indépendante que cette région génétique prédisposait au cancer du rein. La seconde étape nous a permis de démontrer que ce locus agissait comme un activateur de l'expression du gène SHARP1 par l'intermédiaire du facteur de transcription c-Jun et du SNP rs7132434. Des études complémentaires seront nécessaires pour déterminer la fonction, précise de SHARP1 dans la carcinogénèse rénale
Kidney cancer is the 7th largest solid tumors in adults and its incidence is rising. The purpose of our research was to study renal carcinogenesis and to identify prognostic biomarkers in clear cell renal cell carcinoma.We used the isobaric tagging iTRAQ® to perform a relative quantification of kidney tumor proteins. After proteomic analysis, 928 constitutive proteins were identified and 346 had a modified expression in tumor compared with that of normal tissue. Pathway and integrated analyses indicated the presence of an up-regulation of the pentose phosphate pathway in aggressive tumors. In total, 14 proteins were excreted and could potentially become biomarkers. Among them, we confirmed that TGFBI was significantly associated with oncologic outcomes.To understand renal carcinogenesis, we investigated the 12p11.23 renal cancer susceptibility locus. The first step was to confirm this locus by an independent study. Then we performed a functional analysis of the 12p11.23 region in relation to RCC risk. Our results suggest rs7132434 is a functional SNP at 12p11.23 responsible for the GWAS RCC signal, and that this locus acts as an enhancer of SHARP1 expression by binding c-Jun. Further investigations will be necessary to understand the role of SHARP1 in renal carcinogenesis

Le carcinome à cellules claires du rein (ccRCC) est une tumeur très hétérogène. Le taux de métastase est de l’ordre de 50% et les métastases des ccRCC sont peu fréquemment opérées. L’objectif de la thèse est d’une part d’analyser les facteurs prédictifs de métastases dans la tumeur primitive, et d’autre part de comparer le phénotype des tumeurs primitives et de leurs métastases dans le ccRCC par différentes approches histopathologiques et génomiques. Parmi les facteurs prédictifs de métastases, la nouvelle classification OMS/ISUP remplace l’ancienne classification de Fuhrman. L’intérêt pronostique de la nécrose tumorale est également mis en évidence. Une tumeur avec un grade donné associée à la présence de nécrose a un pronostic qui se rapproche d’une tumeur de grade plus élevé sans nécrose. Le pourcentage des cellules de grade 4 pourrait également contribuer à la stratification pronostique des patients. Une différence de survie avec un pronostic défavorable est observée pour les tumeurs dont le pourcentage des cellules de grade 4 est plus élevé (>50% vs. <10%). Au niveau moléculaire le statut du gène VHL, gène suppresseur de tumeur inactivé par un « double hit », est impliqué dans le pronostic des patients. Les ccRCC sans aucune altération de VHL sont des tumeurs plus agressives, qu’il convient d’isoler. Il existe une similarité morphologique et immunohistochimique entre les métastases et la composante de plus haut grade des tumeurs primitives correspondantes. Le profil chromosomique des métastases n’est pas totalement superposable à celui des tumeurs primitives. Il existe anomalies cytogénétiques récurrentes dans des métastases de ccRCC à des sites différents (+2p, +3q, +5, +8q, +12, +20). L’hétérogénéité tumorale retrouvée au niveau des tumeurs primitives est également retrouvée au niveau des métastases sous forme d’hétérogénéité inter- et intra-métastatique. L’analyse combinée des profils génomiques et transcriptomiques de 14 échantillons prélevés au sein d’un ccRCC primitif et de ses métastases ont permis d’identifier trois classes de clones tumoraux distincts, ne suivant aucune logique géographique. Enfin il semble exister un phénomène de multi-colonisation, qui implique non pas un, mais plusieurs clones tumoraux qui pourraient agir conjointement dans le processus métastatique
Clear cell renal cell carcinoma (ccRCC) is a heterogeneous tumor. The metastatic rate is 50% and metastases are only rarely surgically excised. The objective of this thesis was to analyze the predictive factors of metastasis in the primary tumor on one hand; and to compare primary and metastatic phenotypes on the other hand. We combined different histopathological and genomic approaches. Considering prognostic factors, the new WHO/ISUP classification replaces the previous Fuhrman grade. The interest of tumor necrosis is also highlighted. A tumor of a certain grade with necrosis has a prognosis that is close to a tumor of higher grade without necrosis. The percentage of grade 4 cells could additionally help in stratifying patients. A significant difference in survival is observed between tumors with more than 50% grade 4 cells and tumors with less than 10%. At a molecular level, the VHL gene status (tumor suppressor gene inactivated by a double hit) could be implicated in the prognosis of patients. ccRCCs with no alteration of the gene are more aggressive tumors that need to be identified. There exists a morphological and immunohistochemical similarity between metastases and the high-grade component in corresponding primary tumors. Moreover, the chromosomal profile of metastases differs from those of the corresponding primary tumors. Recurrent cytogenetic events are observed in different metastatic sites (+2p, +3q, +5, +8q, +12, +20). The tumor heterogeneity phenomenon in primary tumors is also observed in metastases with inter- and intra- metastatic heterogeneity. The combined analysis of transcriptomic and genomic analyses of 14 specimens extracted from a single ccRCC and its metastases divided samples into three classes of sub-clones with no spatial link. We observe a multi-colonization process that implies not only one but several tumor clones that could cooperate in the metastatic process

Hypoxia is one of the hallmarks of cancer. It was first postulated to occur in solid tumours by Thomlinson and Gray in 1955.1 The presence of hypoxia has been demonstrated in different types of solid tumours.2 Intratumoral hypoxia is caused by the lack of functional blood vessels in proliferating tumour tissue, resulting in low intratumoral oxygen concentrations. If hypoxia is severe or prolonged, cell death occurs.3 Malignant cells can undergo genetic and adaptive changes that allow them to escape from dying of oxygen deprivation. These changes are associated with a more aggressive malignant phenotype 4,5 conferring resistance to radiation 6,7 and chemotherapeutic agents.3,8,9 Hence hypoxia is known to be a key factor responsible for tumour resistance in humans.
