Background Cancer risk is increased by two- to four-fold in kidney transplant recipients (KTRs) compared to the general population. Little attention, however, has been given to KTRs with ultra long-term survival >20 years. Methods We studied 293 of 1241 KTRs (23.6%), transplanted between 1981 and 1999, who showed kidney allograft survival >20 years. These long-term survivors were analyzed for cancer development, cancer type, cancer-associated risk factors, patient and allograft outcomes. Results By 10, 20, and 30 years post-transplantation, these long-term KTRs showed a cancer rate of 4.4%, 14.6%, and 33.2%, and a nonmelanoma skin cancer (NMSC) rate of 10.3%, 33.5%, and 76.8%. By recipient ages of 40, 60, and 80 years KTRs showed a cancer rate of 3.4%, 14.5%, 55.2%, and a NMSC rate of 1.7%, 31.6%, and 85.2%. By 30 years post-transplant, PTLD showed the highest incidence of 8.5%, followed by renal cell carcinoma (RCC) with 5.1%. Risk factors associated with the development of cancer were only recipient age(p = 0.016). Smoking history was associated with the risk of lung cancer (p = 0.018). Risk factors related to the development of NMSC included recipient age (p = 0.001) and thiazide diuretics (p = 0.001). Cancer increased the risk of death by 2.4-fold (p = 0.002), and PTLD increased the risk of kidney allograft loss by 6.5-fold (p = 0.001). No differences were observed concerning the development of donor-specific antibodies (p>0.05). Conclusions In long-term KTRs cancer is a leading cause of death. PTLD remains the most common cancer type followed by RCC. These results emphasize the need for focused long-term cancer surveillance protocols.
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