Cutaneous squamous cell carcinoma and mortality in end-stage renal disease

Published:November 17, 2022DOI:



      In the general population, cutaneous squamous cell carcinoma (cSCC) is associated with increased all-cause mortality. Transplant patients have been shown to have an increased risk of developing cSCC, and their cSCC is associated with an increased risk for mortality. In end-stage renal disease (ESRD) patients, there is extensive mortality and immune dysfunction. Because of this immune system dysfunction, we examined whether cSCC is associated with increased risk of all-cause mortality among ESRD patients, as well as the risk factors for cSCC.


      We analyzed ESRD patients in the United States Renal Data System from 2004-2014, excluding organ transplant recipients. We assessed mortality using a Cox Proportional Hazards (CPH) model to control for various demographic and clinical parameters, identified using international classification of diseases (ICD)-9 codes.


      Of the 1,035,193 patients included, 624 (0.1%) were diagnosed with cSCC. The median survival time for those with cSCC was 3.91 years [95% confidence interval (CI) = 3.67-4.15], versus 2.92 years [95%CI = 2.92-2.93] for patients without cSCC. ESRD patients with cSCC were at lower risk of death [adjusted hazard ratio = 0.75; 95%CI = 0.69-0.82] compared to those without. Decreased risk of death was also associated with parameters such as black race, Hispanic ethnicity, tobacco dependence and actinic keratosis. Increased mortality risk was associated with increasing age, male sex, hemodialysis (versus peritoneal dialysis) and alcohol dependence.


      Contrary to expectations, ESRD patients with a cSCC diagnosis showed reduced all-cause mortality risk relative to those without. The reason for this discrepancy remains unclear, suggesting the need for further study.

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      1. Skin Cancer Facts & Statistics 2021 [cited 2021; Available from:

        • Wehner M.R.
        • et al.
        All-cause mortality in patients with basal and squamous cell carcinoma: a systematic review and meta-analysis.
        J Am Acad Dermatol. 2018; 78 (e3): 663-672
        • Jensen A.O.
        • et al.
        Mortality in Danish patients with nonmelanoma skin cancer, 1978-2001.
        Br J Dermatol. 2008; 159: 419-425
        • Garrett G.L.
        • et al.
        Incidence of and risk factors for skin cancer in organ transplant recipients in the United States.
        JAMA Dermatol. 2017; 153: 296-303
        • Garrett G.L.
        • et al.
        Trends of skin cancer mortality after transplantation in the United States: 1987 to 2013.
        J Am Acad Dermatol. 2016; 75: 106-112
        • Sanders M.L.
        • et al.
        Clinical and genetic factors associated with cutaneous squamous cell carcinoma in kidney and heart transplant recipients.
        Transpl Direct. 2015; 1: e13
        • Tang C.H.
        • et al.
        Increased risk of cutaneous squamous cell carcinoma in organ transplant recipients and patients on chronic dialysis: a cancer registry-based study in Taiwan.
        Acta Derm Venereol. 2019; 99: 1275-1281
        • Kato S.
        • et al.
        Aspects of immune dysfunction in end-stage renal disease.
        Clin J Am Soc Nephrol. 2008; 3: 1526-1533
        • Saran R.
        • et al.
        US renal data system 2017 annual data report: epidemiology of kidney disease in the United States.
        Am J Kidney Dis. 2018; 71 (Suppl 1): A7
        • Charlson M.E.
        • et al.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Deyo R.A.
        • Cherkin D.C.
        • Ciol M.A.
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
        J Clin Epidemiol. 1992; 45: 613-619
        • Schwade M.J.
        • et al.
        Treatment of psoriasis in end-stage renal disease patients is associated with decreased mortality: a retrospective cohort study.
        Am J Med Sci. 2021; 362: 24-33
        • Que S.K.T.
        • Zwald F.O.
        • Schmults C.D.
        Cutaneous squamous cell carcinoma: incidence, risk factors, diagnosis, and staging.
        J Am Acad Dermatol. 2018; 78: 237-247
        • Dusingize J.C.
        • et al.
        Cigarette smoking and the risks of basal cell carcinoma and squamous cell carcinoma.
        J Invest Dermatol. 2017; 137: 1700-1708
        • Kalantar-Zadeh K.
        • Kovesdy C.P.
        • Norris K.C.
        Racial survival paradox of dialysis patients: robust and resilient.
        Am J Kidney Dis. 2012; 60: 182-185
        • Kucirka L.M.
        • et al.
        Association of race and age with survival among patients undergoing dialysis.
        JAMA. 2011; 306: 620-626
        • Shapiro B.B.
        • et al.
        The relationship between ultraviolet light exposure and mortality in dialysis patients.
        Am J Nephrol. 2014; 40: 224-232
        • Yoon U.A.
        • et al.
        The impact of sunlight exposure on mortality of patients with end stage renal disease.
        Sci Rep. 2019; 9: 2230
        • Garcovish S.
        • et al.
        Skin cancer epidemics in the elderly as an emerging issue in geriatric oncology.
        Aging Dis. 2017; 8: 643-661
        • Radujkovic A.
        • et al.
        Vitamin D deficiency and outcome of COVID-19 patients.
        Nutrients. 2020; 12: 2757
        • Sarnak M.J.
        • Jaber B.L.
        Mortality caused by sepsis in patients with end-stage renal disease compared with the general population.
        Kidney Int. 2000; 58: 1758-1764
        • Eide M.J.
        • et al.
        Vitamin D and nonmelanoma skin cancer in a health maintenance organization cohort.
        Arch Dermatol. 2011; 147: 1379-1384
        • Afzal S.
        • Nordestgaard B.G.
        • Bojesen S.E.
        Plasma 25-hydroxyvitamin D and risk of non-melanoma and melanoma skin cancer: a prospective cohort study.
        J Invest Dermatol. 2013; 133: 629-636
        • Yan G.
        • et al.
        The relationship of age, race, and ethnicity with survival in dialysis patients.
        Clin J Am Soc Nephrol. 2013; 8: 953-961
        • Desai N.
        • et al.
        CKD and ESRD in US hispanics.
        Am J Kidney Dis. 2019; 73: 102-111
        • Prichard S.S.
        Comorbidities and their impact on outcome in patients with end-stage renal disease.
        Kidney Int. 2000; 57 (S-100-S-104)
        • Liebman S.E.
        • et al.
        Smoking in dialysis patients: a systematic review and meta-analysis of mortality and cardiovascular morbidity.
        Am J Kidney Dis. 2011; 58: 257-265
        • Misery L.
        Nicotine effects on skin: are they positive or negative?.
        Exp Dermatol. 2004; 13: 665-670
        • Gibson M.
        • et al.
        Nocardiosis in renal transplant patients.
        J Investig Med. 2022; 70: 36-45
        • System., U.S.R.D.
        USRDS annual data report: epidemiology of kidney disease in the United States.
        National Institute of Diabetes and Digestive and Kidney Diseases. National Institutes of Health, 2017