Invasive polarographic oxygen sensor measurements have demonstrated hypoxia in solid tumours and it is generally defined to occur at an oxygen tension less than ten mmHg.10 Perhaps of more importance is that hypoxia has been demonstrated to be a prognostic indicator for local control after treatment with radiotherapy in glioma, head and neck and cervical cancers.11-13 It has also been able to predict for survival and the presence of distant metastases in soft tissue sarcomas.14 Finally, the significance of hypoxia in the activation and induction of functional molecules such as hypoxia inducible factors (HIFs) and VEGF, the modulation of gene expression (e.g. carbonic anhydrase IX), increased proto-oncogene levels, activation of nuclear factors and accumulation of other proteins (e.g. TP53) although progressing, is yet to be defined.15,16
Thus, it is of clinical interest to understand the levels of hypoxia and numbers of hypoxic cell populations in tumours, particularly those resistant to radiation and chemotherapy. In doing so clinicians and researchers may formulate more accurate prognostic information and develop treatments targeting hypoxic cells. Renal cell carcinoma (RCC) is a tumour resistant to radiation and chemotherapy that is yet to have its oxygen status investigated.
Although the “gold standard” of oxygen tension measurement is the Polarographic Oxygen Sensor (POS or Eppendorf pO2 histograph), non-invasive means of measuring oxygen status via imaging, immunohistochemistry or serum tumour markers are more practical. As highlighted by Menon and Fraker, it is imperative that reliable, globally usable, and technically simplistic methods be developed to yield a consistent, comprehensive, and reliable profile of tumour oxygenation. Until newer more reliable techniques are developed, existing independent techniques or appropriate combinations of techniques should be optimized and validated using known endpoints in tumour oxygenation status and/or treatment outcomes.17
Hanahan and Weinberg 18 surmised that the field of cancer research has largely been guided by a reductionist focus on cancer cells and the genes within them- a focus that has produced an extraordinary body of knowledge. Looking forward in time, they believe that progress in cancer research would come from regarding tumours as complex tissues in which mutant cancer cells have conscripted and subverted normal cell types (endothelial cells, immune cells, fibroblasts) to serve as active collaborators in their neoplastic agenda. The interactions between the genetically altered malignant cells and these supporting coconspirators will prove critical to understanding cancer pathogenesis and to the development of novel, effective therapies.18
Essentially, the background outlined here not only highlights the core aim of this thesis: to better understand the oxygen status of renal cell carcinoma and the relationship of this to angiogenesis so that better targeted therapies may be pursued in the future; but it also places this research in the context of the future proposed by Hanahan and Weinberg,18 by clearly focusing on collaborators in the neoplastic agenda, rather than just tumour cells themselves, to better understand RCC.

INTRODUZIONE E SCOPI: Il miglioramento dei tassi di sopravvivenza dei pazienti neoplastici per effetto dei nuovi agenti chemioterapici, inclusi i farmaci biologici, ha determinato un aumento di coloro che sviluppano malattia renale conseguente alla neoplasia. L’incidenza complessiva e la prevalenza dell’insufficienza renale cronica (IRC) nei pazienti affetti da tumore sono tuttavia ancora incerte, ma molte evidenze suggeriscono che il rischio sia elevato e in aumento. Lo studio ROCK ha come obiettivi principali quelli di stimare la prevalenza e l’incidenza dell’IRC ne pazienti inclusi nel Registro Tumori della provincia di Reggio Emilia dall'1° Gennaio al 31 Dicembre 2016. METODI: Studio di coorte monocentrico, osservazionale, retrospettivo. I pazienti saranno caratterizzati per sesso, età, etnia, peso, creatinina sierica e relativo eGFR, numero e tipo di tumore, diagnosi di diabete mellito. Le principali sedi di tumore considerato sono state mammella, colon-retto, polmoni, pancreas, stomaco, prostata, leucemie e linfomi. Un valore di eGFR ≥ 60 ml/min1.73m2 è stato considerato indicativo di una condizione di normofunzione renale, mentre un filtrato glomerulare < 60 ml/min/1.73m2 come indicativo di un’alterazione degli indici di funzione renale. Tutti i valori di eGFR sono stati inoltre ottenuti sia con la formula CKD-EPI, oggi riconosciuta come formula di riferimento per la stima dell’eGFR nella popolazione generale, ma anche con l’equazione di Wright che sembra fornire la stima migliore nel paziente oncologico. RISULTATI: sono stati identificati 4254 con diagnosi di cancro tra il 1° Gennaio e il 31 Dicembre 2016; di questi, 171 sono stati esclusi per mancanza di dati. Dei rimanenti 4083, 776 pazienti (19%) avevano almeno un valore di eGFR <60 mL/min/1.73m2 precedente alla diagnosi di cancro mentre 497 pazienti (11.7%) sono stati identificati come affetti da IRC. La prevalenza di IRC nei successivi 24 mesi dalla diagnosi di cancro è risultata essere di 4.4% (186 pazienti). Per entrambi le coorti (IRC pre-esistente e IRC di nuova diagnosi), sono state effettuate analisi relative a dati anagrafici e clinici. Facendo riferimento alla formula CKD-EPI, i pazienti con IRC pre-esistente (497), l'età media è risultata essere di 81 anni, il 53.7% erano maschi, il 18.3% aveva una diagnosi di diabete mellito tipo 2, il 3.6% di questi pazienti aveva due o più diagnosi di tumore; il 44.3% risultavano in vita al termine del follow-up (31 Dicembre 2018). Usando la formula di Wright, sono stati identificati 504 pazienti con IRC già presente al momento della diagnosi di cancro; questi pazienti presentavano un'età media di 82 anni, nel 55.4% dei casi erano maschi, il 18.8% era affetto da diabete mellito tipo 2 e il 3.8% aveva 2 o più diagnosi di tumore. CONCLUSIONI: Migliorare la conoscenza delle interazioni tra IRC e cancro sono di fondamentale importanza. La rapida evoluzione dei trattamenti e l’anticipazione diagnostica che si è avuta in molte sedi, hanno cambiato in modo drastico i fattori di rischio e prognostici dell’insufficienza renale nel paziente oncologico. L'applicazione di misure volte alla riduzione del rischio di progressione dell'IRC può pertanto migliorare gli outcomes clinici dei pazienti oncologici ad alto rischio.
