Melanomas in renal transplant recipients

BACKGROUND: It is well documented that renal transplant recipients are at increased risk of developing skin cancers, in particular squamous cell carcinomas. Less extensively reviewed in the literature is the increased incidence of malignant melanoma. We have reviewed 10 patients in the Oxford renal transplant population who developed 12 melanomas following transplantation. OBJECTIVES: To determine the incidence and characteristics of melanoma in renal transplant recipients. METHODS: We reviewed the case notes and pathology of all patients who developed melanoma within the Oxford Renal Transplant Unit. The clinical details were recorded including date of transplant, immunosuppressive therapy, interval between transplant and melanoma, site of occurrence, history of sun exposure, type of clinician diagnosing the melanoma, history of other skin malignancies and outcome. From the histopathology we documented various prognostic factors. RESULTS: Ten patients developed 12 melanomas (one patient had three melanomas) from a population of 1874 transplanted patients. The total number of transplant years was 11 942.2. The incidence of melanoma in our population was 12 per 11 942.2 transplant years, which is approximately 8 times greater than the standardized rate for this region. We found that the mean interval between transplant and melanoma was approximately 11 years (median 8.5). A dermatologist was the diagnosing clinician in at least 67% of cases. Melanomas occurred on the trunk in the majority of cases (58%), followed by the upper limb (25%). All patients apart from one are alive with no recurrence of their melanoma. One patient died as a result of metastatic melanoma. The mean follow-up period following melanoma was 3.7 years. In all patients apart from the patient who died, the melanomas were < 1 mm Breslow thickness. That patient's melanoma was 4.5 mm thick. There was no precursor naevus in eight of the 12 melanomas. In two there was a precursor dysplastic naevus. In the cases in vertical growth phase the tumour-infiltrating lymphocyte response was absent in four cases and nonbrisk in one patient. CONCLUSIONS: In the Oxford transplant population studied melanomas occurred at approximately 8 times the rate in the general population. This is the highest rate reported in the literature. The patients had a better outcome than reported previously. This may be due to detection at a relatively early stage. Renal transplant recipients attend dedicated dermatology clinics in Oxford, which may have contributed to the early diagnosis and good outcome.     

糠秕马拉色菌所致荷兰男性脂溢性皮炎一例

糠秕马拉色菌是人体皮肤表面的常驻嗜脂性酵母,可引起皮肤浅部真菌感染如花斑糠疹和马拉色菌毛囊炎.脂溢性皮炎为发生在头皮、面部和躯干上半部的慢性红斑,常伴油性鳞屑,本病的病因尚不清楚,但近年研究提示,其发病机制与马拉色菌酵母有关.     

Prevalence of benign cutaneous disease among Oxford renal transplant recipients

Background The burden of malignant and benign cutaneous disease among renal transplant recipients (RTR) is substantial. Little attention is given to non‐malignant skin problems in the literature despite their potential impact on quality of life or on aesthetics – which may contribute to poor compliance with immunosuppressive medications post‐transplantation. Objectives The aim of this study was to examine prevalence of benign cutaneous disease in a group of RTRs and identify risk factors for individual cutaneous conditions. Methods All cutaneous findings were recorded in a single full body skin examination of 308 RTRs. Data on medical, transplant and medication history were obtained from questionnaire and medical records. Odds ratios were calculated to look at associations between benign cutaneous diseases and various potential risk factors after controlling for gender, age, time since transplantation and skin type. Results Cutaneous infections such as viral warts (38%), fungal infection (18%) and folliculitis (27%) were common and usually chronic. A range of pilosebaceous unit disorders were observed with hypertrichosis being strongly associated with ciclosporin (P < 0.0001). Other iatrogenic cutaneous effects included gingival hyperplasia (27%) and purpura (41%). We identified seborrhoeic warts and skin tags in 55% and 33% respectively. Inflammatory dermatoses were rare (< 2%) apart from seborrhoeic dermatitis (9.5%). Discussion In this first comprehensive study on prevalence of benign cutaneous diseases in a UK transplant population, a wide range of skin disorders was identified. It is therefore important that RTRs have access to dermatology services post‐transplantation for appropriate management of benign cutaneous conditions as well as early detection of cutaneous malignancy and education regarding risks of sun exposure.     

