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Renal Transplantation and Survival Among Patients With Lupus Nephritis: A Cohort Study

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Jorge A1, Wallace ZS1, Lu N1, Zhang Y1, Choi HK1. Ann Intern Med. 2019 Jan 22. doi: 10.7326/M18-1570. [Epub ahead of print]

Abstract

Author information 1 Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (A.J., Z.S.W., N.L., Y.Z., H.K.C.).

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.