BACKGROUND AND AIMS: The improvement in the survival rates of cancer patients due to the new oncological and biological agents has led to an increase in those who develop kidney diseases. It is now well known that chronic kidney disease (CKD) and cancer are connected in several ways. However, the overall incidence and prevalence of CKD in cancer patients are still uncertain, but much evidence suggests that the risk is high and increasing. The purpose of the study is to provide data on the prevalence and incidence of CKD in patients included in the Cancer Registry of the province of Reggio Emilia from January 1st to December 31st 2016. METHODS: single-center, observational and retrospective study. For all patients included, data on sex, age, ethnicity, serum creatinine and related eGFR, type and number of tumors, diagnosis of diabetes mellitus were collected. The main cancer sites considered were breast, colorectal, lungs, pancreas, stomach, prostate, lymphomas and leukemias. An eGFR ≥ 60 ml/min1.73m2 was indicative of a normal kidney function, while an eGFR <60 ml/min/1.73m2 as kidney impairment. All the eGFR data were calculated not only with the CKD-EPI formula, now recognized as the reference formula for estimating eGFR in the general population, but also with the Wright formula which seems to provide the best evaluation in cancer patients. RESULTS: 4254 patients with a cancer diagnosis were identified between January 1st and December 31st 2016; of these, 171 patients were excluded due to lack of data. Of the remaining 4083 patients, 776 (19%) had at least an eGFR value <60 mL/min/1.73m2 prior to cancer diagnosis and 497 patients (11.7%) were identified as affected by CKD. The prevalence of CKD was 4.4% (186 patients) calculated in the following 24 months from cancer diagnosis. For both cohorts of patients (pre-existing CKD and CKD diagnosed at the time of cancer diagnosis), descriptive analyzes were conducted related to personal and clinical data. Referring to the CKD-EPI formula, in patients with pre-existing CKD (497 patients), the mean age was 81 years, 53.7% were men, 18.3% had a known diagnosis of type 2 diabetes mellitus, 3.6% of these patients had 2 or more cancer diagnosis in the study period. 44.3% were alive at the end of the follow-up (December 31st, 2018). Using Wright formula, 504 patients with CKD already present at the time of cancer diagnosis were identified; these patients had an average age of 82 years and in 55.4% of cases were men; 18.8% had type 2 diabetes mellitus and 3.8% had 2 or more cancer diagnosis. CONCLUSIONS: Knowledge of association between CKD and cancer is critically relevant information. Therefore, the rapid evolution of treatments and the diagnostic anticipation have changed the risk and prognostic factors of kidney diseases in cancer patients. Application of measures to reduce the risk progression of CKD could improve the clinical outcomes high risk cancer patients.

Epidermal growth factor receptor (ErbB1) and somatostatin receptors (SSTRs) exert opposing effects on tumor promoting signaling pathways. Whether SSTRs functionally interact with ErbB1 and modulate tumor-promoting signaling is currently unknown. For this reason, the specific emphasis of this thesis is to examine the role of SSTRs in ErbB1 mediated signaling in breast cancer cells and human embryonic kidney (HEK) 293 cells. First, I determined the mRNA and protein expression of SSTR1, SSTR5 and ErbB1 in human breast cancer cell lines namely MCF-7 and MDA-MB231. I next demonstrated that SSTR1 or 5 exist as pre-formed heterodimers with ErbB1, which dissociated in an agonist dependent manner. Somatostatin (SST) modulated epidermal growth factor (EGF) mediated MAPK in a time and agonist dependent manner. Furthermore, SST and/or EGF treatment altered the expression of key adapter proteins including Grb2, SOS, Shc, SH-PTP1 and SH-PTP2, which are known to play a role in MAPK activation. Since breast cancer cells endogenously express SSTR and ErbB subtypes, this study was further extended in HEK-293 to gain insight into the effect of individual SSTR on ErbB1 activated signaling. We demonstrated that HEK-293 cells transfected with SSTR1, SSTR5 or SSTR1/5 negatively regulate EGF mediated effects attributed to the inhibition of ErbB1 phosphorylation, MAPKs and PI3K/AKT pathways. Moreover, SST effects were significantly enhanced in cells when ErbB1 was knocked down using small interference ribonucleic acid (siRNA) or treated with selective ErbB1 antagonist (AG1478). The presence of SSTRs, in addition to modulating signaling pathways, led to the dissociation of constitutive and EGF induced heteromeric complex of ErbB1/ErbB2. Most significantly, cells co-transfected with SSTR1/5 display pronounced effects of SST on the signaling and dissociation of the ErbB1/ErbB2 heteromeric complex than cells expressing either SSTR1 or 5 alone. The findings of this study discovered a new mechanism and potential role of SSTRs in attenuation of ErbB1 mediated signaling pathways via dissociation of ErbB1/ErbB2 heteromeric complex. In conclusion, the results presented in this thesis suggest that formulating novel drugs that activate SSTRs along with inhibition of ErbB1 might likely serve as an important therapeutic approach in the treatment of ErbBs positive tumors.

