The utility of lupus serology in predicting outcomes of renal transplantation in lupus patients: Systematic literature review and analysis of the Toronto lupus cohort

[Diagnostic and therapy of lupus nephritis - 2023]

The manuscript summarizes the consensus of the Austrian Society of Nephrology on the diagnosis and therapy of lupusnephritis, which is built on existing studies and literature. We discuss in detail the immunosuppressive treatment in proliferative forms of lupusnephritis (III and IV ± V) and in pure lupusnephritis V with nephrotic-range proteinuria. Furthermore, the supportive medication in lupusnephritis is summarized in the consensus. The figures were designed to provide the reader a guidance through the therapeutical approach in lupusnephritis for the daily practice.

Kidney transplantation in pediatric patients with rheumatologic disorders

PURPOSE OF REVIEW

Providers caring for children with end-stage kidney disease from rheumatologic conditions face questions such as when to proceed with kidney transplantation, how common is disease recurrence posttransplant, how does recurrent disease impact patient and allograft outcomes, and what approaches are available to prevent and treat recurrent disease. We discuss recent developments and relevant literature that address these questions for the most common rheumatologic disorders that lead to end-stage kidney disease in childhood namely, systemic lupus erythematosus, IgA nephropathy, IgA Vasculitis/Henoch Schoenlein Purpura, and Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated vasculitis.

RECENT FINDINGS

Recent data suggest that children with IgA nephropathy, IgA vasculitis, and ANCA-associated vasculitis have similar patient and allograft survival to other conditions despite the risk of recurrent disease, yet those with lupus have worse posttransplant patient and allograft outcomes. A period of disease quiescence may be prudent prior to transplantation to decrease the risk of recurrence, which is associated with decreased allograft survival. Data on preventive strategies and treatment options are limited.

SUMMARY

It is recommended that patients with systemic rheumatologic conditions not be excluded from kidney transplantation but that patients be counseled on the risk of potential recurrent disease with its impact on transplant outcomes.

Lupus Nephritis and Kidney Transplantation: Where Are We Today?

Lupus nephritis (LN) is the cause of end-stage kidney disease (ESKD) for 1.9% of the ESKD population in the United States. Although the incidence rates of ESKD from LN stopped rising in recent years, racial disparities in waiting time, pre-emptive kidney transplant, and transplant outcomes still exist. Patients with LN who progress to ESKD tend to be female, of African ancestry, and young. Kidney transplantation is safe in this population and associated with a substantial survival benefit, primarily due to reduced deaths from cardiovascular disease and infection. Transplant outcomes for patients with ESKD due to LN are similar to those without LN.

Outcome and Prognosis of Patients With Lupus Nephritis Submitted to Renal Transplantation

This stydy aimed to evaluate the epidemiological and clinical profile and outcome of patients with lupus nephritis (LN) submitted to renal transplantation. Retrospective cohort study based on the records of 35 LN patients submitted to renal transplantation at a single center in Brazil between July 1996 and May 2016. The Kaplan-Meier method was used to estimate 6-month, 1-year and 5-year graft survival. The sample included 38 transplantations (3 of which retransplantations). The mean age at the time of SLE diagnosis was 23.7 ± 9.0 years. Most patients were female (94.7%) and 68.4% were non-Caucasian. Twenty-two (57.9%) underwent renal biopsy prior to transplantation. The mean time from SLE diagnosis to transplantation was 10.3 ± 6.4 years. The mean pre-transplantation dialysis time was 3.8 ± 3.7 years. The grafts came from living related (n = 11) or deceased (n = 27) donors. Three (7.9%) patients experienced acute rejection in the first year. Graft and patient survival rates were, respectively, 97.1% and 100% at 6 months, 84.9% and 96.9% at 1 year, and 76.3% and 92.5% at 5 years. One (2.6%) patient had SLE recurrence. Venous thrombosis (p = 0.017) and antiphospholipid syndrome (APS) (p = 0.036) were more prevalent in patients with graft loss. In our cohort of LN patients submitted to renal transplantation, the 5-year survival rate was high, and APS was an important predictor of poor renal outcome (graft loss).

Methodological considerations in comparing access to Pre-emptive renal transplantation between SLE and other ESRD causes in the USRDS

BACKGROUND

We compared pre-emptive transplant rates between SLE and non-SLE end-stage renal disease (ESRD) from the U.S. Renal Data System (USRDS) and investigated the potential influence of frequency matching and primary ESRD causes in the non-SLE group.

METHODS

4830 adult SLE patients with incident ESRD from USRDS 2005-2009 were frequency matched by age, sex and race to 4830 patients with incident non-SLE ESRD. Multivariable logistic regression models were used to estimate the odds of pre-emptive transplantation in SLE and non-SLE, and with the non-SLE subgroups by primary ESRD cause.

RESULTS

The odds ratios (OR) of receiving a pre-emptive transplant were similar among non-SLE and SLE (referent group): OR = 1.18 (95% CI: 0.92, 1.50; p = 0.20). However, the ORs for receiving a pre-emptive transplant were 0.19 (95% CI: 0.08, 0.42) in type 2 diabetes ESRD, 0.42 (95% CI: 0.23, 0.75) for hypertension-associated ESRD, 1.67 (95% CI: 1.10, 2.54) in type 1 diabetes ESRD, and 2.06 (95% CI: 1.55, 2.73) for "other" ESRD. In contrast to non-SLE, younger SLE patients were less likely to receive a pre-emptive transplant than older SLE patients.

CONCLUSION

The results of this study provide compelling evidence that major improvements need to be made in optimizing access to pre-emptive transplantation in SLE by addressing sociodemographic disparities and the unique challenges faced by SLE patients. Applying careful matching and selecting appropriate comparison groups in future studies may facilitate the development of effective strategies to address these barriers and to increase the number of pre-emptive renal transplants among SLE patients.