Kidney Transplant Boosts Survival in Lupus Nephritis

By Marilynn Larkin

January 23, 2019

By Marilynn Larkin

NEW YORK (Reuters Health) - Kidney transplantation is associated with a survival benefit for patients with lupus nephritis and end-stage renal disease (LN-ESRD), researchers have found.

Patients with LN-ESRD have high mortality rates, Dr. April Jorge of Massachusetts General Hospital in Boston noted in an email to Reuters Health.

"We found that among nearly all such patients in the United States who were waitlisted, renal transplant was associated with a significant survival benefit," she said. "This is an encouraging finding, and clinicians should consider early referral for renal transplantation for patients with LN-ESRD who may be candidates, as this can reduce mortality."

Dr. Jorge and colleagues studied 9,659 patients with LN-ESRD on dialysis who were waitlisted for transplant between 1995 and 2015, including 5,738 (59%) who ultimately received a new kidney.

The average age at waitlist entry was 38 and at transplant, 39. Eighty-two percent of waitlisted patients were female, 48% were African American and 21% were Hispanic. Hypertension was the most common comorbidity, affecting 79% of waitlisted patients.

As reported online January 21 in Annals of Internal Medicine, 973 transplant recipients died during follow-up, as did 1,697 patients who did not receive a transplant. Mortality rates were 22.5 and 56.3 per 1,000 person-years, respectively (hazard ratio, 0.29).

After adjustment, renal transplant was associated with a 70% reduction in risk for death (adjusted HR, 0.30). The lower risk for all-cause mortality was similar across racial groups and persisted across other characteristics - e.g., age at ESRD onset, sex, year of ESRD onset).

After accounting for competing risks, renal transplant was associated with a 74% lower risk for cardiovascular death (aHR, 0.26). Specifically, patients who underwent a transplant had a 70% lower risk for death due to coronary heart disease (aHR, 0.30) and a 61% lower risk for death due to stroke (aHR, 0.39).

The risk of death due to infection or sepsis was also lower in transplant recipients than among those who remained waitlisted (aHR, 0.41 for each).

A secondary analysis included 2,963 patients who had a transplant and 2,963 matched comparators. During follow-up, 470 patients with and 608 without a transplant died, resulting in mortality rates of 21.1 and 77.1 per 1,000 person-years, respectively (HR, 0.24).

Dr. Jorge noted, "As organ transplants are a limited resource, access to transplantation is likely to be a limiting factor for broadening implementation of this intervention."

"Furthermore," she added, "this study did not address factors that may impact transplant eligibility, such as lupus activity or other organ damage from systemic lupus erythematosus."

Dr. Nitender Goyal of Tufts Medical Center in Boston, coauthor of an accompanying editorial, told Reuters Health by email, "Kidney transplant is the best treatment for (LN-ESRD) patients and provides both survival and quality of life benefits. Outcomes are superior when kidney transplant is performed prior to initiation of dialysis when compared with an extended period of dialysis."

"Unfortunately," he said, "a small percentage of patients with LN-ESRD receive a kidney transplant before needing dialysis for many reasons, including organ shortage leading to long wait time, low living donation rate and a concern about recurrence of disease in the transplanted kidney."

"There is unmet need for development of better treatment for patients with LN to prevent progression of disease and maintain kidney health," he said. "Meanwhile, kidney transplantation remains the best (option)."

"Timely transplantation can be achieved by discussing kidney transplantation early in the course of disease so that enough resources can be dedicated to identifying a suitable living donor and barriers to transplantation," he said.


Ann Intern Med 2019.