Long-term prognosis of vascular access in hemodialysis patients with systemic lupus erythematosus: a retrospective cohort study

Patients with systemic lupus erythematosus (SLE) have a higher risk of vascular complications. This retrospective cohort study aimed to analyze the differences in the risk of arteriovenous fistula or graft (AVF/AVG) dysfunction in hemodialysis patients with and without SLE from Taiwan's National Health Insurance Database over a 10-year period. AVF/AVG dysfunction is defined as the occurrence of the first episode of intervention after vascular access creation. A total of 1366 HD patients with SLE had higher incidence rates of AVF/AVG dysfunction than 4098 non-SLE HD patients in the following 4 periods: (1) after 1 year (incidence rates = 15.21% and 13.01%, respectively; subdistribution hazard ratio (SHR) = 1.16; P = 0.007), (2) 1st-to-10th-year period (15.36% and 13.25%; SHR = 1.16; P = 0.007), (3) 5th-to-10th-year period (11.91% and 8.1%; SHR = 1.42; P = 0.003), and (4) overall period (23.53% and 21.66%; SHR = 1.09; P = 0.027). In conclusion, there were significantly higher incidence rates of AVF/AVG dysfunction in SLE patients during the long-term follow-up period. Vascular access function should be monitored regularly by clinical examinations, especially after 1 year and during 5 to 10 years, to improve AVF/AVG patency and dialysis adequacy in SLE patients undergoing maintenance hemodialysis.

Systemic lupus erythematosus diagnosis impacts clinical outcomes of arteriovenous fistulas in comparison to other end-stage renal disease etiologies

OBJECTIVES

Arteriovenous fistulas primary patency at one-year occurs in 43-85% of the patients with end-stage renal disease. The diagnosis attributable to end-stage renal disease has been suggested to impact arteriovenous fistulas outcomes. The objective was to compare primary patency at one week, 1, 3, 6, and 12 months of follow-ups, among systemic lupus erythematosus patients and two control groups; additionally, we evaluated the impact of systemic lupus erythematosus to predict early patency loss.

METHODS

A retrospective review of charts from arteriovenous fistulas created between 2008 and 2017 was performed. One-hundred thirty-four patients were identified and classified according to end-stage renal disease attributable diagnosis as: systemic lupus erythematosus cases (N = 14), control-group-1 (91 patients with primarily diabetes and hypertension), and control-group-2 (29 patients with idiopathic end-stage renal disease). A case-control matched design (1:2:1) was proposed. Logistic regression analysis and Kaplan-Meier curves were used. Institutional Review Board approval was obtained.

RESULTS

More systemic lupus erythematosus patients lost primary patency at 3 (28.6%) and 12 months (71.4%) than patients from control-groups-1 (vs. 3.6% and 35.7%, respectively) and -2 (vs. 0% and 14.3%, respectively), (p ≤ 0.011 for both). Days of primary patency survival were shorter in systemic lupus erythematosus patients (p = 0.003). Systemic lupus erythematosus diagnosis was the only factor associated with early patency loss, HR: 3.141, 95%CI: 1.161-8.493 (systemic lupus erythematosus diagnosis vs. control-group-1) and HR: 12.582, 95%CI: 1.582-100.035 (systemic lupus erythematosus diagnosis vs. control-group-2).

CONCLUSIONS

Diagnosis attributable to end-stage renal disease has a major impact on arteriovenous fistula outcomes in patients. Systemic lupus erythematosus patients have an increased risk of arteriovenous fistulas patency loss within the first six months of follow-up. Patients with idiopathic end-stage renal disease had an excellent one year arteriovenous fistula patency survival.

Lupus nephritis and end-stage kidney disease

Systemic lupus erythematosus (SLE) is a multisystem disease affecting many organs. Varying degrees of renal involvement are seen in up to 60% of adults with SLE, and severe lupus nephritis (LN) (World Health Organization class III and above) progresses to end-stage kidney disease (ESKD) within 15 years of diagnosis in 10% to 30% of patients. In fact, renal injury is the most important predictor of mortality in patients with SLE. Identifying patients at risk of progression to ESKD and providing them with aggressive and appropriate immunosuppressive therapy are important factors that affect the morbidity and mortality of LN patients. Management of LN-related ESKD requires attention to persistent activity of SLE and need for continuous immunosuppressive treatment because a decrease in SLE activity in this population can improve their outcome.

