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Pachi BC, Bialecki LMB, Borba LR, Bischoff HM, Garcia VD, Meinerz G, Keitel E. Epidemiological profile of kidney transplant patients with lupus nephritis. J Bras Nefrol 2025; 47:e20240061. [PMID: 39671453 PMCID: PMC11642653 DOI: 10.1590/2175-8239-jbn-2024-0061en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2024] [Accepted: 10/13/2024] [Indexed: 12/15/2024] Open
Abstract
INTRODUCTION Lupus nephritis (LN) affects up to 50% of patients with systemic lupus erythematosus (SLE) and may lead to kidney failure and require kidney transplantation (KT). Results compared to KT from other causes are controversial, and we aimed to assess the clinical course, complications, and survival of LN patients undergoing KT. METHODOLOGY Retrospective cohort of 99 KT due to LN from 1977 to 2023 at a single center, divided into two groups according to the immunosuppression period: G1 (before 2009) and G2 (from 2009 onwards). Clinical and demographic characteristics, as well as clinical evolution, were compared. RESULTS Patients were predominantly white (65.9%), female (86.9%), in their first KT (83.8%). The median age was 20.0 (11.5-25.0) years at SLE diagnosis, and 30.0 (23.0-40.0) years at KT. Renal graft biopsy was indicated in 46% of patients, with rejection observed in 23%, and LN recurrence in 5%. When assessing the two distinct periods of standard immunosuppression, there was no difference in median glomerular filtration rate and proteinuria at 1 and 5 years, nor in 5-year survival. Throughout follow-up, 37.4% of patients lost their graft, and 13% died with a functioning graft. No graft loss was attributed to LN recurrence. CONCLUSION KT is a successful treatment for LN, with graft survival rates similar to those of transplants from other causes. LN recurrence was not associated with renal graft loss.
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Affiliation(s)
- Beatriz Curto Pachi
- Santa Casa de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Luísa Rigon Borba
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Helena Marcon Bischoff
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Gisele Meinerz
- Santa Casa de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Elizete Keitel
- Santa Casa de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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Lin TC, Tsai MK, Lee JH, Yang YH, Lin YT, Yu HH, Chiang BL, Wang LC. The outcome of kidney transplantation in lupus patients. Pediatr Neonatol 2025:S1875-9572(25)00053-1. [PMID: 40118766 DOI: 10.1016/j.pedneo.2024.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 06/28/2024] [Accepted: 09/27/2024] [Indexed: 03/23/2025] Open
Abstract
BACKGROUND Kidney transplantation represents a therapeutic option for individuals with end-stage renal disease due to lupus. However, the influence of lupus activity and immunosuppressive medications on graft survival remains a matter of concern and it has not been thoroughly elucidated. METHODS In this study, we conducted a retrospective review of 45 lupus patients who underwent kidney transplantation, with the aim of analyzing graft survival and identifying factors influencing the outcome of kidney transplantation in lupus patients. RESULTS Graft survival rates at 1, 5, 10, 15, and 20 years were 98%, 98%, 88%, 85%, and 78%, respectively. Univariate logistic regression revealed hypertension, positive panel reactive antibodies against HLA class II antigens, retransplant, young age at lupus nephritis onset, low postoperative C4 levels, and HBsAg and/or anti-HBe antibody presence were significantly correlated with decreased graft survival (p < 0.05). Multiple regression confirmed the significant association of HBsAg and/or anti-HBe antibody with graft failure (p = 0.0161), with all patients testing negative for anti-HBc antibody. Preoperative markers (C3, C4, anti-dsDNA antibody) and recurrent lupus nephritis did not impact graft failure. CONCLUSION In lupus patients undergoing kidney transplantation, hepatitis B serology emerges as a potential singular predictor for graft failure, while preoperative lupus activity markers and recurrent lupus nephritis do not affect outcomes.
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Affiliation(s)
- Ting-Chih Lin
- Department of Pediatrics, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Meng-Kun Tsai
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jyh-Hong Lee
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Yao-Hsu Yang
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Yu-Tsan Lin
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Hsin-Hui Yu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Bor-Luen Chiang
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan; Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Chieh Wang
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.
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3
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Dobrowolski C, Lao SM, Kharouf F, Croci PP, Wither J, Gladman DD, Garcia LW, Jauhal A, Touma Z. Lupus nephritis: Biomarkers. Adv Clin Chem 2024; 124:87-122. [PMID: 39818439 DOI: 10.1016/bs.acc.2024.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2025]
Abstract
Lupus nephritis (LN) or renal involvement of systemic lupus erythematosus (SLE), is a common manifestation occurring in at least 50 % of SLE patients. LN remains a significant source of morbidity, often leading to progressive renal dysfunction and is a major cause of death in SLE. Despite these challenges, advances in the understanding of the pathogenesis and genetic underpinnings of LN have led to a commendable expansion in available treatments over the past decade. This chapter provides a foundation for the understanding LN pathogenesis, diagnosis, and epidemiology, and guides the reader through recent advances in biomarkers, genetic susceptibility of this intricate condition.
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Affiliation(s)
- Chrisanna Dobrowolski
- Division of Rheumatology, Department of Medicine, Mount Sinai School of Medicine, New York, NY, United States
| | - Shu Min Lao
- Division of Rheumatology, Department of Medicine, Mount Sinai School of Medicine, New York, NY, United States
| | - Fadi Kharouf
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Paula Parnizari Croci
- Hospital Manuel Quintela, Facultad de Medicina, Universidad de la República, Uruguay
| | - Joan Wither
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Dafna D Gladman
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Laura Whitall Garcia
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Arenn Jauhal
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Zahi Touma
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada.
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4
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Mai K, Singer P, Fahmy AE, Teperman LW, Molmenti EP, Grodstein EI, Castellanos L, Sethna CB. Kidney transplant outcomes in children and adolescents with systemic lupus erythematosus. Pediatr Transplant 2022; 26:e14178. [PMID: 34687584 DOI: 10.1111/petr.14178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 08/17/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Literature supports equivalent kidney transplant outcomes in adults with systemic lupus erythematosus (SLE) compared with those without SLE. However, there are conflicting and scant data on kidney transplant outcomes, as well as controversy over optimal timing of transplantation, in children and adolescents with SLE. METHODS Analysis included kidney-only transplant recipients aged 2-21 years from 2000 to 2017 enrolled in the Organ Procurement and Transplant Network (OPTN). The relationship between diagnosis (SLE n = 457, non-SLE glomerular disease n = 4492, and non-SLE non-glomerular disease n = 5605) and transplant outcomes was evaluated. The association between dialysis time and outcomes was analyzed in the SLE group only. RESULTS In adjusted models, SLE had higher mortality compared with non-SLE glomerular recipients (HR 1.24 CI 1.07-1.44) and non-glomerular recipients (HR 1.42 CI 1.20-1.70). SLE was associated with higher graft failure compared with non-SLE glomerular (HR 1.42 CI 1.20-1.69) and non-glomerular disease (HR 1.67 CI 1.22-2.28). SLE had a higher risk of acute rejection at 1 year compared with non-glomerular disease (HR 1.39 CI 1.03-1.88). There was a decreased risk of delayed graft function compared with non-SLE glomerular disease (HR 0.54, CI 0.36-0.82). There were no significant associations between dialysis time and transplant outcomes in the SLE group. CONCLUSION SLE in children and adolescents is associated with worse patient and graft survival compared with non-SLE diagnoses. Outcomes in children and adolescents with SLE are not associated with dialysis time. Further studies are needed to assess implications of potential earlier transplantation and shorter time on dialysis prior to transplantation.
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Affiliation(s)
- Katherine Mai
- Department of Pediatrics, Division of Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA
| | - Pamela Singer
- Department of Pediatrics, Division of Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA.,Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Ahmed E Fahmy
- Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Lewis W Teperman
- Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Ernesto P Molmenti
- Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Elliot I Grodstein
- Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Laura Castellanos
- Department of Pediatrics, Division of Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA.,Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Christine B Sethna
- Department of Pediatrics, Division of Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA.,Department of Transplantation, Northwell Health, Great Neck, New York, USA
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5
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Rodelo J, González LA, Ustáriz J, Matera S, Pérez K, Ramírez Z, Arias LF, García Á, Arbeláez M, Henao J. Kidney transplantation outcomes in lupus nephritis: A 37-year single-center experience from Latin America. Lupus 2021; 30:1644-1659. [PMID: 34225520 DOI: 10.1177/09612033211028663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE We assessed patient and graft outcomes and prognostic factors in kidney transplantation in patients with end-stage kidney disease (ESKD) secondary to lupus nephritis (LN) undergoing kidney transplantation from August 1977 to December 2014 in a Latin American single center. METHODS The primary endpoint was patient survival, and the secondary endpoints were death-censored graft survival for the first renal transplant and the rate of recurrent LN (RLN). Kaplan-Meier method was used for survival analysis. Factors predicting patient and death-censored graft survivals were examined by Cox proportional-hazards regression analyses. RESULTS 185 patients were retrospectively evaluated. Patient survival rates were 88% at one year, 82% at three years, 78% at five years, and 67% at ten years. Death-censored graft survival for the first renal transplant was 93% at one year, 89% at three years, 87% at five years, and 80% at ten years. RLN was diagnosed in 2 patients (1.08%), but no graft was lost because of RLN. Thirty-nine (21.1%) patients died, and 65 (35.1%) patients experienced graft loss during the follow-up. By multivariable analyses, older recipient age and 1-month posttransplantation eGFR <45 ml/min/1.73m2 were associated with lower patient survival and an increased risk of graft loss, while induction immunosuppressive therapy exerted a protective effect on patients' survival. In the subgroup of patients in whom disease activity was measured at the time of transplantation, a higher SLEDAI score was also associated with lower patient survival and an increased risk of graft loss. CONCLUSION In a mostly Mestizo population, kidney transplantation is an excellent therapeutic alternative in LN patients with ESKD. Older recipient age, an eGFR <45 ml/min/1.73m2 at one month posttransplantation, and disease activity at the time of transplantation are predictive of a lower patient and death-censored graft survival, while induction immunosuppressive therapy has a protective effect on patient survival. RLN is rare and does not influence the risk of graft loss.