Melanoma in organ transplant recipients: the old enemy finds a new battleground

Population registry data and published studies have demonstrated that melanomas in the transplant population occur 1.6-2.5 times more commonly compared with the general population. Studies examining possible risk factors have suggested that in this patient population, there is an increased number of melanocytic naevi. Whether this phenomenon is aetiologically related to subsequent melanoma development is currently unclear. Only one study examined the prognosis of melanomas in this population. The Israel Penn International Transplant Tumor Registry has collated patient data voluntarily submitted by transplant physicians throughout the USA since 1968. Analysis of melanomas in this study found that approximately half were Breslow thickness >1.51 mm. Overall, there was a high rate of nodal and distant metastases, with poorer 1-, 3- and 5-year survival rates compared with the general population. There is a paucity of good-quality evidence regarding melanoma in organ transplant recipients. Further research involving international collaborative trials, particularly on risk factors and the prognosis of melanomas in this population, could present a more substantial evidence base from which treatment guidelines based on data could be developed.     

The efficacy and safety of topical 5% 5‐fluorouracil in renal transplant recipients for the treatment of actinic keratoses

Actinic keratoses (AK) occur more commonly and behave more aggressively in renal transplant recipients (RTR). Topical 5% 5‐fluorouracil (5‐FU) cream is a commonly used agent whose efficacy and safety have never been exclusively studied in the RTR population before. Eight RTR were enrolled and 5% 5‐FU cream applied to AK lesions on their face twice daily for 3 weeks. They were reviewed at 2 and 8 weeks, and 12 months post‐commencement of treatment. Their AK were counted and their cumulative surface areas measured. Patients completed surveys monitoring adverse effects and tolerability. Complete (100%) and partial clearance (≥ 75%) rates were measured, as well as mean percentages of the reduction in AK surface area. Patients had complete clearance rates of 63 and 0% at 8 weeks and 12 months, respectively. All (100%) patients had partial clearance at week 8 and 71% had partial clearance at 12 months. Patients had on average 15 AK at week 0 and 1 and 3 at 8 weeks and 12 months, respectively. The mean AK clearance rate was 98% at week 8 and 79% at 12 months. Common side‐effects were erythema, itch and flaking or scaling, mostly mild in severity. 5‐FU appears to be an efficacious and safe treatment for AK in RTR.     

The pattern of mucocutaneous infections and infestations in renal transplant recipients

Immunosuppression-related mucocutaneous lesions are a significant problem in renal transplant recipients. Infections account for the majority of these manifestations. The aim of this study was to determine the spectrum of mucocutaneous infections and infestations in renal transplant recipients. Over a period of three years, all the renal transplant recipients presenting with mucocutaneous lesions (only with infectious etiology) were included in the study. Diagnosis was based on the clinical appearance and appropriate investigations like scraping for KOH, Tzanck smear, cultures, and skin biopsies whenever necessary. In order to study the temporal effect of immunosuppression on these mucocutaneous infections, the patients were divided into six groups -with durations of graft survival ranging from 0-2, 2-6, 6-12, 12-24, 24-60, and more than 60 months in Groups A-F, respectively. A total of 104 renal transplant recipients presented with 117 infections and infestations. The mean age at presentation was 35.9 +/- 1.2 years (15-65 yrs), and the mean duration after the transplant was 23.3 +/- 3.5 months (1-175). The mean serum creatinine level at the time of clinical presentation was 1.4 +/- 0.07 mg/dl (0.7-6). Twenty-seven patients were on a two-drug regimen, prednisolone and azathioprine, and the rest were on a three-drug regimen with cyclosporine in addition. Out of the total of 117 infections in 104 patients, 57 were viral, 49 were fungal, and 8 were bacterial. Two patients had scabies and one had cysticercosis. The mean time interval for the occurrence of infections after the transplant was earlier in patients on three-drug immunosuppression (12.4 +/- 2.3 months) than in those on the two-drug regimen (51.3 +/- 1.8 months), (p<0.01). The viral infections had the shortest mean time interval for presentation following transplant, 15.8 +/- 1.2 months (p<0.05). We did not find any statistically significant difference with regard to age or sex of the patients, duration after the transplant, or the pattern of infection. Careful examination of transplant patients is essential for early detection and proper treatment, because the mucocutaneous infections can have atypical morphologies and are likely to become extensive if not treated early.     

