Renal transplantation for lupus nephritis: non-adherence and graft survival

Abstract

Poor adherence to immunosuppressive treatment is common in patients with systemic lupus erythematosus and may identify those with lupus nephritis (LN) who have a poorer prognosis. Non-adherence has also been reported to be a potential adverse outcome predictor in renal transplantation (rTp). We investigated whether non-adherence is associated with increased rTp graft rejection and/or failure in patients with LN. Methods Patients with LN undergoing rTp in two major London hospitals were retrospectively included. Medical and electronic records were reviewed for documented concerns of nonadherence as well as laboratory biochemical drug levels. The role of non-adherence and other potential predictors of graft rejection/ failure including demographics, comorbidities, age at SLE and LN diagnosis, type of LN, time on dialysis prior to rTp and medication use were investigated using logistic regression. Results Out of 361 patients with LN, 40 had renal transplantation. During a median follow up of 8.7 years, 17/40 (42.5%) of these patients had evidence of non-adherence. A total of 12 (30.0%) patients experienced graft rejection or failure or both. In the adherent group 2/23 (8.7%) had graft rejection, whilst in the non-adherent this rose to 5/17 (29.4%, p=0.11). Graft failure was seen in 5/23 (21.7%) patients from the adherent group and 4/17 (23.5%) in the non-adherent group (p=0.89). Non-adherent patients had a trend towards increased graft rejection, hazard ratio 4.38, 95% CI=0.73-26.12, p=0.11. Patients who spent more time on dialysis prior to rTp were more likely to be adherent to medication, p=0.01. Conclusion Poor adherence to immunosuppressive therapy is common and has been shown to associate with a trend towards increased graft failure in patients with LN requiring renal transplantation. This is the first paper to report that shorter periods on dialysis prior to transplantation might lead to increased non-adherence in lupus patients.

A pharmacist-led intervention to improve kidney transplant recipient outcomes and identify patients at risk of highly variable trough tacrolimus levels: a cohort study

“…The literature data on variables directly related to transplantation indicate that non-adherence is more frequently observed in patients who have not been on dialysis for very long before transplantation29 32 and patients who receive a living-donor transplant 33–36. Although we collected data on the type of donor (living or dead), the context of transplantation (pre-emptive or not) and the time on dialysis before transplantation, it was not clear whether these two variables influenced the variability in the C min .…”

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

“…Our numbers are too small to identify any single factor to account for the lower relapse rate. In general single-center studies have reported a higher recurrence rate because those studies are done using indication biopsies [24][25][26][27].…”

“…Overall, the low relapse rate in renal transplant patients might be attributed to the immunosuppressive regimen, burned-out effect of uremia, and dialysis [24][25][26][27]. Non-Hispanic Black race, female gender, and age <33 years independently were associated with increased risk of recurrence (14).…”