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Affiliation(s)
- Joaquín Rodelo
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Luis Alonso González
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - José Ustáriz
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Silvia Matera
- Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Keylis Pérez
- Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Zoraida Ramírez
- Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Luis Fernando Arias
- Department of Pathology, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Álvaro García
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia.,Division of Nephrology, Nefron Sas, Medellín, Colombia
| | - Mario Arbeláez
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia.,Division of Nephrology, Nefron Sas, Medellín, Colombia
| | - Jorge Henao
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia.,Division of Nephrology, Nefron Sas, Medellín, Colombia
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Chadban SJ, Ahn C, Axelrod DA, Foster BJ, Kasiske BL, Kher V, Kumar D, Oberbauer R, Pascual J, Pilmore HL, Rodrigue JR, Segev DL, Sheerin NS, Tinckam KJ, Wong G, Knoll GA. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation 2020; 104:S11-S103. [PMID: 32301874 DOI: 10.1097/tp.0000000000003136] [Citation(s) in RCA: 345] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.
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Affiliation(s)
- Steven J Chadban
- Royal Prince Alfred Hospital and Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Curie Ahn
- Seoul National University, Seoul, South Korea
| | | | - Bethany J Foster
- The Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
| | | | - Vijah Kher
- Medanta Kidney and Urology Institute, Haryana, India
| | - Deepali Kumar
- University Health Network, University of Toronto, Toronto, Canada
| | | | | | | | | | - Dorry L Segev
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | - Gregory A Knoll
- The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Canada
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7
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Romero Karam LA, Patel AM, Truong L, Gonzalez JM. A Case Report of Recurrent Lupus Nephritis 15 Days After Renal Transplantation. Transplant Proc 2020; 52:614-618. [PMID: 32057496 DOI: 10.1016/j.transproceed.2019.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 09/23/2019] [Accepted: 10/18/2019] [Indexed: 10/25/2022]
Abstract
Renal transplantation is an ever-growing therapeutic option for patients with end-stage renal disease due to lupus nephritis. Outcomes for these patients are comparable to those of patients receiving renal transplantation for other causes. A known complication for these patients is recurrence of lupus nephritis in the renal graft (recurrent lupus nephritis [RLN]). Although disease severity at the time of recurrence is usually milder, a small number of cases have been reported to progress to allograft failure. There is a trend toward preemptive renal transplantation in patients with lupus nephritis, as more favorable outcomes have been observed with this treatment modality. While clinicians usually seek clinical remission of lupus prior to proceeding with renal transplantation, no guidelines are established regarding how often to check for serologic activity of lupus in patients with end-stage renal disease due to lupus nephritis and whether these serologic markers should be taken into account when deciding on the timing of transplantation. We present a case of early RLN co-occurring with acute cellular rejection 15 days after renal transplantation. The patient had been in clinical remission for more than 5 months prior to transplantation but had a rise in anti-double-stranded DNA antibody titers and a decrease in complement C3 level at the time of surgery. Although additional studies are needed to establish the extent to which serologic markers of lupus correlate with renal graft dysfunction, this case suggests hypocomplementemia and high double-stranded DNA antibody titers may be a risk factor for early RLN.
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Affiliation(s)
| | - Amol M Patel
- Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Luan Truong
- Department of Anatomic, Clinical, and Laboratory Pathology, Houston Methodist Hospital, Houston, Texas
| | - Juan M Gonzalez
- Department of Nephrology, Transplant Nephrology, Houston Methodist Hospital, Houston, Texas
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8
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Wong T, Goral S. Lupus Nephritis and Kidney Transplantation: Where Are We Today? Adv Chronic Kidney Dis 2019; 26:313-322. [PMID: 31733715 DOI: 10.1053/j.ackd.2019.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 06/03/2019] [Accepted: 08/09/2019] [Indexed: 12/12/2022]
Abstract
Lupus nephritis (LN) is the cause of end-stage kidney disease (ESKD) for 1.9% of the ESKD population in the United States. Although the incidence rates of ESKD from LN stopped rising in recent years, racial disparities in waiting time, pre-emptive kidney transplant, and transplant outcomes still exist. Patients with LN who progress to ESKD tend to be female, of African ancestry, and young. Kidney transplantation is safe in this population and associated with a substantial survival benefit, primarily due to reduced deaths from cardiovascular disease and infection. Transplant outcomes for patients with ESKD due to LN are similar to those without LN.
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9
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Outcome and Prognosis of Patients With Lupus Nephritis Submitted to Renal Transplantation. Sci Rep 2019; 9:11611. [PMID: 31406264 PMCID: PMC6690950 DOI: 10.1038/s41598-019-48070-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 07/25/2019] [Indexed: 11/09/2022] Open
Abstract
This stydy aimed to evaluate the epidemiological and clinical profile and outcome of patients with lupus nephritis (LN) submitted to renal transplantation. Retrospective cohort study based on the records of 35 LN patients submitted to renal transplantation at a single center in Brazil between July 1996 and May 2016. The Kaplan-Meier method was used to estimate 6-month, 1-year and 5-year graft survival. The sample included 38 transplantations (3 of which retransplantations). The mean age at the time of SLE diagnosis was 23.7 ± 9.0 years. Most patients were female (94.7%) and 68.4% were non-Caucasian. Twenty-two (57.9%) underwent renal biopsy prior to transplantation. The mean time from SLE diagnosis to transplantation was 10.3 ± 6.4 years. The mean pre-transplantation dialysis time was 3.8 ± 3.7 years. The grafts came from living related (n = 11) or deceased (n = 27) donors. Three (7.9%) patients experienced acute rejection in the first year. Graft and patient survival rates were, respectively, 97.1% and 100% at 6 months, 84.9% and 96.9% at 1 year, and 76.3% and 92.5% at 5 years. One (2.6%) patient had SLE recurrence. Venous thrombosis (p = 0.017) and antiphospholipid syndrome (APS) (p = 0.036) were more prevalent in patients with graft loss. In our cohort of LN patients submitted to renal transplantation, the 5-year survival rate was high, and APS was an important predictor of poor renal outcome (graft loss).
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10
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Abstract
Systemic lupus erythematosus is the most characteristic of auto-immune disorders that can lead to tissue damage in many organs, including kidney. Lupus nephritis occurs in 10 to 40% of lupus patients. Its clinical hallmark is the appearance of a proteinuria as soon as a 0.5 g/g or 0.5 g/d threshold, which calls for a renal histological evaluation in order to determine the lupus nephritis severity and the need for specific therapy. More than half of renal biopsies lead to the diagnosis of active lupus nephritis-class III or class IV A according to the ISN/RPS classification-that are the most severe in regards to renal prognosis and mortality. Their treatment aims to their clinical remission and to the prevention of relapse with minimal adverse effects for eventually the preservation of renal function, the prevention of other irreversible damage, and the reduction of risk of death. The remission is obtained through induction therapies of which the association of high dose steroids and cyclophosphamide is the most experienced. When this association must be challenged by the prevention of side-effect, in particular infertility, mycophenolate can be given instead of cyclophosphamide. Maintenance therapy, for the prevention of relapse, consists in mycophenolate or in azathioprine, mycophenolate being the most efficient however associated with a high risk of teratogenicity. Withdrawal of maintenance therapy is possible after two to three years in absence of high risk factors of relapse of lupus nephritis, however a reliable assessment of the risk of relapse is still lacking. Only pure membranous lupus nephritis (pure class V) associated with high level proteinuria requires specific therapies that usually associates steroids and an immunosuppressive drug. However, their choice hierarchy and even the use of less immunosuppressive strategies remain to be determined in terms of benefice over risk ratios. In spite of its trigger effect on lupus activity, pregnancy can be safe and successful if scheduled in the lowest risk periods with close multidisciplinary monitoring before, during and after. When necessary, renal replacement therapy does not require specific adaptation, renal transplantation is the best option when possible, as early as possible.
