Impact of pre-transplant time on dialysis on survival in patients with lupus nephritis

Eleana Ntatsaki,Alba Velo-Garcia,David A Isenberg,Vassilios S Vassiliou,Alan D Salama

doi:10.1007/s10067-018-4115-1

Abstract

Lupus nephritis (LN) is an important cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE) often leading to end-stage renal failure (ESRF) and necessitating renal transplantation (rTp). Optimal timing of rTp in SLE patients with ESRF is uncertain and could potentially affect survival. We investigated the time spent on dialysis before rTp and survival following rTp in a cohort of SLE patients. Retrospective analysis of all adult SLE patients receiving rTp over a 40-year period (1975–2015) in two tertiary UK centres. Cox proportional hazard regression and receiver operator curves (ROC) were used to determine the risk associated with time on dialysis before rTp and other potential predictors. Forty patients (age 35 ± 11 years, 34 female, 15 Caucasian, 15 Afro–Caribbean and 10 South Asian) underwent rTp. During a median follow-up of 104 months (IQR 80,145), eight (20%) patients died and the 5-year survival was 95%. Univariate analysis identified time on dialysis prior to rTp as the only potentially modifiable risk predictor of survival with a hazard ratio of 1.013 for each additional month spent on dialysis (95% CI = 1.001–1.026, p = 0.03). ROC curves demonstrated that > 24 months on dialysis had an adverse effect with sensitivity of 0.875 and specificity 0.500 for death. No other modifiable predictors were significantly associated with mortality, indicating that time on dialysis had an independent effect. Increased time on dialysis pre-transplantation is an independent modifiable risk factor of mortality in this cohort of patients with lupus nephritis.

Highlights

Systemic lupus erythematosus (SLE) is a heterogenous autoimmune rheumatic disease with high prevalence in women of childbearing age [1]
We investigated the long-term survival of patients with Lupus nephritis (LN) receiving renal transplantation (rTp) and the prognostic effect of the time spent on dialysis pretransplant in our cohort of LN patients from two major London hospitals followed up since 1975. This was a retrospective review of all adult SLE patients from two major London, UK institutions: University College London Hospital (UCLH) and Royal Free Hospital (RFH), who developed renal failure and received a renal transplant over a 40-year period (1975–2015)
All patients with SLE and related end-stage renal failure and who required renal transplantation from January 1975 to December 2015 were included in this study

Summary

Introduction

Systemic lupus erythematosus (SLE) is a heterogenous autoimmune rheumatic disease with high prevalence in women of childbearing age [1]. The kidneys are often affected, with at least one-third of SLE patients developing overt renal disease, while 10–25% may reach end-stage renal failure (ESRF) requiring dialysis or kidney transplantation and 10– 20% of patients die within 10 years [2]. There are racial, ethnic and regional variations in the incidence, prevalence and prognosis of LN [3]. Younger age (< 33 years), non-European ancestry and male gender (in some but not all series) were found to associate with earlier development of renal disease. Black and Hispanic patients with LN tend to have poorer prognosis and a higher risk of renal disease and mortality [4]

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