Update on the pathogenesis of post-transplant skin cancer in renal transplant recipients

Remarkable advances in the field of transplantation over the last several decades have benefited many thousands of patients. Five-year survival ranges from 90% for a live donor renal transplant to 85% for a cadaveric renal transplant. However, with this success come the complications of chronic immunosuppression. Lifelong immunosuppressive treatment for adequate graft function results in reduction of immunosurveillance, with increased risk of various cancers leading to substantial morbidity and mortality in these patients. This review discusses multifactorial intrinsic and extrinsic factors contributing to the pathogenesis of skin cancers in renal transplant recipients and reviews potential solutions.     

Seborrheic dermatitis

Seborrheic dermatitis is a common inflammation of the skin, occurring most often on the face, scalp and chest. It is closely related to infantile seborrheic dermatitis, or diaper rash. Seborrheic dermatitis is particularly common in patients with Parkinson's disease or with HIV/AIDS. The recent resurgence of interest in Malassezia yeasts has revived the old hypothesis that seborrheic dermatitis is caused by an altered relationship between these skin commensals and the host. Moreover, the success of antifungal medications in treating seborrheic dermatitis provides new evidence for this view. LEARNING OBJECTIVE: Upon completing this paper, the reader should be aware of the clinical presentation of seborrheic dermatitis and which populations are at particular risk of developing this disorder. In addition, s/he will be aware of the role of Malassezia yeasts in seborrheic dermatitis and the way in which knowledge of the importance of these yeasts has altered the treatment of this disorder.     

A population-based study of skin cancer incidence and prevalence in renal transplant recipients

BACKGROUND: Cancers occurring following solid organ transplantation are a rapidly growing public health concern. Defining the extent of the problem has been limited by surveillance systems with incomplete registration of cases and the paucity of reliable national incidence data. OBJECTIVES: To determine the incidence of all cancers following renal transplantation and to make a detailed examination of trends and patterns associated with postrenal transplant skin cancers. METHODS: Integration of data from the national renal transplant database and the national cancer registry in Ireland enabled accurate determination of the number of renal transplant recipients (RTRs) with skin cancers and other malignancies in the time period 1 January 1994 to 31 December 2001. RESULTS: We demonstrated a biphasic increase in skin cancer incidence following renal transplantation, determined by the age at transplantation. There was a steady increase in risk for older RTRs (age 50+ years) from year 2 post-transplant, whereas the increased risk in younger RTRs (age < 50 years) occurred later but much more significantly, reaching 200 times the risk for an age-matched nontransplanted population by year 6 post-transplant. The number of nonmelanoma skin cancers (NMSCs) registered in RTRs accounted for 1% of all NMSCs registered nationally over the study period. The standardized incidence rates for invasive NMSC (33-fold increase) and in situ carcinoma of the skin (65-fold increase) were significantly increased (P < 0.05). The risk for invasive squamous cell carcinoma (SCC) was increased 82-fold compared with the nontransplanted population. Male RTRs were at particular risk of invasive SCC at sun-exposed sites such as the scalp and the external ear. Risk of malignant melanoma and Kaposi sarcoma were also increased relative to the nontransplanted population. CONCLUSIONS: This comprehensive national study illustrates how rates of skin cancer in Irish RTRs have influenced the national incidence of skin cancer. The high incidence of SCC, basal cell carcinoma and Bowen's disease in the early post-transplant period for older patients and the cumulative risk in younger patients with increased duration of transplantation highlight the importance of implementing early and continued cancer surveillance regimens post-transplant.     

萘替芬酮康唑乳膏治疗面部脂溢性皮炎疗效观察

目的 探讨萘替芬酮康唑乳膏和复方乳酸乳膏混合外涂治疗面部脂溢性皮炎的临床疗效和安全性。方法 将65例面部脂溢性皮炎患者随机分成两组,治疗组33例,将适量萘替芬酮康唑乳膏和复方乳酸乳膏1:1放于洗净的手掌,混合调匀,再均匀涂于面部皮损处;对照组32例,将适量曲安奈德尿素乳膏和复方乳酸乳膏以1:1按上法均匀涂于面部皮损处。疗程均为4周,每2周复诊1次,观察疗效和不良反应。结果 治疗第2,4周后,两组症状总积分均较治疗前显著下降,差异有统计学意义(P<0.05);治疗组有效率分别为72.73%和78.13%,对照组分别为81.82%和87.50%,差异均无统计学意义(P均>0.05)。结论 外涂萘替芬酮康唑乳膏与外涂曲安奈德尿素乳膏治疗面部脂溢性皮炎疗效均满意且相当,但外涂萘替芬酮康唑乳膏更安全,无糖皮质激素乳膏外用的不良反应。     