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Affiliation(s)
- Quentin Raimbourg
- Service de néphrologie, hôpital Bichat, 46, rue Henri-Huchard, 75877 Paris cedex 18, France; Université Paris Diderot, 5, rue Thomas-Mann, 75013 Paris, France; Inserm U1149, Département hospitalo-universitaire (DHU) Fibrosis-Inflammation-Remodeling (FIRE), 16, rue Henri Huchard, 75890 Paris cedex 18, France
| | - Éric Daugas
- Service de néphrologie, hôpital Bichat, 46, rue Henri-Huchard, 75877 Paris cedex 18, France; Université Paris Diderot, 5, rue Thomas-Mann, 75013 Paris, France; Inserm U1149, Département hospitalo-universitaire (DHU) Fibrosis-Inflammation-Remodeling (FIRE), 16, rue Henri Huchard, 75890 Paris cedex 18, France.
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11
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Jorge A, Lu N. Renal Transplantation and Survival Among Patients With Lupus Nephritis: A Cohort Study. Ann Intern Med 2019; 170:240-247. [PMID: 30665236 PMCID: PMC6739121 DOI: 10.7326/m18-1570] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Patients with end-stage renal disease (ESRD) due to lupus nephritis (LN) have high rates of premature death. Objective To assess the potential effect on survival of renal transplant among patients with ESRD due to LN (LN-ESRD) in the United States. Design Nationwide cohort study. Setting United States Renal Data System, the national database of nearly all patients with ESRD. Participants Patients with incident LN-ESRD who were waitlisted for a renal transplant. Measurements First renal transplant was analyzed as a time-varying exposure. The primary outcomes were all-cause and cause-specific mortality. Time-dependent Cox regression analysis was used to estimate the hazard ratio (HR) of these outcomes associated with renal transplant in the primary analysis. Sequential cohort matching was used in a secondary analysis limited to patients with Medicare, which allowed assessment of time-varying covariates. Results During the study period, 9659 patients with LN-ESRD were waitlisted for a renal transplant, of whom 5738 (59%) had a transplant. Most were female (82%) and nonwhite (60%). Transplant was associated with reduced all-cause mortality (adjusted HR, 0.30 [95% CI, 0.27 to 0.33]) among waitlisted patients. Adjusted HRs for cause-specific mortality were 0.26 (CI, 0.23 to 0.30) for cardiovascular disease, 0.30 (CI, 0.19 to 0.48) for coronary heart disease, 0.41 (CI, 0.32 to 0.52) for infection, and 0.41 (CI, 0.31 to 0.53) for sepsis. Limitation Unmeasured factors may contribute to the observed associations; however, the E-value analysis suggested robustness of the results. Conclusion Renal transplant was associated with a survival benefit, primarily due to reduced deaths from cardiovascular disease and infection. The findings highlight the benefit of timely referral for transplant to improve outcomes in this population. Primary Funding Source National Institutes of Health.
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Affiliation(s)
| | - Na Lu
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Bulfinch 165, Boston, MA 02114
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12
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Abstract
Systemic lupus erythematosus (SLE) is a systemic disease of unknown aetiology with variable course and prognosis. Lupus nephritis (LN) is one of the important disease manifestations of SLE with considerable influence on patient outcomes. Immunosuppression therapy has made it possible to control the disease with improved life expectancy and quality of life. In the last few decades, various studies across the globe have clarified the role, dose and duration of immunosuppression currently in use and also provided evidence for new agents such as mycophenolate mofetil, calcineurin inhibitors and rituximab. However, there is still a need to develop new and specific therapy with less adverse effects. In this review, the current evidence of the treatment of LN and its evolution, and new classification criteria for SLE have been discussed. Also, rationale for low-dose intravenous cyclophosphamide as induction agent followed by azathioprine as maintenance agent has been provided with emphasis on individualized and holistic approach.
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Affiliation(s)
- Ajay Jaryal
- Department of Nephrology, Indira Gandhi Medical College (IGMC), Shimla, India
| | - Sanjay Vikrant
- Department of Nephrology, Indira Gandhi Medical College (IGMC), Shimla, India
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Althaf MM, El Kossi M, Jin JK, Sharma A, Halawa AM. Human leukocyte antigen typing and crossmatch: A comprehensive review. World J Transplant 2017; 7:339-348. [PMID: 29312863 PMCID: PMC5743871 DOI: 10.5500/wjt.v7.i6.339] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/22/2017] [Accepted: 10/17/2017] [Indexed: 02/05/2023] Open
Abstract
Renal transplantation remains the best option for patients suffering from end stage renal disease (ESRD). Given the worldwide shortage of organs and growing population of patients with ESRD, those waitlisted for a transplant is ever expanding. Contemporary crossmatch methods and human leukocyte antigen (HLA) typing play a pivotal role in improving organ allocation and afford better matches to recipients. Understanding crossmatch as well as HLA typing for renal transplantation and applying it in clinical practice is the key step to achieve a successful outcome. Interpretation of crossmatch results can be quite challenging where clinicians have not had formal training in applied transplant immunology. This review aims to provide a worked example using a clinical vignette. Furthermore, each technique is discussed in detail with its pros and cons. The index case is that of a young male with ESRD secondary to Lupus nephritis. He is offered a deceased donor kidney with a 1-0-0 mismatch. His complement dependent cytotoxicity (CDC) crossmatch reported positive for B lymphocyte, but flow cytometry crossmatch (FCXM) was reported negative for both B and T lymphocytes. Luminex-SAB (single antigen bead) did not identify any donor specific antibodies (DSA). He never had a blood transfusion. The positive CDC-crossmatch result is not concordant with DSA status. These implausible results are due to underlying lupus erythematosus, leading to false-positive B-lymphocyte crossmatch as a result of binding immune complexes to Fc-receptors. False positive report of CDC crossmatch can be caused by the underlying autoimmune diseases such as lupus erythematosus, that may lead to inadvertent refusal of adequate kidney grafts. Detailed study of DSA by molecular technique would prevent wrong exclusion of such donors. Based on these investigations this patient is deemed to have "standard immunological risk" for renal transplantation.
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Affiliation(s)
- Mohammed Mahdi Althaf
- Jack Pryor Renal Unit, Norfolk and Norwich University Hospital - NHS Foundation Trust, Norwich NR4 7UY, United Kingdom
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
| | - Mohsen El Kossi
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Jon Kim Jin
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Nottingham Children Hospital, Nottingham NG7 2UH, United Kingdom
| | - Ajay Sharma
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Royal Liverpool University Hospitals, Liverpool L7 8XP, United Kingdom
| | - Ahmed Mostafa Halawa
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Department of Transplantation Surgery, Sheffield Teaching Hospitals, Sheffield S5 7AU, United Kingdom
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Naranjo-Escobar J, Manzi E, Posada JG, Mesa L, Echeverri GJ, Duran C, Schweneiberg J, Caicedo LA, Villegas JI, Tobón GJ. Kidney transplantation for end-stage renal disease in lupus nephritis, a very safe procedure: a single Latin American transplant center experience. Lupus 2017; 26:1157-1165. [DOI: 10.1177/0961203317696591] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Lupus nephritis (LN) is one of the most frequent complications of SLE and occurs in up to 50% of cases depending on the studied population. Of these, approximately 20% progress to end-stage renal disease (ESRD), with the treatment of choice being a kidney transplant. Objective The objective of this study was to describe the clinical outcome of patients transplanted due to LN, compared with patients transplanted for other causes, in a Latin American population from the Fundación Valle del Lili in Cali, Colombia. Methods Observational, retrospective case study with controls matched by age, sex and type of donor in a single center between 1996 and 2014. Results Sixty-five kidney transplants were performed in patients with LN and ESRD. The survival of patients with LN was 98% at 1, 10 and 15 years ( p = .99). For controls by age and sex, survival was also 98% at 15 years post-transplant, and for controls by donor, the survival rate was 100% at 5 years and 98% at 15 years. Graft survival in patients with LN to 1, 5 and 15 years was 92%, 83% and 71%, respectively; for controls by age and sex, it was 90%, 84% and 64%, respectively, and for the controls by donor, it was 89%, 86% and 79%, respectively ( p = .7718). There were no statistically significant differences found in the cumulative incidence of acute graft rejection in the first year, but it was found that acute rejection is a factor that relates to the loss of function of the renal graft ( p = .032). Of the patients transplanted for LN, two (3.1%) experienced a recurrence of the disease. One patient died after a diagnosis of recurrence of LN due to an infection. Conclusions Kidney transplantation is a good option for patients with ESRD due to LN. In this Hispanic population, the survival of patients, graft survival, and cumulative incidence of graft rejection are not different from those of other transplanted patients. In addition, recurrence of LN was rare, showing the benefits of renal transplantation in LN patients with ESRD.
