Relapse and Outcome of Lupus Nephritis After Renal Transplantation in the Modern Immunosuppressive Era

Abstract

BackgroundRecurrence of lupus nephritis in the graft is a concern in lupus patients with end-stage renal disease undergoing renal transplantation. The recurrence of lupus nephritis has been variable among different studies depending on the patient characteristics, immunosuppressive regimen, and indications of renal biopsy. Therefore, we investigated the recurrence of lupus nephritis among our patients to see if the new post-transplant regimen has impacted the recurrence. MethodsWe collected data on all recipients with end-stage renal disease secondary to lupus nephritis, who received renal transplants between 2006-2017 in our center. Patient demographics, transplant, and dialysis-related information have been recorded including kidney biopsy, graft loss, and survival were recorded. An association between recurrent lupus nephritis with survival and/or graft loss was examined using survival models. ResultsThe overall mean±SD age at baseline was 42±13 years; 89% were female; 89% were African American; the previous time on dialysis was a median of 4 years (IQR: 2-8 years), 81% received hemodialysis and 31% received living donor transplantation in the cohort. Our patients received the standard immunosuppressive regimen consisting of prednisone, tacrolimus, and mycophenolate mofetil. Four (10.5%) of the 38 patients had biopsy-proven lupus nephritis recurrence. A total of 10 patients (26%) had graft loss or died during the median follow-up time of 1,230 days (IQR: 460-2,227 days). Recurrence of lupus nephritis showed a trend for increased risk of graft loss or patient death (Hazard Ratio: 3.14, 95%Confidence Interval: 0.65-15.24) compared to the recipient without recurrence in our unadjusted proportional Cox regression model. ConclusionThe recurrence rate of lupus nephritis in our patient population is much lower compared to past studies from different immunosuppressive eras. Patients with recurrent lupus nephritis showed an increased risk of graft loss or death.

Referral and evaluation for kidney transplantation among patients with lupus nephritis-related end-stage kidney disease

“…Historically, when patients with LN approached ESKD, the trend was for rheumatologists 2 and nephrologists 3 to start patients on hemodialysis and suspend kidney transplant in allowance for the quiescence of the underlying autoimmune processes of SLE and LN. However, recent studies demonstrated a lower risk of graft failure following recurrent LN 5,6,10 secondary to advancements in immunosuppressive therapies 5,6 and a lower risk of premature mortality among patients with LN-ESKD spending less time on dialysis prior to kidney transplant. 7,17,18 With kidney transplant now being a well-established treatment option for patients with LN-ESKD, it is vital that a concerted effort is put forth in understanding at what point in the disease process is this younger patient population initiating first steps to transplant.…”

“…4 However, studies conducted more recently report that due to advancements in post-transplant immunosuppressive therapies, only 2.5%-10.5% of patients with LN-ESKD will experience recurrent LN post-transplant. 5,6 Additionally, in a recent national study examining post-transplant outcomes among patients with LN-ESKD waitlisted for kidney transplant, authors reported a survival benefit associated with patients who received a kidney transplant compared to those that remained on the waitlist. 7 Finally, recommendations to intentionally delay kidney transplant are not standardized and are in direct contrast to literature for all-cause ESKD, which suggests a shorter time from ESKD diagnosis to kidney transplant leads to better post-transplant outcomes.…”