姜黄消痤搽剂治疗脂溢性皮炎临床疗效观察

目的探讨姜黄消痤搽剂治疗脂溢性皮炎的疗效。方法治疗组予姜黄消痤搽剂涂患处,对照组外用哈西奈德溶液。两组均早晚各用药1次,疗程为14天,疗程结束时评价疗效;随访2个月观察复发情况。结果治疗组有效率为87.23%,对照组为79.17%,两组比较差异无显著性(P>0.05);治疗组复发率为15.79%,对照组为47.62%,两组比较差异有显著性(P<0.05)。结论姜黄消痤搽剂治疗头皮脂溢性皮炎疗效确切,复发率低。     

头皮屑和头皮脂溢性皮炎患者头皮脂类水平的检测

目的探讨头皮屑及头皮脂溢性皮炎患者与正常受试者头皮不同部位表面脂类水平。方法使用se-bumeter于洗发后连续4天测量头皮屑及头皮脂溢性皮炎患者和健康对照者额、顶、枕部头皮皮脂。结果头皮屑及头皮脂溢性皮炎组头皮表面脂量与额部在前3天、顶部在第2,3天、枕部在第2,3,4天均较对照组显著性增高,有统计学意义(P<0.05);头皮屑及头皮脂溢性皮炎组第1,2,3,4天额部、顶部头皮表面脂量均显著高于枕部(P<0.05)。结论头皮屑及头皮脂溢性皮炎组和对照组同一天枕部头皮表面脂量明显少于额部和顶部,而额部和顶部的头皮表面脂量接近。头皮屑及头皮脂溢性皮炎患者额、顶、枕部头皮表面脂量分别于第3,2,3天达到饱和。     

Association of seborrhoeic warts with skin cancer in renal transplant recipients**

Background Renal transplant recipients (RTR) have a well recognized increased risk of cutaneous malignancy. A clinical observation that RTR with skin cancer often had multiple seborrhoeic warts prompted an investigation in RTR into the relationship between seborrhoeic warts and skin cancer and an exploration into potential risk factors for seborrhoeic warts in this population, including infection with human papillomavirus (HPV). Methods This was a case control study involving 308 RTR. Clinical examinations identified seborrhoeic warts. Histological records reviewed to look for evidence of prior cutaneous malignancy. Seroprevalence of antibodies to 34 different HPV types tested using multiplex serology. Odds ratios (OR) calculated using unconditional logistic regression analysis to look for associations between skin cancer, HPV infection and seborrhoeic warts, controlling for potential confounding factors of gender, age and time since transplantation. Results Seborrhoeic warts were associated with non‐melanoma skin cancer [OR = 3.7; 95% confidence intervals (CI) ranging from 1.6–8.9; P = 0.002] when confounding factors of gender, age and time since transplantation were controlled for. There was also an association between seborrhoeic warts and viral warts (OR = 3.0, CI: 1.6–5.4; P < 0.0001), but no association between seborrhoeic warts and infection with single or multiple HPV types. Conclusions Seborrhoeic warts are associated with cutaneous malignancy, but not with any of the HPV types tested. The reasons for this association are unclear. RTR with multiple seborrhoeic warts may require more regular cutaneous examination to monitor for early signs of skin cancer.     

Maintenance Therapy of Facial Seborrheic Dermatitis with 0.1% Tacrolimus Ointment

Background

Topical calcineurin inhibitors (TCIs) have been successfully used to treat seborrheic dermatitis (SD) patients. Meanwhile, treatment of atopic dermatitis (AD) with low-dose, intermittent TCI has been proved to reduce disease flare-ups. This regimen is known as a maintenance treatment.

Objective

The aim of this trial was to investigate the efficacy and tolerability of a maintenance treatment with tacrolimus ointment in patients with facial SD.

Methods

During the initial stabilization period, patients with facial SD or AD applied 0.1% tacrolimus ointment twice daily for up to 4 weeks. Clinical measurements were evaluated on either in the whole face or on separate facial regions. When an investigator global assessment score 1 was achieved, the patient applied tacrolimus twice weekly for 20 weeks. We also compared our results with recent published data of placebo controlled study to allow an estimation of the placebo effect.