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Affiliation(s)
- J Naranjo-Escobar
- Rheumatology Unit, Fundación Valle del Lili, Cali, Colombia
- ICESI University School of Medicine, Cali, Colombia
| | - E Manzi
- Centre of Clinical Research, Transplant Unit, Fundación Valle del Lili, Cali, Colombia
| | - J G Posada
- Internal Medicine and Nephrology Unit, Fundación Valle del Lili, Cali, Colombia
| | - L Mesa
- Internal Medicine and Nephrology Unit, Fundación Valle del Lili, Cali, Colombia
| | - G J Echeverri
- Abdominal Transplantation Surgery, Fundación Valle del Lili, Cali, Colombia
| | - C Duran
- Internal Medicine and Nephrology Unit, Fundación Valle del Lili, Cali, Colombia
| | - J Schweneiberg
- Internal Medicine and Nephrology Unit, Fundación Valle del Lili, Cali, Colombia
| | - L A Caicedo
- Abdominal Transplantation Surgery, Fundación Valle del Lili, Cali, Colombia
| | - J I Villegas
- Abdominal Transplantation Surgery, Fundación Valle del Lili, Cali, Colombia
| | - G J Tobón
- ICESI University School of Medicine, Cali, Colombia
- Rheumatology Unit and Laboratory of Immunology, Fundación Valle del Lili, Cali, Colombia
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Çeltİk A, Şen S, Tamer AF, Yılmaz M, Sarsık B, Özkahya M, Başçı A, Töz H. Recurrent lupus nephritis after transplantation: Clinicopathological evaluation with protocol biopsies. Nephrology (Carlton) 2016; 21:601-7. [DOI: 10.1111/nep.12657] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 09/22/2015] [Accepted: 10/15/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Aygül Çeltİk
- School of Medicine, Division of Nephrology; Ege University; Izmir Turkey
| | - Saİt Şen
- Ege University; School of Medicine, Department of Pathology; Izmir Turkey
| | | | - Mümtaz Yılmaz
- School of Medicine, Division of Nephrology; Ege University; Izmir Turkey
| | - Banu Sarsık
- Ege University; School of Medicine, Department of Pathology; Izmir Turkey
| | - Mehmet Özkahya
- School of Medicine, Division of Nephrology; Ege University; Izmir Turkey
| | - Alı Başçı
- School of Medicine, Division of Nephrology; Ege University; Izmir Turkey
| | - Hüseyİn Töz
- School of Medicine, Division of Nephrology; Ege University; Izmir Turkey
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Broder A, Mowrey WB, Kim M, Murakhovskaya I, Billett H, Neugarten J, Costenbader KH, Putterman C. Association between antiphospholipid antibodies and all-cause mortality among end-stage renal disease patients with and without SLE: a retrospective cohort study. Rheumatology (Oxford) 2015; 55:817-25. [PMID: 26705328 DOI: 10.1093/rheumatology/kev423] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the association between the presence of aPL and/or LA and all-cause mortality among end-stage renal disease (ESRD) patients with and without SLE. METHODS We included ESRD patients >18 years old followed at an urban tertiary care centre between 1 January 2006 and 31 January 2014 who had aPL measured at least once after initiating haemodialysis. All SLE patients met ACR/SLICC criteria. APL/LA+ was defined as aCL IgG or IgM >40 IU, anti-β2glycoprotein1 IgG or IgM >40 IU or LA+. Deaths as at 31 January 2014 were captured in the linked National Death Index data. Time to death was defined from the first aPL measurement. RESULTS We included 34 SLE ESRD and 64 non-SLE ESRD patients; 30 patients died during the study period. SLE ESRD patients were younger [40.4 (12.5) vs 51.9 (18.1) years, P = 0.001] and more were women (88.2% vs 54.7%, P < 0.001) vs non-SLE ESRD patients. The frequency of aPL/LA+ was 24% in SLE and 13% in non-SLE ESRD (P = 0.16). Median (inter-quartile range) follow-up time was 1.6 (0.3-3.5) years in SLE and 1.4 (0.4-3.2) years in non-SLE, P = 0.74. The adjusted hazard ratio (HR) for all-cause mortality for SLE patients who were aPL/LA+ vs aPL/LA- was 9.93 (95% CI 1.33, 74.19); the adjusted HR for non-SLE aPL/LA+ vs aPL/LA- was 0.77 (95% CI 0.14, 4.29). CONCLUSION SLE ESRD patients with aPL/LA+ had higher all-cause mortality risk than SLE ESRD patients without these antibodies, while the effects of aPL/LA on mortality were comparable among non-SLE ESRD patients.
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Affiliation(s)
- Anna Broder
- Division of Rheumatology, Department of Medicine,
| | - Wenzhu B Mowrey
- Division of Biostatistics, Department of Epidemiology and Population Health
| | - Mimi Kim
- Division of Biostatistics, Department of Epidemiology and Population Health
| | | | | | - Joel Neugarten
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY and
| | - Karen H Costenbader
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
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Chung MC, Yu TM, Shu KH, Lan JL, Chen DY, Ho HC, Wu MJ. Influence of pretransplantation dialysis time and lupus activity on outcome of kidney transplantation in systemic lupus erythematosus. Transplant Proc 2014; 46:336-8. [PMID: 24655957 DOI: 10.1016/j.transproceed.2013.11.085] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/15/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Kidney transplantation (KT) has better outcome compared with dialysis in lupus patients. The duration lupus patients need to wait before KT remains debatable, especially in patients with lupus activity. We analyzed a renal transplantation database to elucidate if pretransplantation dialysis (PTD) time and lupus activity affected outcome. METHODS From 1984 to 2012, 31 Chinese lupus nephritis patients underwent KT at our hospital. The lupus activity was defined as nonrenal systemic lupus erythematosus disease activity index (SLE-DAI) score. Biopsy-proven acute rejection/recurrent lupus nephritis (RLN) were recorded. Chronic allograft dysfunction (CAD) was defined as doubling of serum creatinine level. Graft failure was defined as return to dialysis. We calculated relative hazard ratios (HR) with 95% confidence intervals (CI) from Cox proportional-hazards regression models. RESULTS In total, 31 lupus patients with KT (7 men and 24 women), with a mean age of 35.3 years at transplantation, were enrolled in this study. The mean follow-up duration was 8.2 years. The mean PTD time was 3.3 years. Both PTD time and lupus activity before transplantation had no effect on CAD and graft failure. Longer PTD time was associated with more acute rejection (HR = 1.20; 95% CI, 1.02-1.41). Also, maximal lupus activity after transplantation was associated with more CAD (HR = 6.44; 95% CI, 1.36-30.57). CONCLUSION For Chinese lupus patients with KT, longer PTD time was associated with worse outcome. Patients should undergo KT immediately if a kidney is available for donation, even with active lupus disease. It is necessary to monitor lupus activity after transplantation due to its effect on outcome.
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Affiliation(s)
- M-C Chung
- Division of Nephrology, Taichung Veterans General Hospital, Taiwan
| | - T-M Yu
- Division of Nephrology, Taichung Veterans General Hospital, Taiwan
| | - K-H Shu
- Division of Nephrology, Taichung Veterans General Hospital, Taiwan; School of Medicine, Chung Shan Medical University, Taiwan
| | - J-L Lan
- College of Medicine, China Medical University, Taiwan
| | - D-Y Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taiwan; Department of Medical Research, Taichung Veterans General Hospital, Taiwan
| | - H-C Ho
- Division of Urology, Taichung Veterans General Hospital, Taiwan
| | - M-J Wu
- Division of Nephrology, Taichung Veterans General Hospital, Taiwan; School of Medicine, Chung Shan Medical University, Taiwan; College of Medicine, China Medical University, Taiwan; Institute of Biomedical Science, National Chung Hsing University, Taiwan; Department of Life Science, Tunghai University, Taiwan.
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Lionaki S, Skalioti C, Boletis JN. Kidney transplantation in patients with systemic lupus erythematosus. World J Transplant 2014; 4:176-182. [PMID: 25346890 PMCID: PMC4208080 DOI: 10.5500/wjt.v4.i3.176] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 04/24/2014] [Accepted: 07/17/2014] [Indexed: 02/05/2023] Open
Abstract
Despite improvements in overall prognosis in lupus nephritis, 10%-30% of patients with proliferative renal involvement progress to end stage renal disease, according to the severity of the disease and associated socioeconomic factors. Kidney transplantation has been recognized as the most appropriate treatment for those patients, but several issues remain after renal function restoration in a lupus recipient. Among these are the fear of lupus nephritis recurrence in the graft, the choice of immunosuppressive therapy in cases of recurrent lupus for a patient who has already received a toxic and prolonged immunosuppressive course, and finally, the management of comorbidities to reduce associated morbidities in the long term. All the above topics are examined in this review, with the hope of providing a clear picture of data as illustrated in the current literature.
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Inda-Filho A, Neugarten J, Putterman C, Broder A. Improving outcomes in patients with lupus and end-stage renal disease. Semin Dial 2013; 26:590-6. [PMID: 24004337 DOI: 10.1111/sdi.12122] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The development of lupus-related end-stage renal disease (ESRD) confers the highest mortality rates among individuals with lupus. Lupus-related ESRD is also associated with higher morbidity and mortality rates compared with non-lupus ESRD. We review the evidence that persistent lupus activity, hypercoagulability, and continuing immunosuppression may contribute to unfavorable outcomes in dialysis and renal transplantation among lupus patients. Robust epidemiologic studies are needed to develop individualized evidence-based approaches to treating lupus-related ESRD. In the meantime, managing lupus-related ESRD presents a significant challenge for clinicians and requires a team approach involving nephrologists and rheumatologists. Goals of therapy after developing ESRD should include continuing monitoring of lupus activity, minimizing corticosteroid exposure, and choosing the most appropriate renal replacement therapy based on patient's risk profile and quality-of-life considerations.