Pyelonefrit är en inflammation i njurarna och undersökningen som främst används vid utredning är dimerkaptosuccinat (DMSA)-scintigrafi. Pyelonefrit drabbar framförallt barn och risk finns för njurparenkymskador. Syftet med studien var att utreda om DMSA-scintigrafi efter pyelonefrit hos barn är berättigad. Detta granskades genom att beräkna den generella risken för cancer, specifika riskökningen för njurparenkymcancer, antal upptäckta njurparenkymskador och eventuella könsskillnader. Vetenskapliga artiklar söktes upp via sökmotorn PRIMO. Metoden var retrospektiv med kvantitativ ansats där materialet bestod av svarsutlåtanden från DMSA-scintigrafier på barn 0-2 år med frågeställning njurparenkymskador efter pyelonefrit. Urvalet bestod av 91 barn; 52 flickor och 39 pojkar varav 16 stycken exkluderades. Av de studerade 75 barnen hade sex (8 %) njurparenkymskador, med medelålder på 9,2 månader, och det fanns ingen signifikant skillnad mellan kön och njurparenkymskada (p=0,246). Medelvärdet på given aktivitet gav en effektiv medeldos på 0,69 mSv. Den generella riskökningen vid en DMSA-scintigrafi blev 0,01-0,014 och 0,00019 för njurparenkymcancer. Trots att relativt få barn drabbas av njurparenkymskador, finns ändå risk att drabbas av komplikationer från skadan. Skadorna är därför viktiga att upptäcka. Riskökningen för cancerutveckling och njurparenkymcancer efter DMSA-scintigrafi är mycket låg. Nyttan (att upptäcka njurparenkymskadorna) överväger risken (strålningen), vilket gör DMSA-scintigrafin till en berättigad undersökningsmetod.
A dimercaptosuccinic acid (DMSA) scintigraphy is used to test for pyelonephritis, an inflammation of the kidneys with risk of renal scarring. Aiming to investigate if DMSA scan after pyelonephritis in children is justified, we calculated the general cancer risk, the specific increased renal cancer risk, the number of discovered renal scarring and potential differences between the sexes. The method was retrospective and quantitative and data was based on results from DMSA scans of children aged 0-2 years. From the original set of 91 children (52 girls, 39 boys), 16 were excluded. Of the remaining 75, six (8 %) had renal scarring; with an average age of 9,2 months, and there was no significant difference between sex and renal parenchymal damage (p=0,0246). The mean activity from a DMSA scan equaled an effective dose of 0.69 mSv, with general cancer versus renal cancer risk being 0.01-0.014 and 0.00019, respectively. Even though only a few children develop renal scarring, there is still a risk of complications. Renal scarring is therefore important to discover. The increased risk for cancer and renal cancer after a DMSA scan is low. The benefits (discovering renal scarring) are greater than the risk (radiation), making the DMSA scan justified.

Cancer Chemotherapy treatment involves the administration of drugs to patients, these drugs mainly work by interacting with the cell cycle or inhibiting DNA synthesis. Unfortunately, the toxicity of these chemotherapy drugs is severe and can have serious side-effects on different tissues and organs of the body. In chemotherapy treatment about 85% of cancer patients exhibit some degree of liver or kidney damage. Therefore, the aim of this study was to investigate the cytotoxicity of some of the most commonly used chemotherapy drugs; Methotrexate (MTX), Etoposide, Cisplatin and Doxorubicin (DOX) on liver and kidney cell lines (HepG2, Huh7.5, COS-7 and HK2). Therefore, our focus were on studying the molecular mechanism by which these drugs cause cell death in liver and kidney cells. This study also investigated the effects of some Ca2+ binding proteins (RGN, SERCA1, SERCA2b, SPCA1a, SPCA2) to test their ability to decrease the toxicity of these chemotherapeutic drugs in liver and kidney cells. The results showed that Etoposide, Cisplatin and DOX induce cell death in both kidney and liver cell lines via several different pathways such as apoptosis, necrosis, and autophagy. The results presented here also showed that several of the drugs used induced cell death by a novel new autophagic pathway in liver and kidney cells. Our data also suggested that regucalcin (RGN) and the endoplasmic reticulum Ca2+ pumps (SERCA1 and SERCA2b), but not the secretory pathway Ca2+ pumps (SPCA1a and SPCA2) were able to protect against different types of chemotherapy-induced toxicity in liver and kidney cells. These new observations will help to build up our awareness of the diverse effect of these drugs have on liver and kidney cells and may also help to develop protective interventions and strategies in the future to reduce hepatotoxicity and nephrotoxicity caused by these drugs.