Results

The time to the first relapse during phase II was similar in both groups otherwise significantly longer than the placebo group. The recurrence-free curves of two groups were not significantly different from each other; otherwise the curve of the placebo group was significantly different. There were no significant differences between the 2 groups in the number of DEs, and treatment days for disease exacerbations (DEs). The adverse event profile was also similar between the 2 groups. During the 20 weeks of treatment, the study population tolerated tacrolimus ointment well.

Conclusion

The results of this study suggest that maintenance treatment with tacrolimus may be effective in preventing the occurrence of facial SD exacerbations.     

Risk factors for fracture in adult kidney transplant recipients

AIM: To determine the general and transplant-specific risk factors for fractures in kidney transplant recipients. METHODS: We conducted a cohort study of all adults who received a kidney-only transplant (n = 2723) in Ontario, Canada between 2002 and 2009. We used multivariable Cox proportional hazards regression to determine general and transplant-specific risk factors for major fractures (proximal humerus, forearm, hip, and clinical vertebral). The final model was established using the backward elimination strategy, selecting risk factors with a P-value ≤ 0.2 and forcing recipient age and sex into the model. We also assessed risk factors for other fracture locations (excluding major fractures, and fractures involving the skull, hands or feet). RESULTS: There were 132 major fractures in the follow-up (8.1 fractures per 1000 person-years). General risk factors associated with a greater risk of major fracture were older recipient age [adjusted hazard ratio (aHR) per 5-year increase 1.11, 95%CI: 1.03-1.19] and female sex (aHR = 1.81, 95%CI: 1.28-2.57). Transplant-specific risk factors associated with a greater risk of fracture included older donor age (5-year increase) (aHR = 1.09, 95%CI: 1.02-1.17) and end-stage renal disease (ESRD) caused by diabetes (aHR = 1.72, 95%CI: 1.09-2.72) or cystic kidney disease (aHR = 1.73, 95%CI: 1.08-2.78) (compared to glomerulonephritis as the reference cause). Risk factors across the two fracture locations were not consistent (major fracture locations vs other). Specifically, general risk factors associated with an increased risk of other fractures were diabetes and a fall with hospitalization prior to transplantation, while length of time on dialysis, and renal vascular disease and other causes of ESRD were the transplant-specific risk factors associated with a greater risk of other fractures. CONCLUSION: Both general and transplant-specific risk factors were associated with a higher risk of fractures in kidney transplant recipients. Results can be used for clinical prognostication.     

热带、亚热带四地区青少年脂溢性皮炎的现患情况及危险因素分析

目的评估热带、亚热带四地区青少年脂溢性皮炎的现患状况及其危险因素,为青少年脂溢性皮炎防治提供依据。方法采用横断面问卷调查方法,于2001年9～10月、2004年9～12月及2005年9～12月分别对澳门、广州、马来西亚和印度尼西亚内的103所中学,以学校为单位随机整群抽取18所中学,共13215名12～20岁的中学生,进行逐一检查并以问卷调查法收集脂溢性皮炎的流行病学资料。所有资料进行logistic回归分析。结果澳门、广州、马来西亚和印度尼西亚地区中学生脂溢性皮炎总患病率为10.17%,其中男8.15%,女12.40%,两者患病率差异有显著性意义(P=0.000);男、女性各年龄组间患病率差异均有显著性意义(P均=0.000);男、女性患病高峰年龄皆为20岁。四地中学生脂溢性皮炎患病率分别为2.66%,2.85%,17.16%和26.45%,澳门、广州两地与马来西亚、印度尼西亚两地间患病率差异有显著性意义(P=0.000)。由多因素logistic回归分析可知性别、年龄、在发病地居住年数、腹胀、便秘、经常排气、腹部常疼痛或不适、常食辛辣及煎炸食物、腋毛多、汗毛和/或胡须多、面部和胸部皮肤油腻为其危险因素。结论澳门、广州、马来西亚和印度尼西亚中学生脂溢性皮炎患病率较高,危险因素主要涉及年龄、性别、生活环境、生活习惯、内分泌和消化道功能紊乱等。     

Halo naevi and café au lait macule regression in a renal transplant patient on immunosuppression

A case of halo naevi and café au lait macule regression in a renal transplant patient receiving long‐term immunosuppressive therapy is described. We propose the direct transfer of an auto‐reactive antibody, CD8 T‐cells or tumour necrosis factor α from the transplant donor to the recipient as a possible cause. We have also considered insufficient immunosuppressive therapy as a possible mechanism.     