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Affiliation(s)
- Antonio Inda-Filho
- Division of Nephrology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Bertsias GK, Tektonidou M, Amoura Z, Aringer M, Bajema I, Berden JHM, Boletis J, Cervera R, Dörner T, Doria A, Ferrario F, Floege J, Houssiau FA, Ioannidis JPA, Isenberg DA, Kallenberg CGM, Lightstone L, Marks SD, Martini A, Moroni G, Neumann I, Praga M, Schneider M, Starra A, Tesar V, Vasconcelos C, van Vollenhoven RF, Zakharova H, Haubitz M, Gordon C, Jayne D, Boumpas DT. Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis 2012; 71:1771-82. [PMID: 22851469 PMCID: PMC3465859 DOI: 10.1136/annrheumdis-2012-201940] [Citation(s) in RCA: 703] [Impact Index Per Article: 54.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 07/03/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To develop recommendations for the management of adult and paediatric lupus nephritis (LN). METHODS The available evidence was systematically reviewed using the PubMed database. A modified Delphi method was used to compile questions, elicit expert opinions and reach consensus. RESULTS Immunosuppressive treatment should be guided by renal biopsy, and aiming for complete renal response (proteinuria <0.5 g/24 h with normal or near-normal renal function). Hydroxychloroquine is recommended for all patients with LN. Because of a more favourable efficacy/toxicity ratio, as initial treatment for patients with class III-IV(A) or (A/C) (±V) LN according to the International Society of Nephrology/Renal Pathology Society 2003 classification, mycophenolic acid (MPA) or low-dose intravenous cyclophosphamide (CY) in combination with glucocorticoids is recommended. In patients with adverse clinical or histological features, CY can be prescribed at higher doses, while azathioprine is an alternative for milder cases. For pure class V LN with nephrotic-range proteinuria, MPA in combination with oral glucocorticoids is recommended as initial treatment. In patients improving after initial treatment, subsequent immunosuppression with MPA or azathioprine is recommended for at least 3 years; in such cases, initial treatment with MPA should be followed by MPA. For MPA or CY failures, switching to the other agent, or to rituximab, is the suggested course of action. In anticipation of pregnancy, patients should be switched to appropriate medications without reducing the intensity of treatment. There is no evidence to suggest that management of LN should differ in children versus adults. CONCLUSIONS Recommendations for the management of LN were developed using an evidence-based approach followed by expert consensus.
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Affiliation(s)
- George K Bertsias
- Department of Medicine, Rheumatology, Clinical Immunology and Allergy, University of Crete, Iraklion, Greece
| | - Maria Tektonidou
- First Department of Internal Medicine, Rheumatology, University of Athens, Athens, Greece
| | - Zahir Amoura
- Department of Internal Medicine, French National Reference Center for SLE, Université Paris VI Pierre et Marie Curie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center Carl Gustav Carus, Dresden, Germany
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jo H M Berden
- Department of Nephrology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - John Boletis
- Department of Nephrology and Transplantation Center, Laiko General Hospital, Athens, Greece
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Thomas Dörner
- Department of Medicine, Rheumatology and Clinical Immunology, Charité—University Medicine Berlin, Berlin, Germany
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, University of Padova, Padova, Italy
| | - Franco Ferrario
- Nephropathology Center, San Gerardo Hospital, Monza and Milan Bicocca University, Monza, Italy
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH University of Aachen, Aachen, Germany
| | - Frederic A Houssiau
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Bruxelles, Belgium
| | - John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, and Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California, USA
| | - David A Isenberg
- Centre for Rheumatology Research, Division of Medicine, University College London, London, UK
| | - Cees G M Kallenberg
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Liz Lightstone
- Section of Renal Medicine, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Alberto Martini
- Pediatria II, Reumatologia, IRCCS Istituto G Gaslini, Università di Genova, Genova, Italy
| | - Gabriela Moroni
- Divisione di Nefrologia e Dialisi Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Irmgard Neumann
- Division of Nephrology, Internal Medicine, Wilhelminenspital, Vienna, Austria
| | - Manuel Praga
- Nephrology Division, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Matthias Schneider
- Department of Medicine, Rheumatology, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | | | - Vladimir Tesar
- Department of Nephrology, First School of Medicine, Charles University, Prague, Czech Republic
| | - Carlos Vasconcelos
- Unidade de Imunologia Clinica, Hospital Santo Antonio, Centro Hospitalar do Porto, UMIB-ICBAS, Universidade do Porto, Porto, Portugal
| | - Ronald F van Vollenhoven
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital in Solna, Stockholm, Sweden
| | - Helena Zakharova
- Nephrology Unit, Moscow City Hospital n.a. S.P. Botkin, Moscow State Medicine and Dentistry University, Moscow, Russian Federation
| | - Marion Haubitz
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover and Klinikum Fulda, Fulda, Germany
| | - Caroline Gordon
- Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, West Midlands, UK
| | - David Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
| | - Dimitrios T Boumpas
- Department of Medicine, Rheumatology, Clinical Immunology and Allergy, University of Crete, Iraklion, Greece
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Canaud G, Audard V, Kofman T, Lang P, Legendre C, Grimbert P. Recurrence from primary and secondary glomerulopathy after renal transplant. Transpl Int 2012; 25:812-24. [DOI: 10.1111/j.1432-2277.2012.01483.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Preemptive kidney transplantation in systemic lupus erythematosus. Transplant Proc 2012; 43:3713-4. [PMID: 22172832 DOI: 10.1016/j.transproceed.2011.08.092] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 08/30/2011] [Indexed: 12/11/2022]
Abstract
Preemptive kidney transplantation is associated with superior outcomes. Patients who have kidney failure due to systemic lupus erythematosus (SLE) may not receive a preemptive kidney transplant because of the concern for risk of disease recurrence with shortened graft and patient survival. We identified 8001 patients in the United Network for Organ Sharing dataset who underwent kidney transplantation between October 1987 and February 2009 with kidney failure due to SLE. Seven hundred thirty patients received a preemptive kidney transplant with 7271 patients who were on dialysis before transplantation; their mean ages were 40.0±11.6 years and 36.9±11.7 years, respectively, (P<.01). Women constituted 82.5% of preemptive and 81.4% of non-preemptive groups (P=.47). Preemptive transplant recipients were more likely to receive a living donor kidney transplant (odds ratio [OR]=3.6; 95% confidence interval [CI]=3.3-4.5; P<.01). In unadjusted analyses, preemptive transplantation was associated with lower risk of recipient death (hazard ratio [HR]=0.52; 95% CI=0.38-0.70; P<.01). The difference remained significant after adjustment fr covariates (HR=0.55; 95% CI=0.36-0.84; P<.01). Graft survival was also superior among preemptive kidney transplant recipients in both unadjusted (HR=0.56; 95% CI=0.49-0.68; P<.01), and adjustment analyses (HR=0.69; 95% CI=0.55-0.86; P<.01). We concluded that preemptive kidney transplantation among patients with SLE was associated with superior patient and graft outcomes and should be considered when feasible.
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Mosca M, Tani C, Aringer M, Bombardieri S, Boumpas D, Brey R, Cervera R, Doria A, Jayne D, Khamashta MA, Kuhn A, Gordon C, Petri M, Rekvig OP, Schneider M, Sherer Y, Shoenfeld Y, Smolen JS, Talarico R, Tincani A, van Vollenhoven RF, Ward MM, Werth VP, Carmona L. European League Against Rheumatism recommendations for monitoring patients with systemic lupus erythematosus in clinical practice and in observational studies. Ann Rheum Dis 2010; 69:1269-74. [PMID: 19892750 PMCID: PMC2952401 DOI: 10.1136/ard.2009.117200] [Citation(s) in RCA: 271] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES To develop recommendations for monitoring patients with systemic lupus erythematosus (SLE) in clinical practice and observational studies and to develop a standardised core set of variables to monitor SLE. METHODS We followed the European League Against Rheumatism (EULAR) standardised procedures for guideline development. The following techniques were applied: nominal groups, Delphi surveys for prioritisation, small group discussion, systematic literature review and two Delphi rounds to obtain agreement. The panel included rheumatologists, internists, dermatologists, a nephrologist and an expert related to national research agencies. The level of evidence and grading of recommendations were determined according to the Levels of Evidence and Grades of Recommendations of the Oxford Centre for Evidence-Based Medicine. RESULTS A total of 10 recommendations have been developed, covering the following aspects: patient assessment, cardiovascular risk factors, other risk factors (osteoporosis, cancer), infection risk (screening, vaccination, monitoring), frequency of assessments, laboratory tests, mucocutaneous involvement, kidney monitoring, neuropsychological manifestations and ophthalmology assessment. A 'core set' of minimal variables for the assessment and monitoring of patients with SLE in clinical practice was developed that included some of the recommendations. In addition to the recommendations, indications for specific organ assessments that were viewed as part of good clinical practice were discussed and included in the flow chart. CONCLUSIONS A set of recommendations for monitoring patients with SLE in routine clinical practice has been developed. The use of a standardised core set to monitor patients with SLE should facilitate clinical practice, as well as the quality control of care for patients with SLE, and the collection and comparison of data in observational studies.
