Risk factors for systemic lupus erythematosus flares in patients with end-stage renal disease: a case-control study

Severe lupus after two years of hemodialysis: It exists and can be serious

Progression of lupus nephropathy (LN) to end-stage renal disease is a serious complication and requires subsequent replacement therapy. Lupus disease activity is extinguished in chronic hemodialysis. We report the observation of a 35-year-old female patient, in conventionnel hemodialysis for two years (chronic glomerulonephritis), admitted to the emergency room for convulsions, left flaccid tenderness, cutaneous-mucosal pallor and altered general condition evolving since three days before her admission. we also observed a spontaneous ecchymotic lesions on the right arm. Echodoppler of the right upper extremity was in favor of a partially thrombosed aneurysm of the right brachial artery. The biological workup showed pancytopenia, the requested immunological workup showed a low complement C₃, a positive level of anti-DNA antibodies. The patient was treated as severe lupus flare: Bolus of methylprednisolone, followed by oral administration, associated with Mycophenolate mofétil (MMF) at a dose of 1 g/d. The evolution was favorable on the clinical, biological and radiological levels. Systemic lupus erythematous (SLE) can occur even after several years of hemodialysis and sometimes in a severe form, pushing the clinician to think of this pathology in the presence of evocative signs.

Successful Treatment with Belimumab in a Patient with Refractory Systemic Lupus Erythematosus after Initiation of Hemodialysis: Considering the Synergistic Effect of Belimumab and Immunological Burn-Out Phenomenon in End-Stage Renal Disease Patients on Hemodialysis

BACKGROUND

In patients with systemic lupus erythematosus (SLE), disease activity can persist even after initiating dialysis. However, guidelines for the treatment of patients with SLE after dialysis is initiated have not yet been established.

CASE PRESENTATION

We describe the case of a 54-year-old Japanese woman who was diagnosed with SLE at age 12, progressed to end-stage renal disease (ESRD), and initiated hemodialysis for lupus nephritis. However, SLE activity persisted after hemodialysis. Cyclophosphamide and mycophenolate mofetil were administered in addition to prednisolone and immunoadsorption, but this treatment strategy was limited by side effects. The patient was subsequently treated with belimumab, and the activity of SLE decreased rapidly.

CONCLUSIONS

ESRD patients with SLE show no significant decrease in transitional B cells and have elevated levels of B-cell activating factor (BAFF). Both transitional B cells and BAFF are important therapeutic targets for belimumab, indicating that patients with ESRD may benefit from belimumab therapy. However, the effects of belimumab may be potentiated in patients with uremia, who may be more susceptible to adverse events such as infections. Patients with SLE who receive belimumab after initiation of hemodialysis therefore require careful follow-up. Here, we report the first case of belimumab administration in a patient with SLE after initiation of hemodialysis.

Real-world electronic health record identifies antimalarial underprescribing in patients with lupus nephritis

Antimalarials (AMs) reduce disease activity and improve survival in patients with systemic lupus erythematosus (SLE), but studies have reported low AM prescribing frequencies. Using a real-world electronic health record cohort, we examined if patient or provider characteristics impacted AM prescribing. We identified 977 SLE cases, 94% of whom were ever prescribed an AM. Older patients and patients with SLE nephritis were less likely to be on AMs. Current age (odds ratio = 0.97, p < 0.01) and nephritis (odds ratio = 0.16, p < 0.01) were both significantly associated with ever AM use after adjustment for sex and race. Of the 244 SLE nephritis cases, only 63% were currently on AMs. SLE nephritis subjects who were currently prescribed AMs were more likely to be followed by a rheumatologist than a nephrologist and less likely to have undergone dialysis or renal transplant (both p < 0.001). Non-current versus current SLE nephritis AM users had higher serum creatinine (p < 0.001), higher urine protein (p = 0.05), and lower hemoglobin levels (p < 0.01). As AMs reduce disease damage and improve survival in patients with SLE, our results demonstrate an opportunity to target future efforts to improve prescribing rates among multi-specialty providers.