The objective of this PhD research was the development of novel 3D interactive medical platforms for medical image analysis, simulation and visualisation, with a focus on oncology images to support clinicians in managing the increasing amount of data provided by several medical image modalities. DoctorEye and Automatic Tumour Detector platforms were developed through constant interaction and feedback from expert clinicians, integrating a number of innovations in algorithms and methods, concerning image handling, segmentation, annotation, visualisation and plug-in technologies. DoctorEye is already being used in a related tumour modelling EC project (ContraCancrum) and offers several robust algorithms and tools for fast annotation, 3D visualisation and measurements to assist the clinician in better understanding the pathology of the brain area and define the treatment. It is free to use upon request and offers a user friendly environment for clinicians as it simplifies the implementation of complex algorithms and methods. It integrates a sophisticated, simple-to-use plug-in technology allowing researchers to add algorithms and methods (e.g. tumour growth and simulation algorithms for improving therapy planning) and interactively check the results. Apart from diagnostic and research purposes, it supports clinical training as it allows an expert clinician to evaluate a clinical delineation by different clinical users. The Automatic Tumour Detector focuses on abdominal images, which are more complex than those of the brain. It supports full automatic 3D detection of kidney pathology in real-time as well as 3D advanced visualisation and measurements. This is achieved through an innovative method implementing Templates. They contain rules and parameters for the Automatic Recognition Framework defined interactively by engineers based on clinicians’ 3D Golden Standard models. The Templates enable the automatic detection of kidneys and their possible abnormalities (tumours, stones and cysts). The system also supports the transmission of these Templates to another expert for a second opinion. Future versions of the proposed platforms could integrate even more sophisticated algorithms and tools and offer fully computer-aided identification of a variety of other organs and their dysfunctions.

Les cancers du rein métastatiques résistants aux inhibiteurs de tyrosine kinase peuvent faire l’objet de traitements fondés sur le blocage des points de contrôles immunitaires (ICB). Cependant, les ICB induisent des réponses chez une minorité de patients, et des efforts sont en cours pour identifier les mécanismes à l'origine de la résistance. Les ICB compromettent l'intégrité de la barrière intestinale, affectant ainsi la composition du microbiote, favorisant ainsi soit l'accumulation intestinale, soit la translocation de commensaux immunogènes capables de moduler le tonus immunitaire systémique et de reprogrammer le microenvironnement tumoral. Pour déterminer si des profils microbiens distincts du microbiote intestinal pourraient expliquer la résistance aux ICB, ma thèse a montré que dans une cohorte de 249 patients atteints de cancer traités par ICB que la prescription d’antibiotiques (ATB) a significativement diminué la survie sans progression (PFS) et la survie globale (OS) par rapport aux patients sans ATB. Nous avons confirmé ces données en analysant 121 cencers du rein traités par ICB à Gustave Roussy et 239 cancers du poumon traités par ICB au Memorial Sloan Kettering Cancer Center. Nous avons validé que la dysbiose liée à l'ATB diminue l'activité des ICB. Par la suite, nous avons analysé de manière prospective les microbiotes fécaux de 100 patients atteints de tumeurs sensibles à l'anti-PD-1 en utilisant la métagénomique (MG). Nous avons démontré que les bactéries intestinales présentes avant le traitement anti-PD-1 étaient systématiquement différentes entre les patients qui ont répondu (R) au traitement et les patients qui n’ont pas (NR). Entre les R, nous avons observé une surreprésentation d’Akkermansia muciniphila. Au sein d'une large cohorte de patients RCC (n = 85) traités avec un anticorps anti-PD-1, nous avons analysé le microbiote fécal de 69 patients. Des empreintes de MG spécifiques étaient liées aux meilleures réponses et à la survie sans progression. A. muciniphila et Bacteroides spp étaient plus abondants chez les R. Pour valider la pertinence de ces constatations, nous avons mis en évidence deux principaux éléments de preuve. Premièrement, nous avons démontré que chez les patients atteints de NSCLC, la présence de lymphocytes T CD4 + et CD8 + à mémoire spécifiques de l’IFNγ + vis-à-vis de A. muciniphila prédit une PFS plus longue. Deuxièmement, une transplantation de microbiote fécal (FMT) a été réalisée à l'aide de selles de patient pour recoloniser des souris axéniques ou traitées par ATB dans deux modèles murins. Les matières fécales de R entrainaient une réponse immunitaire plus forte contre la tumeur par rapport aux matières fécales de NR. Ensuite, une supplémentation orale d'A. muciniphila post-FMT avec des matières fécales de NR restaurait l'efficacité de l'anti- PD-1. Dans ce contexte, les cellules dendritiques sécrétaient plus d'IL-12, augmentant le recrutement de lymphocytes T CCR9 + CXCR3 + CD4 + à partir des ganglions lymphatiques mésentériques jusque dans les lits tumoraux, ainsi qu'une augmentation du rapport CD4 + /Treg dans le lit tumoral de souris co-traitées avec mAb anti-PD-1 et A. muciniphila. Enfin, nous avons montré qu'une supplémentation orale avec Bacteroides (B. salyersiae mais pas B. xylanisolvens) ou A. muciniphila pourrait restaurer l'efficacité des ICB dans un modèle FMT- défavorable/dysbiotique". La découverte de bactéries immunogènes capables de prédire et d'accroître les avantages cliniques de l'ICB contribuera au développement de nouveaux outils de biomarqueurs et d'un futur concept thérapeutique, grâce auxquels le traitement du cancer peut être amélioré par la modulation du microbiote intestinal
