From the Journals

Renal transplant improves survival in lupus nephritis patients

Publish date: January 21, 2019
By
Andrew D. Bowser

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Prompt transplant crucial in lupus nephritis

This research by Jorge et al is “strong” and has two key implications for clinical practice, said authors of an accompanying editorial in the Annals of Internal Medicine.

The first is that transplantation should be incorporated into the treatment plan for lupus nephritis patients and is particularly important before kidney failure onset, according to Nitender Goyal, MD, Daniel E. Weiner, MD, MS, and Andrew S. Levey, MD.

“This will allow patients, families, and clinicians to devote sufficient resources to completing the transplant evaluation and searching for living donors, the preferred donor source to maximize patient and allograft survival,” they wrote.

Secondly, the evidence to date suggests wider implementation of preemptive kidney transplants would be warranted in patients with lupus nephritis, they said.

Currently, only about 9% of lupus nephritis patients with kidney failure related to lupus nephritis undergo preemptive transplants, versus 17% of patients undergoing kidney transplants for other reasons, according to the authors.

Recent studies, however, suggest preemptive transplants and early kidney transplants in lupus nephritis are indeed linked to improved patient and allograft survival, just as in other conditions, they added.

Taken together, the findings of those studies and the current study by Dr. Jorge and colleagues underscore the pronounced survival advantage attributable to kidney transplant in patients with kidney failure due to lupus nephritis, they concluded.

“It is essential that transplant be considered as promptly as possible for patients with lupus nephritis and that barriers to early transplant be surmounted,” they wrote.

The editorial was authored by Nitender Goyal, MD, Daniel E. Weiner, MD, MS, and Andrew S. Levey, MD, of Tufts Medical Center, Boston. Dr. Goyal and Dr. Levey reported no conflicts of interest. Dr. Weiner provided disclosures related to Keryx Biopharmaceuticals, Relypsa, Inc., Janssen Biopharmaceuticals, Akebia Therapeutics, and others.


 

FROM ANNALS OF INTERNAL MEDICINE

Renal transplant is associated with a substantial survival benefit in patients with end-stage renal disease due to lupus nephritis, according to researchers who conducted a nationwide cohort study encompassing nearly all such patients treated in the United States over a 20-year period.

Transplant conferred a 70% reduction in overall death risk in these lupus nephritis end-stage renal disease (ESRD) patients, largely due to reduced deaths caused by infection and cardiovascular disease, according to the researchers, led by April Jorge, MD, and Zachary Wallace, MD, of Massachusetts General Hospital, Harvard Medical School, Boston.

Those findings suggest that patients with lupus nephritis ESRD should routinely be considered for renal transplant in a timely manner, the investigators wrote in Annals of Internal Medicine.

“Improved access to renal transplantation for this population may considerably improve outcomes,” they said.

The study was based on an analysis of 9,659 patients who had lupus nephritis ESRD between 1995 and 2014 and were waitlisted for renal transplant. The data came from the United States Renal Data System, which includes most ESRD patients treated in the country. Of those 9,659 patients, 5,738 (59%) underwent kidney transplant.

Mortality rates were 22.5 per 1,000 person-years for lupus nephritis ESRD patients who underwent transplant, and 56.3 per 1,000 person-years for those patients who did not receive transplant, the investigators found.

Renal transplant reduced risk of death by 70% in results of multivariate analysis (hazard ratio, 0.30; 95% CI, 0.27-0.33).

That lower risk of all-cause mortality was consistent across racial groups and for other characteristics, such as sex, age at ESRD onset, and Medicare enrollment status.

Risk of cardiovascular death was 74% lower with renal transplant (adjusted hazard ratio, 0.26; 95% CI, 0.23-0.30), and risk of death from infection was also markedly lower among those who underwent transplant (adjusted hazard ratio, 0.41; 95% CI, 0.32-0.52), investigators found in a cause-specific mortality analysis.

While transplant has been associated with improved survival in patients with ESRD from all causes, there are “unique concerns” regarding the potential for infections or other post-transplant complications from transplant in lupus nephritis patients with ESRD, Dr. Jorge and colleagues wrote.

“To that end, our study provides evidence for a substantial survival benefit of renal transplant among patients with lupus nephritis ESRD,” they noted.

Dr. Jorge reported grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases during the conduct of the study. One co-author provided additional disclosures related to Teva Pharmaceuticals and Gilead Sciences outside of the study conduct.

SOURCE: Jorge A, et al. Ann Intern Med 2019 Jan 21. doi: 10.7326/M18-1570.

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