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Affiliation(s)
- M Mosca
- Correspondence to Dr Marta Mosca, University of Pisa, via Roma 67, Ospedale S. Chiara, Pisa, 56126, Italy.
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Burgos PI, Perkins EL, Pons-Estel GJ, Kendrick SA, Liu JM, Kendrick WT, Cook WJ, Julian BA, Alarcón GS, Kew CE. Risk factors and impact of recurrent lupus nephritis in patients with systemic lupus erythematosus undergoing renal transplantation: data from a single US institution. ARTHRITIS AND RHEUMATISM 2009; 60:2757-66. [PMID: 19714623 PMCID: PMC2771574 DOI: 10.1002/art.24776] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To determine the risk factors for recurrent lupus nephritis, allograft loss, and survival among patients with systemic lupus erythematosus (SLE) undergoing kidney transplantation. METHODS The archival records of all kidney transplant recipients with a prior diagnosis of SLE (according to the American College of Rheumatology criteria) from June 1977 to June 2007 were reviewed. Patients who had died or lost the allograft within 90 days of engraftment were excluded. Time-to-event data were examined by univariable and multivariable Cox proportional hazards regression analyses. RESULTS Two hundred twenty of nearly 7,000 renal transplantations were performed in 202 SLE patients during the 30-year interval. Of the 177 patients who met the criteria for study entry, the majority were women (80%) and African American (65%), the mean age was 35.6 years, and the mean disease duration was 11.2 years. Recurrent lupus nephritis was noted in 20 patients (11%), allograft loss in 69 patients (39%), and death in 36 patients (20%). African American ethnicity was found to be associated with a shorter time-to-event for recurrent lupus nephritis (hazard ratio [HR] 4.63, 95% confidence interval [95% CI] 1.29-16.65) and death (HR 2.47, 95% CI 0.91-6.71), although, with the latter, the association was not statistically significant. Recurrent lupus nephritis and chronic rejection of the kidney transplant were found to be risk factors for allograft loss (HR 2.48, 95% CI 1.09-5.60 and HR 2.72, 95% CI 1.55-4.78, respectively). In patients with recurrent lupus nephritis, the lesion in the engrafted kidney was predominantly mesangial, compared with a predominance of proliferative or membranous lesions in the native kidneys. CONCLUSION African American ethnicity was independently associated with recurrent lupus nephritis. Allograft loss was associated with chronic transplant rejection and recurrence of lupus nephritis. Recurrent lupus nephritis is infrequent and relatively benign, without influence on a patient's survival.
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Affiliation(s)
- Paula I. Burgos
- Divisions of Clinical Immunology and Rheumatology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA 35294
| | - Elizabeth L. Perkins
- Divisions of Clinical Immunology and Rheumatology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA 35294
| | - Guillermo J. Pons-Estel
- Divisions of Clinical Immunology and Rheumatology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA 35294
| | - Scott A. Kendrick
- Divisions of Nephrology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA 35294
| | - Jigna M. Liu
- Divisions of Clinical Immunology and Rheumatology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA 35294
| | - William T. Kendrick
- Divisions of Nephrology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA 35294
| | - William J. Cook
- Department of Medicine, Pathology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA 35294
| | - Bruce A. Julian
- Divisions of Nephrology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA 35294
| | - Graciela S. Alarcón
- Divisions of Clinical Immunology and Rheumatology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA 35294
- Department of Medicine, Epidemiology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA 35294
| | - Clifton E. Kew
- Divisions of Nephrology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA 35294
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Yu TM, Chen YH, Lan JL, Cheng CH, Chen CH, Wu MJ, Shu KH. Renal outcome and evolution of disease activity in Chinese lupus patients after renal transplantation. Lupus 2008; 17:687-94. [PMID: 18625644 DOI: 10.1177/0961203308089439] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Lupus nephritis constitutes the major cause of morbidity and mortality in SLE. The long-term outcome of renal transplantation in lupus patients remains controversial, and the recurrence of lupus activity is a major concern. This study aims to determine the long-term outcome of renal transplantation in Chinese lupus patients and the evolution of lupus activity. A total of 23 lupus patients undergoing renal transplantation were enrolled and compared with 94 matched controls. The overall patient and graft survival rates at 10 years post-transplant in lupus group were not different from the control group (95.2% and 57.7% vs. 90.7% and 66.3%). Recurrence of lupus nephritis in renal allograft and flare-ups of lupus activity were not observed in this study. The SLE group had less acute rejection than the control group (20.4% vs. 29.8%, P<0.05). The infection rate between the two groups was similar (39.1% vs. 51.1%, P=0.427), although SLE group had a significantly higher rate of developing avascular necrosis (17.4% vs. 2.1%, P=0.04). In conclusion, patient and graft survival rates and other major complications in Chinese lupus patients are comparable to non-lupus transplant recipients caused by other diseases. Chinese patients with SLE are suitable candidates for renal transplantation.
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Affiliation(s)
- T M Yu
- Division of Nephrology, Taichung Veterans General Hospital, and Department of Internal Medicine, Chung-Shan Medical University, Taichung, Taiwan
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Signori Baracat AL, Ribeiro-Alves MAVF, Alves-Filho G, Mazzali M. Systemic lupus erythematosus after renal transplantation: is complement a good marker for graft survival? Transplant Proc 2008; 40:746-8. [PMID: 18455005 DOI: 10.1016/j.transproceed.2008.02.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Renal transplantation is considered a safe procedure for patients with systemic lupus erythematosus (SLE). However, the recurrence of disease and its impact on graft survival remains controversial. METHODS To analyze the presence of lupus serology activity during dialysis and its impact on lupus recurrence after transplantation, we performed a retrospective analysis of 23 lupus patients who received 26 kidney transplantations. RESULTS Twenty-three patients received 26 renal transplantations from 1984 to 2003. Twelve patients presented pretransplant lupus activity (low complement and ANA > 1/40), without correlation with length of dialysis, but associated with proliferative glomerulonephritis (class IV) pretransplant. Among 26 grafts, 6 were lost in the first 6 months posttransplant. Among the remaining 20 functioning grafts, low complement activity occurred in 8, being associated with recurrence of immune deposits in 3 cases. Analysis of lupus activity showed that only one patient with a normal complement level posttransplant presented SLEDAI > 4, associated with persistent proteinuria and a graft biopsy without immune deposits. Graft survival was reduced in the presence of low complement posttransplantation. CONCLUSION Low complement levels after renal transplantation, in association with proteinuria may be considered to be a risk factor for recurrence of immune deposits, with a negative impact on graft survival.
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Affiliation(s)
- A L Signori Baracat
- Division of Nephrology, Department of Medicine, School of Medical Sciences, State University of Campinas, UNICAMP, Brazil
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Rietveld A, Berden JHM. Renal replacement therapy in lupus nephritis. Nephrol Dial Transplant 2008; 23:3056-60. [PMID: 18662976 DOI: 10.1093/ndt/gfn429] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Golgert WA, Appel GB, Hariharan S. Recurrent glomerulonephritis after renal transplantation: an unsolved problem. Clin J Am Soc Nephrol 2008; 3:800-7. [PMID: 18272827 DOI: 10.2215/cjn.04050907] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite advances in prevention of acute rejection and improved short- and long-term kidney graft survival, recurrent glomerulonephritis remains problematic and poorly characterized. This study analyzed prevalence and outcome of recurrent glomerulonephritis from various registries. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Definition, classification, and limitations in evaluating epidemiology of native and recurrent glomerulonephritis are discussed. Epidemiology of native glomerulonephritis as the cause of end-stage renal failure and subsequent recurrence of individual glomerulonephritis was evaluated using data from various registries, and pathogenesis of individual glomerulonephritis is discussed. RESULTS Analysis of data from transplant registries revealed that glomerulonephritis is an important cause of end-stage renal disease in white and pediatric recipients; however, glomerulonephritis as the cause of end-stage renal disease is not characterized well in black recipients, and many of them are perhaps labeled to have hypertensive nephrosclerosis as the cause of renal disease without renal biopsy. A systematic approach toward urinalysis after transplantation and utility of immunofluorescence and electron microscopic examination of renal biopsy tissues will identify the true prevalence of recurrent glomerulonephritis. Data on recurrent glomerulonephritis should be compiled by either using registry analysis or pooling data from multiple centers. This will provide true data on prevalence and outcome and could potentially initiate translational research studies. CONCLUSIONS The understanding of the pathogenesis of recurrent glomerulonephritis is critical to optimize prevention as well as to treat individual recurrent glomerulonephritis, which can enhance long-term graft survival.