Metastatic RCC resistant to tyrosine kinase inhibitors are amenable to new therapies based on immune checkpoint blockade (ICB). However, ICB induces responses in a sizeable minority of patients and efforts are ongoing in order to identify mechanisms driving resistance. ICB compromise the integrity of the intestinal barrier, hereby affecting the composition of the intestinal microbiome, thereby promoting either the intestinal accumulation or the translocation of immunogenic commensals capable of modulating the systemic immune tone and reprogramming the tumor microenvironment. To address whether distinct microbial patterns of the intestinal microbiome could account for the resistance to ICB in RCC, during my PhD I showed in a cohort of 249 patients with cancers treated with ICB that antibiotic (ATB) prescription in a therapeutic window of -2 months up to +1 month after starting ICB significantly decreased progression-free survival (PFS) and overall survival (OS) compared to patients without ATB. We confirmed this data analyzing 121 RCC treated with ICB at Gustave Roussy and 239 NSCLC treated with ICB at Memorial Sloan Kettering Cancer Center. We validated that ATB-related dysbiosis decreases activity of ICB. More precisely, patients in RCC ATB group treated with ICB had a higher rate of primary progressive disease. Subsequently, we prospectively analyzed the fecal microbiomes of 100 patients with tumours amenable to anti-PD-1 mAb using quantitative metagenomics (MG) by shotgun sequencing. We demonstrated that gut bacteria present before anti-PD-1 therapy was consistently different between patients who responded (R) to treatment and patients who did not (NR). In R we observed an overrepresentation of un- and classified Firmicutes. The commensal most significantly associated with favorable clinical outcome and PFS was Akkermansia muciniphila. Within a large cohort of RCC patients (n = 85) treated in the NIVOREN study with anti-PD-1 Ab at Gustave Roussy, we analyzed the fecal microbiome of 69 patients. Specific MG-fingerprints were related to best responses and PFS. A. muciniphila and Bacteroides spp were more abundant in R (Derosa et al. ASCO Merit Award 2018). To validate the relevance of these findings, we brought up two major lines of evidence. First, we demonstrated that in NSCLC patients, the presence of specific IFNγ+ memory CD4+ and CD8+ T cells toward A. muciniphila predicted a longer PFS. Secondly, fecal microbiota transplantation (FMT) was performed using patient feces to recolonize germ-free or ATB-treated mice in two tumor models (MCA-205 and RENCA, the renal cell carcinoma model). Feces from R conveyed a stronger immune response against the tumor compared to feces from NR. Next, in MCA-205 model oral supplementation with A. muciniphila post-FMT with NR feces restored the efficacy of PD-1 Abs. In this setting, dendritic cells secreted more IL-12, increasing the recruitment of CCR9+CXCR3+CD4+ T lymphocytes from the mesenteric lymph nodes into tumor beds as well as an increase of CD4+/Treg ratio within the tumor bed of mice co-treated with anti-PD-1 mAb and A. muciniphila. Finally, we showed that oral supplementation with Bacteroides (B. salyersiae but not B. xylanisolvens) or A. muciniphila could restore the efficacy of ICB in "unfavorable/dysbiotic" FMT. The discovery of immunogenic bacteria capable of predicting and increasing clinical benefit of ICB will help for the development of novel biomarker tools and a future therapeutic concept, whereby treatment of cancer can be improved by the modulation of gut microbiome

Les malalties renals es deriven de defectes congènits, lesions renals agudes (AKI) o malalties renals cròniques (CKD), entre altres causes. La lesió renal d’isquèmia /reperfusió (IRI), que es troba en moltes situacions clíniques, és una de les causes principals de l’AKI que causen lesions i mort de cèl·lules epitelials del túbul proximal (PTEC). La gravetat de l’AKI i la capacitat de regenerar-se després de la lesió són determinants importants de la morbiditat i mortalitat dels pacients en un entorn hospitalari. Els homes són més propensos a la malaltia renal aguda i crònica i a avançar fins a la malaltia renal en fase final (ESRD) que les dones i actualment s’accepta que els andrògens, i no l’absència d’estrògens, són responsables d’això. S’accepta que la regeneració per PTEC supervivent és el mecanisme predominant de reparació/regeneració després de lesions tubulars isquèmiques al ronyó adult de mamífer. Les PTEC són també el lloc on s’origina el carcinoma de cèl·lules renals de cèl·lules clares (ccRCC) en humans. El ccRCC també presenta diferències de sexe, amb els homes que tenen gairebé el doble de la incidència de les dones a nivell mundial. Això va conduir a la hipòtesi que la regeneració després de lesions renals i el desenvolupament de ccRCC podrien compartir repertoris d’expressió gènica similars. Els andrògens són molt rellevants en el desenvolupament dels ronyons, cosa que suggereix que la regeneració i el càncer en les cèl·lules del túbul proximal poden recapitular, en part, els programes dependents dels andrògens en el desenvolupament del ronyó. En aquest projecte, hem volgut trobar dianes que participin en la regeneració renal i en processos de càncer renal. A més, ens va interessar estudiar la regulació de l’hormona sexual en aquestes vies. Es van realitzar anàlisis detallades de dades transcriptòmiques d’un model porcí d’AKI. Es van determinar gens que expressaven un dimorfisme sexual a tota la IRI i es van validar dianes en mostres humanes. A més, es van determinar els conjunts de gens implicats en la IRI i es van caracteritzar de manera sexual i de temps. Vam trobar que els grups genètics relacionats amb els processos de regeneració eren més actius en les dones que en els homes. A més, la resposta immune a la lesió va ser més gran en homes que en dones. Després, van vincular els processos de regeneració amb ccRCC mitjançant la superposició entre les anàlisis del transcriptomes AKI i ccRCC. A més, hem trobat diferències importants entre els transcriptomes de ronyó de ratolí i de porc després de la lesió renal. Es va establir un model in vitro d’IRI renal i es va permetre validar parcialment les troballes in vivo. Entre d’altres, vam observar que durant la IRI renal, STAT3 està regulat per la fosforilació de diferents residus. Aquest estudi constitueix una caracterització extensiva de les diferències de sexe existents durant la IRI renal. Ofereix una plantilla per caracteritzar més les diferències de sexe en malalties renals a nivell molecular.
