Renal transplant reduces mortality risk in lupus nephritis-related ESRD
Renal transplant may improve survival in patients with end-stage renal disease (ESRD) caused by lupus nephritis, a recent study showed.
Researchers obtained data from the US Renal Data System to identify 9,659 patients with ESRD due to lupus nephritis who had been waitlisted for a renal transplant between January 1995 and December 2015 (mean age at waitlist entry 38 years, 82 percent female). Of these, 59 percent (n=5,738) received a transplant (mean age, 39 years).
Waitlisted patients who received a transplant had a reduced risk of all-cause mortality compared with those who did not receive a transplant (22.5 vs 56.3 per 1000 person-years, adjusted hazard ratio [HR], 0.30, 95 percent confidence interval [CI], 0.27–0.33). [Ann Intern Med 2019;doi:10.7326/M18-1570]
Among those who had received a transplant, there was little difference in risk of all-cause mortality between ethnicities, sex, and age at or year of ESRD onset.
The mortality risk among transplant recipients was reduced regardless of cause (HR, 0.26, 95 percent CI, 0.23–0.30 for cardiovascular disease [CVD], HR, 0.30, 95 percent CI, 0.19–0.48 for coronary heart disease, HR, 0.39, 95 percent CI, 0.24–0.61 for stroke, HR, 0.41, 95 percent CI, 0.32–0.52 for infection, and HR, 0.41, 95 percent CI, 0.31–0.53 for sepsis), though there was no difference between those who did or did not receive transplant in terms of death due to cancer.
While renal transplant appears to improve survival in patients with all-cause ESRD, [J Am Soc Nephrol 2005;16:1859-1865; N Engl J Med 1999;341:1725-1730] patients with ESRD due to lupus nephritis are at risk for transplant-related complications such as infections and graft thrombosis. [Semin Arthritis Rheum 1997;27:17-26]
“Patients with [ESRD due to lupus nephritis] may have higher risk for infection due to the intensive immunosuppression used to treat lupus nephritis and other disease manifestations. Associated antiphospholipid antibody syndrome is also a concern among patients with [ESRD due to lupus nephritis] because it may increase risk for graft thrombosis,” said the researchers.
“[In this study], renal transplant was associated with substantially lower risks for cardiovascular death and death due to infection among patients with [ESRD due to lupus nephritis], which largely explains the all-cause mortality benefit,” they said.
“[O]ur study provides evidence for a substantial survival benefit of renal transplant among patients with [ESRD due to lupus nephritis and suggests] that timely referral for transplant in this population may alleviate both CVD mortality and infection-related mortality … improved access to renal transplantation for this population may considerably improve outcomes,” they concluded.
“Progress in the treatment of lupus nephritis remains slow, and too many patients with lupus nephritis still develop kidney failure,” said Drs Nitender Goyal, Daniel Weiner, and Andrew Levey from Tufts Medical Center in Boston, Massachusetts, US, in an editorial. [Ann Intern Med 2019;doi:10.7326/M18-3721]
“Because data from other studies have suggested higher patient and allograft survival with both pre-emptive and early kidney transplant, it is essential that transplant be considered as promptly as possible for patients with lupus nephritis and that barriers to early transplant be surmounted,” they said.