Abstract
Kidney transplant programs have different approaches to induction immunosuppression, and conflicting data exist on the role of steroid maintenance in recipients with glomerulonephritis (GN). GN patients are unique because of a higher risk for immune system exhaustion due to prior exposure to immunosuppressants to treat their GN; this raises questions regarding the optimal immunosuppression needed for transplant success and reduction of complications. We sought to assess the effect of induction type and steroid maintenance on the recipient and kidney graft survival in those with IgA nephropathy (IgAN), systemic lupus erythematosus related GN (SLE), small-vessel vasculitis (SVV), and anti-glomerular basement membrane disease (anti-GBM). We analyzed the Scientific Registry of Transplant Recipients (SRTR) database for adult, primary kidney recipients with the above glomerulonephritides through September 2019. Kaplan–Meier curves were generated to examine kidney graft and recipient survival. We used multivariable Cox proportional hazard models to investigate the impact of induction type and steroid maintenance in each group separately. Our study included 9176 IgAN, 5355 SLE, 1189 SVV, and 660 anti-GBM recipients. Neither induction type nor steroid maintenance therapy influenced recipient or death-censored graft survival in this cohort of recipients. Our findings provide an opportunity for recipients with a history of one of the studied glomerulonephritides to receive a more tailored immunosuppression regimen, considering their previous exposure to immunosuppressants.
Highlights
In the United States, glomerulonephritis (GN) is the etiology of end-stage kidney disease (ESKD) in approximately 7% of patients initiating dialysis and the third leading indication for kidney transplantation [1].The mainstay of managing glomerulonephritides is immunosuppression to induce and maintain disease remission
We sought to evaluate the role of induction immunosuppression and steroid avoidance in the setting of kidney transplant recipients with a history of glomerulonephritis, including IgA nephropathy (IgAN), systemic lupus erythematosus-related GN (SLE), anti-glomerular basement membrane disease, and small-vessel vasculitis (SVV)
Our study cohort consisted of 9176 recipients with IgAN, 5355 recipients with systemic lupus erythematosus related GN (SLE), 1189 recipients with SVV, and 660 anti-GBM recipients
Summary
In the United States, glomerulonephritis (GN) is the etiology of end-stage kidney disease (ESKD) in approximately 7% of patients initiating dialysis and the third leading indication for kidney transplantation [1].The mainstay of managing glomerulonephritides is immunosuppression to induce and maintain disease remission. Steroid regimens, including pulse doses or maintenance, are frequently utilized in glomerulonephritides with the customary goal to wean or replace with other immunosuppressive agents as soon as possible. For those unable to achieve disease remission, ongoing disease activity may lead to end-stage kidney disease (ESKD), as well as immune system exhaustion (loss of essential functional activity of immune cells such as anti-viral activity and tumor surveillance), and immune senescence (reduced proliferative capacity of immune cells or replicative senescence) due to chronic antigen stimulation and repeated treatment attempts [2,3]. We sought to evaluate the role of induction immunosuppression and steroid avoidance in the setting of kidney transplant recipients with a history of glomerulonephritis, including IgA nephropathy (IgAN), systemic lupus erythematosus-related GN (SLE), anti-glomerular basement membrane disease (anti-GBM), and small-vessel vasculitis (SVV)
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