Las enfermedades renales se derivan de defectos congénitos, lesiones renales agudas (AKI) o enfermedad renal crónica (CKD), entre otras causas. La lesión renal de isquemia / reperfusión (IRI), que se encuentra en muchas situaciones clínicas, es una de las causas principales de AKI que causan lesiones y muerte de células epiteliales del túbulo proximal (PTEC). La gravedad de AKI y la capacidad de regenerarse después de la lesión son determinantes importantes de la morbilidad y mortalidad de los pacientes en un entorno hospitalario. Los hombres son más propensos a la enfermedad renal aguda y crónica y avanzar hasta la enfermedad renal en fase final (ESRD) que las mujeres y actualmente se acepta que los andrógenos, y no la ausencia de estrógenos, son responsables de esto. Se acepta que la regeneración por PTEC superviviente es el mecanismo predominante de reparación/regeneración después de lesiones tubulares isquémicas en el riñón adulto de mamífero. Las PTEC son también el lugar donde se origina el carcinoma de células renales de células claras (ccRCC) en humanos. El ccRCC también presenta diferencias de sexo, con los hombres que tienen casi el doble de la incidencia de las mujeres a nivel mundial. Esto condujo a la hipótesis de que la regeneración después de lesiones renales y el desarrollo de ccRCC podrían compartir repertorios de expresión génica similares. Los andrógenos son muy relevantes en el desarrollo de los riñones, lo que sugiere que la regeneración y el cáncer en las células del túbulo proximal pueden recapitular, en parte, los programas dependientes de los andrógenos en el desarrollo del riñón. En este proyecto, hemos querido encontrar dianas que participen en la regeneración renal y en procesos de cáncer renal. Además, nos interesó estudiar la regulación de la hormona sexual en estas vías. Se realizaron análisis detallados de datos transcriptómicas de un modelo porcino de AKI. Se determinaron genes que expresaban un dimorfismo sexual en toda la IRI y se validaron dianas en muestras humanas. Además, se determinaron los conjuntos de genes implicados en la IRI y se caracterizaron de forma sexual y de tiempo. Encontramos que los grupos genéticos relacionados con los procesos de regeneración eran más activos en las mujeres que en los hombres. Además, la respuesta inmune a la lesión fue mayor en hombres que en mujeres. Después, hemos vinculado los procesos de regeneración con ccRCC mediante la superposición entre los análisis del transcriptomas AKI y ccRCC. Además, encontramos diferencias importantes entre los transcriptomas de riñón de ratón y de cerdo tras la lesión renal. Se estableció un modelo in vitro de IRI renal y se permitió validar parcialmente los hallazgos in vivo. Entre otros, observamos que durante la IRI renal, STAT3 está regulado por la fosforilación de diferentes residuos. Este estudio constituye una caracterización extensiva de las diferencias de sexo existentes durante la IRI renal. Ofrece una plantilla para caracterizar más las diferencias de sexo en enfermedades renales a nivel molecular.
Kidney diseases arise from congenital defects, acute kidney injury (AKI) or chronic kidney disease (CKD), among other causes. Renal ischemia/reperfusion injury (IRI), which is faced in many clinical situations, is a major cause of AKI leading to injury and death of proximal tubule epithelial cells (PTEC). The severity of AKI and the capacity to regenerate after injury are important determinants of patient morbidity and mortality in the hospital setting. Men are more prone to acute and chronic kidney disease and to progress to end-stage renal disease (ESRD) than women and it is currently accepted that androgens, and not the absence of estrogens, are responsible for that. It is accepted that regeneration by surviving PTEC is the predominant mechanism of repair/regeneration after ischemic tubular injury in the adult mammalian kidney. PTEC are also the site where the clear cell renal cell carcinoma (ccRCC) originates in humans. ccRCC also exhibits sex differences, with males having almost twice the incidence of females globally. This led to the hypothesis that regeneration after kidney injury and ccRCC development might share similar gene expression repertoires. Androgens are very relevant in kidney development, which suggests that regeneration and cancer in proximal tubule cells might recapitulate, in part, androgen-dependent programs in kidney developmental. In this project, we aimed to find targets that participate in renal regeneration and in renal cancer processes. Moreover, we were interested to study the sex hormone regulation of these pathways. Thorough analyses of transcriptomic data from a porcine model of AKI was performed. We determined genes that expressed a sexual dimorphism throughout IRI and we validated theses targets in human samples. Furthermore, we determined the gene sets involved in IRI and characterize them in a time and sex manner. We found that gene sets related to regeneration processes were more active in females than in males. Also, the immune response at injury was higher in males than in females. Afterwards, we linked regeneration processes with ccRCC by the overlap between AKI and ccRCC transcriptome analyses. Besides, we found major differences between the mouse and the pig kidney transcriptomes upon renal injury. An in vitro model of renal IRI was established and allowed to partially validate the in vivo findings. Among others, we observed that during renal IRI, STAT3 is regulated by phosphorylation of different residues. This study constitutes an extensive characterization of the sex differences that exist during renal IRI. It offers a template for further characterization of sex differences in kidney diseases at the molecular level.

