Systemic lupus Erythematosus activity and Hydroxychloroquine use before and after end-stage renal disease

Abstract

Background SLE manifestations after ESRD may be underdiagnosed and undertreated, contributing to increased morbidity and mortality. Whether specific symptoms persist after ESRD or a shift towards new manifestations occurs has not been extensively studied, especially in the non-Caucasian patients in the United States. In addition, hydroxychloroquine (HCQ) prescribing patterns post-ESRD have not been described. The objective of this study was to assess lupus activity and HCQ prescribing before and after ESRD development. Knowledge gained from this study may aid in the identification of SLE manifestations and improve medication management post-ESRD. Methods We performed a retrospective cohort study of SLE patients with incident ESRD between 2010 and 2017. SLE-related symptoms, serologic markers of disease activity, and medication use were collected from medical records before and after ESRD development. Results Fifty-nine patients were included in the study. Twenty-five (43%) patients had at least one clinical (non-renal) SLE manifestation documented within 12 months before ESRD. Of them, 11/25 (44%) continued to experience lupus symptoms post-ESRD; 9 patients without clinical or serological activity pre-ESRD developed new symptoms of active SLE. At the last documented visit post-ESRD, 42/59 (71%) patients had one or more clinical or serological markers of lupus activity; only 17/59 (29%) patients achieved clinical and serological remission. Thirty-three of 59 (56%) patients had an active HCQ prescription at the time of ESRD. Twenty-six of the 42 (62%) patients with active SLE manifestations post-ESRD were on HCQ. Patients who continued HCQ post-ESRD were more likely to be followed by a rheumatologist (26 [87%] vs 17 [61%], p = 0.024), had a higher frequency of documented arthritis (10 [32%] vs 1 [4%], p = 0.005), CNS manifestations (6 [20%] vs 1 [4%], p = 0.055), and concurrent immunosuppressive medication use (22 [71%] vs 12 [43%], p = 0.029). Conclusions Lupus activity may persist after the development of ESRD. New onset arthritis, lupus-related rash, CNS manifestations, low complement and elevated anti-dsDNA may develop. HCQ may be underutilized in patients with evidence of active disease pre- and post ESRD. Careful clinical and serological monitoring for signs of active disease and frequent rheumatology follow up is advised in SLE patients both, pre and post-ESRD.

Prescribing Patterns of Hydroxychloroquine and Glucocorticoids Among Lupus Patients After New‐Onset End‐Stage Renal Disease

“…Although many SLE patients may experience disease remission after ESRD, up to 79% of SLE ESRD patients show signs of clinical or serologic activity (13)(14)(15)20,29). In the absence of evidence-based guidelines, medication management post-ESRD presents a major challenge: over-or undertreating SLE may lead to unfavorable outcomes.…”

“…A major limitation is the lack of data on SLE activity in the USRDS. We previously evaluated the relationship between disease activity and medication use in a retrospective study at our center (20). In that study, among 59 SLE ESRD patients, 71% had evidence of clinically and/or serologically active disease after ESRD onset, consistent with prior reports.…”

“…Some patients may experience persistent activity and flares that may be difficult to distinguish from complications related to ESRD (cytopenias, fever, serositis, and seizures) (17,18). Many SLE patients stop following up with rheumatologists after ESRD onset, which makes the diagnosis of subsequent flares even more difficult (19,20). In addition, physicians may be less likely to continue HCQ due to the potential concerns for higher risks of retinal and cardiac complications resulting from the decreased renal clearance of HCQ in ESRD (12).…”

Clinical Use of Belimumab for Systemic Lupus Erythematosus in the Setting of Advanced Chronic Kidney Disease and End-Stage Kidney Disease on Dialysis

“…2 Despite prevailing dogma that patients with ESKD attain disease remission, nonrenal SLE activity (mucocutaneous, musculoskeletal, hematological, and serological) can persist and has been described in as many as 50% of SLE patients after progression to ESKD. [3][4][5] Undertreatment of SLE activity in those with ESKD has been associated with increased mortality. 6 There are no evidence-based guidelines on SLE treatment after progression to ESKD.…”