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Affiliation(s)
- William A Golgert
- Division of Nephrology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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Buhaescu I, Covic A, Deray G. Treatment of Proliferative Lupus Nephritis—A Critical Approach. Semin Arthritis Rheum 2007; 36:224-37. [PMID: 17067659 DOI: 10.1016/j.semarthrit.2006.09.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2006] [Revised: 09/02/2006] [Accepted: 09/12/2006] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To discuss the current management of proliferative lupus nephritis (PLN), with a focus on strategies to improve long-term outcome and reduce treatment toxicity while minimizing the risk of relapse. METHODS The literature on treatment strategies used in systemic lupus erythematosus (SLE) and PLN from 1975 to 2006, using PubMed from the National Library of Medicine, was reviewed. RESULTS The high efficacy of the standard therapeutic regimen of PLN, traditionally associating cyclophosphamide (CYC) with corticosteroids (CS), has markedly ameliorated the prognosis of the disease, with more than 80% of patients achieving complete or partial remission. The ameliorated renal prognosis has positively influenced the general survival rates. Ten-year survival rates now surpass 75% and continue to improve. In view of the improved survival, the major aims of treatment now include preventing long-term organ damage and minimizing treatment toxicity, which can contribute significantly to the chronic morbidity and mortality of lupus. A number of high-quality trials have been reported, making us more confident of the value of different immunosuppressive protocols, and several novel immunosuppressive drugs are still under investigation. CONCLUSION Recent basic and clinical research has enormously improved our understanding of the pathogenesis of SLE and has suggested new, targeted approaches to therapy. These targeted novel therapies are expected to help the patients with PLN in the next decade.
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Affiliation(s)
- Irina Buhaescu
- Saint Vincent Hospital, Department of Internal Medicine, Worcester, Massachusetts 01608, USA.
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Fujii A, Yamaguchi Y, Horita S, Yumura W, Fuchinoue S, Teraoka S. Early recurrence of lupus nephritis after renal transplantation - a case report. Clin Transplant 2006; 20 Suppl 15:42-5. [PMID: 16848875 DOI: 10.1111/j.1399-0012.2006.00549.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The risk of recurrent lupus nephritis (LN) in renal transplant recipients with systemic lupus erythematosus (SLE) used to be rare (1-4%). However, recent studies have suggested a higher rate of recurrence in SLE patients after renal transplantation (up to 30%). The interval from transplantation to recurrence of LN has been reported to vary from five days to eight years. We report here a renal transplant recipient with SLE who had recurrent LN 10 d after transplantation.
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Affiliation(s)
- Akiko Fujii
- Department of Pathology, Mitsui Memorial Hospital, Tokyo, Japan
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Dong G, Panaro F, Bogetti D, Sammartino C, Rondelli D, Sankary H, Testa G, Benedetti E. Standard chronic immunosuppression after kidney transplantation for systemic lupus erythematosus eliminates recurrence of disease. Clin Transplant 2005; 19:56-60. [PMID: 15659135 DOI: 10.1111/j.1399-0012.2004.00297.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND There is only limited experience in patients with systemic lupus erythematosus (SLE) with drugs that have developed for immunosuppression after organ transplantation, namely calcineurin inhibitors (CI). The aim of this study is to determine the effect of these drugs on disease activity after kidney transplant in patients affected by SLE. METHODS Between January 1990 to March 2003, 13 patients with end- stage renal disease secondary to SLE received 14 kidney transplants. The outcome variables assessed include graft and patient survival as well as clinical and serological lupus activity. RESULTS All received CI-based immunosuppression (cyclosporine or tacrolimus). Actuarial patient and graft survivals at 5 yr were 100 and 93%, respectively. Recurrence of clinical or serological disease was never detected. CONCLUSIONS To date, only anecdotal experience with CI in the treatment of SLE has been reported. The favorable response observed in our patients suggests that CI at low-doses are effective in preventing SLE-reactivation. Further studies focused on calcineurin inhibitor treatment in SLE patients who fail to respond to standard medical management should be conducted.
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Affiliation(s)
- Guanglong Dong
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, IL 60612, USA
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Abstract
Most patients with systemic lupus erythematosus (SLE) are suitable candidates for renal transplantation. However, a number of them may present some disease-related problems. As cardiovascular disease is a leading cause of morbidity and mortality in SLE patients, a careful pretransplant cardiovascular screening is recommended. A search for antiphospholipid antibodies is also useful as the presence of these antibodies can cause an early graft thrombosis. The risk of recurrence of SLE nephritis after transplantation may range between 2 and 30%. In most cases recurrence is characterized by mild histologic lesions. Only rarely does it lead to graft failure. Postransplant immunosuppression does not differ from that used routinely. Whenever possible, a steroid-free immunosuppression should be scheduled to prevent iatrogenic toxicity in patients who have already received long-term steroid treatment. The results of kidney transplantation largely depend on the clinical conditions at transplantation. In patients with poor clinical status or receiving an aggressive immunosuppression it is advisable to postpone the transplant. When some selection criteria are respected, the results of renal trasplantation in SLE patients are at least as good as in other transplant recipients.
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Amigo MC. Coagulopathies and the kidney. Lupus 2004; 13:765-8. [PMID: 15540507 DOI: 10.1191/0961203304lu1076xx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- M-C Amigo
- Department of Rheumatology, Instituto Nacional de Cardiologia Ignacio Chávez, Universidad Nacional Autónoma de México, Mexico City, Mexico.
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Laboi P, Dedi R, Campbell H, Hartley B, Turney JH. De novo SLE after cadaveric renal transplantation. Am J Kidney Dis 2003; 42:E24-7. [PMID: 12955708 DOI: 10.1016/s0272-6386(03)00808-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
De novo lupus nephritis in a renal transplant recipient has not been previously reported. We present a transplant recipient with long-standing insulin-dependent diabetes mellitus who presented 9 years posttransplant with hematoproteinuria and acute renal failure. New findings of positive antinuclear antibody and double-stranded deoxyribonucleic antibody and renal histology findings consistent with lupus nephritis suggest a diagnosis of de novo systemic lupus erythematosis.
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Affiliation(s)
- Paul Laboi
- Department of Renal Medicine and Histopathology, Leeds General Infirmary, Leeds, United Kingdom.
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Abstract
The antiphospholipid (aPL) antibody syndrome is an autoimmune condition in which vascular thrombosis and/or recurrent pregnancy losses occur in patients with laboratory evidence for antibodies that bind to phospholipids. There have been significant advances in the recognition of the role of phospholipid-binding cofactors, primarily beta2GPI, as the true immunologic targets of the antibodies. Recent evidence suggests that the antibodies disrupt phospholipid-dependent anticoagulant mechanisms and/or that aPL antibodies induce the expression of procoagulant and proadhesive molecules on endothelial cells. Current diagnosis is based on clinical findings and empirically derived tests, such as assays for antibodies that bind to phospholipids or putative cofactors and coagulation assays that detect inhibition of phospholipid-dependent coagulation reactions. Current treatment relies primarily on anticoagulant therapy. Research advances are expected to bring mechanistically based diagnostic tests and improved therapy that target the roots of the disease process.
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Affiliation(s)
- Jacob H Rand
- Department of Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Deegens JKJ, Artz MA, Hoitsma AJ, Wetzels JFM. Outcome of renal transplantation in patients with systemic lupus erythematosus. Transpl Int 2003. [DOI: 10.1111/j.1432-2277.2003.tb00322.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Goral S, Ynares C, Shappell SB, Snyder S, Feurer ID, Kazancioglu R, Fogo AB, Helderman JH. Recurrent lupus nephritis in renal transplant recipients revisited: it is not rare. Transplantation 2003; 75:651-6. [PMID: 12640304 DOI: 10.1097/01.tp.0000053750.59630.83] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Although recurrent lupus nephritis (RLN) after kidney transplantation is reported to be rare (1%-4%), recent studies suggest a higher incidence. The purpose of this study was to determine the incidence of RLN in a large cohort of renal transplant recipients with systemic lupus erythematosus (SLE). METHODS The records of 54 renal transplant recipients with SLE were reviewed. Thirty-one patients underwent biopsy because of worsening renal function and proteinuria. All biopsy specimens were evaluated by light microscopy, immunofluorescence (IF), and electron microscopy (EM). RESULTS Among the 50 patients with at least 3 months of follow-up, RLN was present in 15 (52% of patients who underwent biopsy, 30% of total patients): mesangial lupus nephritis (LN) (class II) in eight, focal proliferative LN (class III) in four, and membranous LN (class Vb) in three patients. One patient had graft loss because of RLN (class II) at 10.5 years. The duration of dialysis before transplantation was not different between patients with RLN compared to patients without RLN (P=0.40). Overall patient survival (n=50) was 96% at 1 year and 82% at 5 years, and graft survival was 87% at 1 year and 60% at 5 years. Graft survival was worse in patients who underwent biopsy compared with patients who never underwent biopsy (P<0.01). CONCLUSIONS RLN is more common than previously reported, but in our series, graft loss because of RLN was rare. Aggressive use of allograft biopsies and morphologic evaluation with IF and EM are important factors in the diagnosis of RLN. The impact of new immunosuppressive agents on the incidence of RLN remains to be seen.
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Affiliation(s)
- Simin Goral
- Renal, Electrolyte and Hypertension Division, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-6144, USA.