Objectif: Environ 30% des patients ayant un cancer du rein métastatique présentent d’emblée des résistances aux agents de thérapie ciblée. Les autres patients développent des résistances thérapeutiques à plus long terme. Une amélioration de la capacité du clinicien à prédire la réponse thérapeutique avant l’initiation du traitement pourrait améliorer le pronostic des patients. Le but de notre projet a été de développer un modèle de xénogreffes dérivées de patients afin d’évaluer la sensibilité des cellules tumorales de chaque patient aux différents agents de thérapie ciblée, avant d’initier un traitement.Méthodes: La membrane chorio-allantoïque de l’embryon de poulet a servi de base à notre modèle. Dans une première phase de notre travail, une xénogreffe de cellules tumorales rénales humaines en suspension a été réalisée afin de vérifier que les caractéristiques histologiques et phénotypiques des tumeurs d’origine étaient conservées dans les xénogreffes réalisées sur notre modèle. Dans une seconde étape, des fragments tissulaires de tumeurs rénales de 5 patients opérés pour néphrectomie cytoréductive dans notre centre hospitalier étaient prélevés et greffés sur notre modèle (>60/patient). Différents agents dethérapie ciblée étaient testés sur les xénogreffes ainsi réalisées.Résultats : Les caractéristiques histo-pathologiques et phénotypiques des tumeurs rénales d’origine étaient conservées après xénogreffes. Il existait une hétérogénéité spatiale intra-tumorale en termes de sensibilité aux différents agents de thérapie ciblée. Il existait également un polymorphisme nucléotidique au sein des différentes régions de chaque tumeur rénale.Conclusion : Ce modèle de xénogreffes rénales dérivées de patients est utile pour l’évaluation de la sensibilité aux agents de thérapie ciblée des cellules tumorales en amont de la prise en charge thérapeutique. Ce modèle permet au clinicien de personnaliser le traitement de chaque patient ayant un cancer du rein métastatique, avant la mise en route d’un traitement systémique. Une évaluation prospective de notre modèle pourrait permettre de mieux appréhender les potentielles retombées cliniques liées à son utilisation
Objective: Approximately 30% of patients with metastatic renal cancer are resistant to targeted therapy agents. The other patients will eventually develop long-term therapeutic resistances. An improvement in the clinician's ability to predict therapeutic response before treatment initiation could improve patients' prognosis. The aim of our projet was to develop a patient-derived xenograft models to be able to test the sensibility of each patient's renal tumor cells to the different available targeted therapy agent prior to treatment.Methods: The chicken embryo chorioallantoic membrane has been the base of our model. In a first phase of our work, a xenograft of human kidney tumor cells has been carried out in order to verify that the histologic and phenotypic characteristics of the original tumors were preserved in the xenografts performed on our model. As a second step, fragments of the kidney tumor speciments of 5 patients undergoing cytoreductive nephrectomy in our hospital center were grafted on our model (> 60/patient). Different targeted therapy agents were tested on the xenografts we performed.Results: The histopathologic and phenotypic characteristics of the original renal tumors were preserved in our xenografts. There was intra-tumor spatial heterogeneity in terms of sensitivity in different targeted therapy agents. There was also a nucleotide polymorphism within the different regions of each renal tumor.Conclusion: This patient-derived renal xenograft model could be useful prior to treatment for the evaluation of each patients'renal tumor cells to the different available targeted therapy agents. This model could make it possible to personalize the treatment of each metastatic kidney cancer patient, prior to systemic treatment. A prospective evaluation of our model could help assess the potential clinical benefits of its use

In recent years, numerous cancers have been described as having a "cancer stem cell" (CSC) population also known as "cancer initiating cells". CSCs refer to a subset of tumour cells that has the ability to self-renew and generate the diverse cells that comprise the tumor. Their name derives from their "stem-like" properties and ability to continually sustain tumorigenesis. CSCs have the same properties that define a normal tissue adult stem cell, even if they are aberrant: self-renewal and differentiation. Renal cell carcinoma (RCC) accounts for about 3% of adult cancers and is among the 10 most common malignancies in Europe. RCC has several morphological subtypes and clear cell RCC accounts for ~80% of cases. RCC has a late diagnosis and is therapy resistant. In renal pathologies there are situation in which the presence and function of adult renal stem cells may have clinical relevance. In the last years the existence of different sources of renal stem cells has been proposed even if the phenotype of a resident stem cell of the kidney has not been exhaustively described. Even in RCC the definition of a kidney cancer stem cell may have a role for better understanding renal cell carcinoma biology. A number of approaches based on the exploitation of renal stem cell markers have allowed the prospective isolation of human renal stem cells, even if the relative promiscuity of these markers limits their usefulness when highly purified stem cells are needed. So we decided to use a functional approach for the isolation of normal and cancer stem cells of the kidney by culturing the cells in suspension, non-adherent conditions, at low density with specific growth factors. In these conditions only a little percentage of cells survives growing as spherical aggregates in suspension. We called them "nephrospheres". Using fluorescent lipophilic dyes PKH, we demonstrated the clonal origin of the spheres and the presence of a heterogeneous population inside the spheres. In fact the dye dilutes in active replicating cells while is retained in quiescent cells; we can observe in normal and cancer nephrospheres some most fluorescent cells, the quiescent stem cells, and some less fluorescent or not fluorescent cells, that are the active replicating progenitors. We performed a characterization of the nephrospheres by immunofluorescence after cytospin or FACS evaluating the expression of some epithelial and stem cell markers. By Real Time PCR we found that some genes related with stemness or involved in the maintenance of pluripotency are overexpressed in normal and cancer nephrospheres if compared with the corresponding differentiated primary cell cultures. We then evaluated the differentiative abilities of the cells derived from normal nephrospheres by culturing the cells in specific media and semisolid substrates; the cells are able to differentiate into epithelial and neuronal-like phenotype and to form tubular/glomerular-like tridimensional structures. We the isolated the stem cell population form normal nephrospheres on the basis of the PKH fluorescence. We identified 3 PKH populations: PKHhigh population, with a high level of fluorescence, PKHlow population, with a low level of fluorescence, and PKHneg population, negative for PKH. The populations were separated with cell sorting and cultivated to form spheres. Only PKHhigh cells were able to generate new spheres, demostrating that the PKHhigh cells represent the stem cell population inside the nephrospheres. Normal and cancer PKHhigh cells will be deeply characterized in the future.