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LUPUS NEPHRITIS RECURRING LESS OFTEN IN TRANSPLANT PATIENTS DUE TO IMPROVED IMMUNOSUPPRESSION DRUGS
Newswise — CHICAGO – Recurrent lupus nephritis, a severe complication for patients with systemic lupus erythematosus (SLE) with end-stage renal disease who undergo kidney transplant, is happening less often now compared to the past. This positive trend is likely due to improvements in the immunosuppression regimen these patients now receive, according to new research findings presented this week at the 2018 ACR/ARHP Annual Meeting (Abstract #711).
SLE, also called lupus, is a chronic autoimmune disease where the body attacks its own tissue, causing systemic inflammation in multiple organs. In addition to affecting the skin and joints, lupus can affect organs such as the kidneys, lungs, heart, and brain. Lupus nephritis occurs when the kidneys are affected by SLE. In severe cases, end-stage renal disease (kidney failure) can occur, causing patients to need a transplant.
Recurrent lupus nephritis in the transplanted kidney is a concern for lupus patients with end-stage renal disease. Past studies have shown variable recurrence rates for these patients depending on patient characteristics, as well as immunosuppressive regimens.
“In our practice, we are seeing less recurrence, and patients are doing better compared to what has been reported in the literature,” said Debendra N. Pattanaik, MBBS, MD, Associate Professor of Medicine, University of Tennessee Health Science Center (UTHSC), and the study’s presenting author. “We decided to look at our patient population who received transplants in our center. The immunosuppressive regimen has changed significantly in the last decades, which might have impacted the recurrence of lupus. Currently, the standard post-transplant regimen consists of prednisone, mycophenolate mofetil and tacrolimus compared to prednisone, azathioprine and cyclosporine, which was mainly used in the past.”
The study, conducted by researchers at UTHSC in Memphis, included 38 patients treated with kidney transplant due to end-stage renal disease from lupus nephritis between 2006 and 2017. Patient electronic medical records were reviewed retrospectively, as well as information from the United Network for Organ Sharing (UNOS) database. The researchers recorded patient demographic information, and transplant and dialysis-related information, including kidney biopsy, graft loss (loss of transplanted kidney) and overall survival.. They then examined the association between recurrent lupus nephritis, survival, and graft loss.
The mean age of the 38 patients in the study at baseline was 41±12 years, and 89 percent were female and 89 percent were African-American. The study subjects spent a median of four years on previous dialysis. Eighty percent had received hemodialysis and 31 percent had received a living donor transplant. All the patients in the study received a standard immunosuppression regimen: prednisone, tacrolimus and mycophenolate mofetil. Four (11 percent) of the 38 patients had a biopsy-proven lupus nephritis recurrence. Ten patients (26 percent) had graft loss or death during the median follow-up time of 1,230 days. Patients with recurrent lupus nephritis showed a trend for increased risk of graft loss or death compared to recipients without recurrence in the study’s unadjusted, proportional Cox regression model.
The current standard of post-transplant immunosuppression may play a role in this lower relapse rate for lupus nephritis patients undergoing renal transplant, according to the study’s findings.
“Graft loss secondary to recurrence of lupus should be less of a concern when nephrologists and rheumatologists are considering renal transplant for their patients,” said Dr. Pattanaik.
His center’s immunosuppressive regimen consists of mycophenolate mofetil, which has been used for treatment of proliferative lupus nephritis.
“This change might explain our findings. The next logical question for research is whether kidney transplantation can be performed in patients without complete clinical and serological remission of lupus nephritis, or to go ahead and do the transplant even in patients with active lupus.”
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Abstract #: 711
Recurrence of Lupus Nephritis in Renal Transplant Recipients
Debendra Pattanaik1, Joseph Green2, Manish Talwar1, Miklos Molnar1 and Syed Hasan Raza1, 1University of Tennessee Health Science Center, Memphis, TN, 2University of Tennessee Health Science Center, memphis, TN
Background/Purpose: Recurrence of lupus nephritis in the graft is a concern in lupus patients with end stage renal disease who undergo renal transplantation. The recurrence of lupus nephritis has been variable among different studies depending on the patient characteristics, immunosuppressive regimens and indications of renal biopsy. One of the major change is the use of posttransplant immunosuppressive regimen consisting of tacrolimus and mycophenolate mofetil instead of cyclosporine and azathioprine in addition to prednisone. Many of the previous studies reported the recurrence of lupus nephritis where cyclosporine and azathioprine were used as posttransplant regimen. We investigated the recurrence of lupus nephritis among our patients to see if the new posttransplant regimen has impacted the recurrence.
Methods: All recipients, who were transplanted between 2006-2017 in our center, with end stage renal disease secondary to lupus nephritis have been included in the study (n=38). Medical records of all 38 patients were reviewed retrospectively in the electronic medical record and information from the United Network for Organ Sharing Network (UNOS) were also reviewed retrospectively. Demographic information, transplant and dialysis related information have been recorded including kidney biopsy, graft loss and survival. The result of the indication biopsies has also been recorded. Association between recurrent lupus nephritis and survival and graft loss were examined using survival models.
Results: The overall mean± SD age at baseline was 42±13 years; 89% were female; 89% were African-American; the previous time on dialysis was median of 4 years (IQR: 2-8 years), 80% received hemodialysis and 31% received living donor transplantation in the cohort. All our patients received the standard immunosuppressive regimen consisting of prednisone, tacrolimus and mycophenolate mofetil. Four (11%) of the 38 patients had biopsy proven lupus nephritis recurrence. Total of 10 patients (26%) had graft loss or death during the median follow up time was 1,230 days (IQR: 460-2,227 days). Patient with recurrence showed trend for increased risk for graft loss or death (Hazard Ratio:3.14, 95%Confidence Interval: 0.65-15.24) compared to the recipient without recurrence in our unadjusted proportional Cox regression model.
Conclusion: Recurrence rate of lupus nephritis in our patient population is much lower compared to previous data from different immunosuppressive era. Patient with recurrent disease showed trend for increased risk for graft loss or death. The current standard of posttransplant immunosuppressive regimen may have played role in lower relapse rate.
Disclosures: D. Pattanaik, None J. Green, None M. Talwar, None M. Molnar, None S. H. Raza, None
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