Consensus-based Recommendations on the Management of Immunosuppression After Squamous Cell Carcinoma Diagnosis in Kidney Transplant Recipients: An International Delphi Consensus Statement

Background. – Posttransplant immunosuppression in kidney transplant recipients is associated with an increased risk of developing cutaneous squamous cell carcinoma (CSCC), contributing to significant morbidity and mortality. Various dermatological and immunosuppression modulation strategies have been identified that may reduce the risk of CSCC, both in primary and secondary prevention settings. Recent recommendations have provided consensus regarding dermatological approaches to prevent CSCC. Comparable transplant nephrology recommendations to guide immunosuppression modulation for CSCC prevention are currently lacking, leading to marked variation in practice. Methods. – To address this knowledge gap, 46 international transplant nephrology experts participated in a 3-round Delphi survey to develop consensus recommendations for CSCC secondary prevention based on the actinic damage and skin cancer index stages of CSCC. Results. – The panel of experts reached consensus to consider a change in immunosuppression after multiple low-risk invasive CSCC (stage 5a, 1/y >3 y) and encouraged collaboration with dermatology to optimize dermatologic preventative care after the first CSCC. There was also consensus to prioritize azathioprine modification where this is present in an immunosuppressive regimen. Conclusions. – This study provides the first international consensus recommendations for management of immunosuppression in kidney transplant recipients at discrete stages of CSCC. Additional prospective studies are necessary to determine the optimal management of immunosuppression in this patient population. These recommendations have been endorsed by the Board of the American Society of Transplantation.