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McGrory CH, McCloskey LJ, DeHoratius RJ, Dunn SR, Moritz MJ, Armenti VT. Pregnancy outcomes in female renal recipients: a comparison of systemic lupus erythematosus with other diagnoses. Am J Transplant 2003; 3:35-42. [PMID: 12492708 DOI: 10.1034/j.1600-6143.2003.30107.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This study compares pregnancy outcomes in systemic lupus erythematosus (SLE) patients post renal transplant with recipients with other primary diagnoses, utilizing data from the National Transplantation Pregnancy Registry, Philadelphia, PA. Recipients were referred from transplant centers nationwide. A retrospective analysis was performed using data from questionnaires, hospital records and telephone interviews. Outcomes of pregnancies post renal transplant secondary to lupus nephritis (SLE: n = 38; 60 pregnancies) were compared with the pregnancy outcomes of renal recipients with other diagnoses (non-SLE: n = 247; 374 pregnancies). Drug-treated hypertension during pregnancy was less common in the SLE group than in the non-SLE group (45.0% vs. 62.5%, p = 0.015). There were fewer cesarean sections in the SLE group (30.2 vs. 53.2%, p = 0.008). There was no primary or gestational diabetes in the SLE group. There were no other statistical differences in maternal conditions or pregnancy outcomes between the SLE and non-SLE groups, or in the incidence of post pregnancy graft loss. Female recipients transplanted for renal failure secondary to lupus nephritis can successfully maintain pregnancy. Outcomes are comparable to renal recipients with other diagnoses. Newborns in both groups were often premature and had low birthweight. Overall childhood health was reported to be good; there were no apparent predominant structural malformations among the children.
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Affiliation(s)
- Carolyn H McGrory
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Abstract
Hughes (antiphospholipid) syndrome is a noninflammatory autoimmune disease. The most critical pathologic process is thrombosis, which results in most of the clinical features suffered by these patients. Recurrent thrombosis together with an adverse pregnancy history and the presence of antiphospholipid antibodies defines the syndrome.
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Affiliation(s)
- M J Cuadrado
- Lupus Research Unit, Rayne Institute, St. Thomas' Hospital, London, United Kingdom
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Thervet E, Anglicheau D, Legendre C. Recent issues concerning renal transplantation in systemic lupus erythematosus patients. Nephrol Dial Transplant 2001; 16:12-4. [PMID: 11208985 DOI: 10.1093/ndt/16.1.12] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Ward MM. Access to renal transplantation among patients with end-stage renal disease due to lupus nephritis. Am J Kidney Dis 2000; 35:915-22. [PMID: 10793027 DOI: 10.1016/s0272-6386(00)70263-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Access to living related renal and cadaveric renal transplantation was compared between 5,863 adults with incident end-stage renal disease (ESRD) caused by lupus nephritis and 463,141 adults with other causes of ESRD who were included in the US Renal Data System from 1987 to 1995. Using Cox regression models that adjusted for differences in age, sex, race, region of residence, and year of onset of ESRD, patients with ESRD caused by lupus nephritis were as likely as patients with other causes of ESRD to receive a living related renal transplant (adjusted hazard ratio [HR] = 1.02; 95% confidence interval [CI], 0.93 to 1.10; P = 0.70) but were 20% less likely to receive a cadaveric renal transplant (adjusted HR = 0.80; 95% CI, 0.75 to 0.85; P < 0.0001). Patients with ESRD caused by lupus nephritis were significantly more likely to be entered onto a waiting list for cadaveric renal transplantation (adjusted HR = 1. 15; 95% CI, 1.10 to 1.21; P < 0.0001) but were less likely to receive a cadaveric transplant once entered onto a waiting list (adjusted HR = 0.73; 95% CI, 0.69 to 0.78; P < 0.0001). Patients with ESRD caused by lupus nephritis had equal access to living related renal transplantation and greater enrollment on waiting lists for cadaveric transplantation than patients with ESRD from other causes, indicating that medical ineligibility is not a major barrier to transplantation. Both medical and nonmedical factors may contribute to the decreased likelihood of cadaveric transplantation among patients with ESRD caused by lupus nephritis.
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Affiliation(s)
- M M Ward
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94305, USA.
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Kuper BC, Failla S. SYSTEMIC LUPUS ERYTHEMATOSUS. Nurs Clin North Am 2000. [DOI: 10.1016/s0029-6465(22)02458-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Stone JH. End-stage renal disease in lupus: disease activity, dialysis, and the outcome of transplantation. Lupus 1999; 7:654-9. [PMID: 9884106 DOI: 10.1191/096120398678920811] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Lupus nephritis remains a major cause of morbidity in SLE. Approximately 10% of patients with SLE develop end-stage renal disease (ESRD). In most SLE patients, disease activity diminishes as ESRD approaches. Consequently, the survival of SLE patients on dialysis (both hemo- and peritoneal) appears to be comparable to that of non-SLE patients. However, the role of antiphospholipid (aPL) antibodies in causing dialysis-related morbidity among patients with SLE requires further investigation. In contrast to the outcomes of dialysis, recent evidence suggests that renal transplantation outcomes among SLE patients are inferior to those of non-SLE patients, primarily because of the risk of recurrent lupus nephritis in the allograft and the effect of aPL-related events on transplantation outcomes. Future avenues of investigation should be directed at developing better strategies to manage and prevent these complications.
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Affiliation(s)
- J H Stone
- Division of Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
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Stone JH, Amend WJ, Criswell LA. Outcome of renal transplantation in ninety-seven cyclosporine-era patients with systemic lupus erythematosus and matched controls. ARTHRITIS AND RHEUMATISM 1998; 41:1438-45. [PMID: 9704643 DOI: 10.1002/1529-0131(199808)41:8<1438::aid-art14>3.0.co;2-a] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of renal transplantation in systemic lupus erythematosus (SLE). METHODS A total of 97 SLE patients who underwent renal transplantation between January 1984 and September 1996 were selected for study and were matched with a group of non-SLE controls (1 control for each SLE patient) who also received transplants during that period. SLE patients and controls were matched on 6 covariates: age, sex, race, type of allograft (cadaveric versus living-related), number of previous transplants, and year of transplantation. All study subjects received either cyclosporine or FK-506/tacrolimus as part of their immunosuppressive regimen. In a rigorous medical records review, the status of each allograft and the cause of each graft loss was determined. Using a stratified Cox proportional hazards model, the transplantation outcomes of the SLE patients were compared with those of the controls. The effects of 9 individual variables on transplantation outcomes were also examined, and the statistically significant variables were compared in a stratified, multivariate Cox proportional hazards model. RESULTS The control group included patients with 20 different causes of end-stage renal disease (ESRD). The mean followup times for the SLE patients and controls were 323 weeks and 320 weeks, respectively. During the followup period, 52 SLE patients and 37 controls lost their allografts. The 1-, 2-, 5-, and 10-year allograft survival probabilities for the 2 groups (SLE versus controls) were as follows: 81.7% versus 88.2% (1-year); 74.7% versus 84.4% (2-year); 45.9% versus 75.0% (5-year); and 18.5% versus 34.8% (10-year). In the multivariate model, the relative hazard of allograft loss associated with SLE as the cause of ESRD was 2.1 (95% confidence interval 1.06-4.06, P = 0.0328). The total number of HLA mismatches, smoking status, and delayed allograft function were also associated with allograft loss in the multivariate model. CONCLUSION Compared with matched controls, renal transplant patients with SLE had inferior transplantation outcomes, with more than twice the risk of allograft loss.
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Affiliation(s)
- J H Stone
- Johns Hopkins University, Baltimore, Maryland 21205, USA
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Stone JH, Millward CL, Olson JL, Amend WJ, Criswell LA. Frequency of recurrent lupus nephritis among ninety-seven renal transplant patients during the cyclosporine era. ARTHRITIS AND RHEUMATISM 1998; 41:678-86. [PMID: 9550477 DOI: 10.1002/1529-0131(199804)41:4<678::aid-art15>3.0.co;2-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine the frequency of recurrent lupus nephritis (LN) in patients with systemic lupus erythematosus (SLE) who underwent renal transplantation. METHODS We reviewed the posttransplant clinical course and renal biopsy results in 97 consecutive SLE patients who underwent a total of 106 renal transplantation procedures at our center from January 1984 to September 1996. RESULTS There were 81 female and 16 male patients, with a mean age of 35 years. Mean duration of dialysis prior to transplantation was 33.5 months; 9 patients were never dialyzed. In all patients, the disease was clinically and serologically quiescent at the time of transplantation. The mean posttransplantation followup period was 62.6 months. Patients underwent a total of 143 posttransplant biopsies. Nine patients had pathologic evidence of recurrent LN. Six of the patients with recurrence had cadaveric grafts, 2 had living-related grafts, and 1 had a living-unrelated graft. Recurrence occurred an average of 3.1 years after transplantation; the longest interval was 9.3 years and the shortest, 5 days. Histopathologic diagnoses on recurrence included diffuse proliferative glomerulonephritis, focal proliferative glomerulonephritis, membranous glomerulonephritis, and mesangial glomerulonephritis. In 4 patients, recurrent LN contributed to graft loss. Three of the patients with recurrence had serologic evidence of active lupus, but only 1 had symptoms of active lupus (arthritis). Three patients who lost their grafts secondary to recurrent LN underwent second renal transplantation procedures and had functioning grafts at 7, 30, and 35 months, respectively. CONCLUSION In the largest single medical center series of renal transplant patients with SLE, recurrent LN was more common than reported in the literature, but was not always associated with allograft loss. Recurrent LN was often present in the absence of clinical and serologic evidence of active SLE.
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Affiliation(s)
- J H Stone
- Rosalind Russell Arthritis Center, University of California, San Francisco, USA
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