The dialysis scenario in patients with systemic lupus erythematosus

Although prognosis of lupus nephritis has improved over time, a substantial amount of lupus patients still reach end-stage renal disease and require dialysis. Treatment of these patients can be challenging, since the disease poses a number of problems that can portend a poor prognosis, such as infections, lupus reactivations, vascular access thrombosis and cardiovascular complications. Consensus is lacking among investigators about the real incidence of these complications and related diagnosis and treatment. Moreover, the choice of the type of dialysis treatment and the overall prognosis are still a matter of debate. In this paper, we have reviewed the currently available literature in an attempt to answer the most controversial issues about the topic.

Improving outcomes in patients with lupus and end-stage renal disease

The development of lupus-related end-stage renal disease (ESRD) confers the highest mortality rates among individuals with lupus. Lupus-related ESRD is also associated with higher morbidity and mortality rates compared with non-lupus ESRD. We review the evidence that persistent lupus activity, hypercoagulability, and continuing immunosuppression may contribute to unfavorable outcomes in dialysis and renal transplantation among lupus patients. Robust epidemiologic studies are needed to develop individualized evidence-based approaches to treating lupus-related ESRD. In the meantime, managing lupus-related ESRD presents a significant challenge for clinicians and requires a team approach involving nephrologists and rheumatologists. Goals of therapy after developing ESRD should include continuing monitoring of lupus activity, minimizing corticosteroid exposure, and choosing the most appropriate renal replacement therapy based on patient's risk profile and quality-of-life considerations.

The outcome of the primary vascular access and its translation into prevalent access use rates in chronic haemodialysis patients

Background

The American Fistula First Breakthrough Initiative currently aims for a 66% arterio-venous fistula (AVF) rate, while in the UK, best practice tariffs target AVF and arterio-venous graft (AVG) rates of 85%. The present study aims to assess whether these goals can be achieved.

Methods

We conducted a retrospective cohort study on patients who initiated haemodialysis from 1995 to 2006. Outcomes were the final failure-free survival of the first permanent access and the type of second access created. Prevalent use rates for the access types were calculated on the 1st January of each year for the second half of the study period.

Results

Two hundred and eleven out of 246 patients (86%) received an AVF, 16 (6%) an AVG and 19 (8%) a permanent catheter (PC) as the first permanent access. Eighty-six (35%) patients had final failure of the primary access. One- and 3-year final failure-free survival rates were 73 and 65% for AVF compared with 40 and 20% for AVG and 62 and 0% for PC, respectively. In patients with primary AVF, female sex {hazard ratio (HR) 2.20 [confidence interval (CI) 1.29–3.73]} and vascular disease [HR 2.24 (CI 1.26–3.97)] were associated with a poorer outcome. A similar trend was observed for autoimmune disease [HR 2.14 (CI 0.99–4.65)]. As second accesses AVF, AVG and PC were created in 47% (n = 40), 38% (n = 33) and 15% (n = 13). The median prevalent use rate was 80.5% for AVF, 14% for AVG and 5.5% for PC.

Conclusions

The vascular access targets set by initiatives from the USA and UK are feasible in unselected haemodialysis patients. High primary AVF rates, the superior survival rates of AVFs even in patient groups at higher risk of access failure and the high rate of creation of secondary AVFs contributed to these promising results.

Persistent low albumin and temporary vascular access in pediatric patients with SLE on hemodialysis

Pediatric patients with systemic lupus erythematosus (SLE) often present with significant kidney disease. In a previous cross-sectional analysis, we showed that pediatric patients with ESRD secondary to SLE have lower serum albumin levels and less permanent vascular access for hemodialysis (HD) compared to pediatric patients on HD secondary to other causes. The goal of this longitudinal study was to determine if there was an improvement in these targets over time. To this end, we performed a longitudinal analysis of patients receiving HD in the ESRD Clinical Performance Measures Project 2000-2004 study years, comparing achievement of clinical targets between pediatric patients with SLE and pediatric patients with other causes of ESRD. In the longitudinal follow-up, pediatric patients with SLE were less likely to reach target albumin levels than other children with ESRD maintained on HD [odds ratio (OR) 0.18, 95% confidence interval (CI) 0.09, 0.35] and were less likely to have arteriovenous fistulas or grafts than other pediatric patients (OR 0.45, 95% CI 0.23, 0.89). Pediatric patients with SLE maintained on HD are at particularly high risk for failing to meet some clinical targets that have been associated with improved long-term outcomes in other populations. This is true even as they remain on dialysis over time.