Skin cancer chemoprophylaxis in renal transplant recipients: 5 years of experience using low-dose acitretin

Renal transplant recipients have an increased risk of developing skin cancers, which are often multiple and aggressive. Frequently, these tumours develop on a background of widespread epidermal dysplasia. Systemic retinoids are known inhibitors of skin cancer but reports of their use in renal transplant patients are limited. We describe our experience using 0.3 mg/kg daily of acitretin in 16 patients over a 5-year period. Overall, there was a significant reduction in the number of new tumours excised in 12 of 16 patients during treatment compared with the same pretreatment interval. A significant chemoprophylactic effect was shown for up to 4 years of treatment. Patients with five or more tumours prior to acitretin benefited most. Two patients discontinued treatment because of side-effects and two patients developed hyperlipidaemia. Two patients with end-stage graft failure proceeded to haemodialysis. The introduction of low-dose acitretin proved to be a useful strategy in the long-term reduction of skin cancer in renal transplant recipients with multiple skin cancers and extensive epidermal dysplasia.     

Skin cancer surveillance in renal transplant recipients: re-evaluation of U.K. practice and comparison with Australian experience

Background  Nonmelanoma skin cancer (NMSC) is the most common tumour following solid organ transplantation. In 2000 a survey of U.K. centres managing renal transplant recipients (RTRs) showed that only 21% offered skin cancer surveillance.
Objectives  The survey was repeated in 2006 in the U.K. and Australia. The aims were to determine if U.K. practice had changed since 2000, to define skin cancer surveillance practice in Australian RTRs and to compare this with that in the U.K.
Methods  Questionnaires were sent to 84 U.K. and 45 Australian centres providing long-term RTR follow-up.
Results  Fifty-six (67%) U.K. centres caring for 82% ( n  =   16 349) of the RTR population replied. Sixty-six per cent provided annual skin cancer surveillance and 39% offered full skin examination (FSE) compared with 21% and 20% in 2000. Eighty-one per cent of surveillance was performed by nondermatologists ( n  =   30), nine (30%) of whom had received formal training for the role. Thirty-one (69%) Australian centres covering 86% ( n  =   5392) of the RTR population responded. Ninety-seven per cent provided skin cancer surveillance, and 61% offered FSE. Forty per cent ( n  =   12) of skin cancer surveillance was conducted by nondermatologists. Two nondermatologists had received formal training.
Conclusions  Despite a substantial improvement in the provision of skin cancer surveillance for RTRs in the U.K. between 2000 and 2006, only 39% of units offer FSE. In contrast, virtually all Australian centres offer annual skin cancer surveillance, with more dermatology involvement. Lack of training for nondermatologists involved in skin cancer surveillance is evident in both countries. The availability of dermatologists and the variation in NMSC risk between the populations may explain the different practices observed.     

A prospective study of the incidence of skin cancer and its risk factors in a Spanish Mediterranean population of kidney transplant recipients

BACKGROUND: Skin cancer is the most common malignancy occurring in kidney transplant recipients (KTRs). OBJECTIVES: Our purpose was to investigate, prospectively, the cumulative incidence of cancerous and precancerous skin lesions as well as their risk factors in a close follow-up population of KTRs from a Mediterranean area of Spain. PATIENTS AND METHODS: One hundred and seventy-four consecutive KTRs were examined at the moment of transplant and then at 6-month intervals. The cumulative incidence of skin cancer was computed. To analyse the role of potential risk factors (age at transplantation, cause of renal failure, duration of pretransplant dialysis, type of immunosuppressive regimen, sun-reactive skin type and history of occupational sun exposure), the Cox regression method was used. RESULTS: After a median follow-up of 72 months (range, 12-140), 39 patients (25.3%) developed 142 tumours [84 basal cell carcinoma (BCC) and 58 squamous cell carcinoma (SCC)]. The BCC/SCC ratio was 1.4 : 1. The cumulative incidence for skin cancer was 13% after 3 years of graft survival, increasing to 27.5% at 6 years and 48% at 10 years. Only age at the time of transplantation and occupational sun exposure had statistical significance as risk factors (P < 0.001). CONCLUSIONS: Our study confirms the high incidence of non-melanoma skin cancer among KTRs in a Mediterranean population with occupational sun exposure and the patient's age at the time of transplantation being the main risk factors. We believe that all organ transplant programs should provide educational information about protecting oneself from the sun as well as include follow-up visits by dermatologists in order to facilitate early diagnosis and treatment of skin cancer.