Renal transplantation for lupus nephritis: non-adherence and graft survival

Objectives: Poor adherence to immunosuppressive treatment is common in patients with systemic lupus erythematosus and may identify those with lupus nephritis (LN) who have a poorer prognosis. Non-adherence has also been reported to be a potential adverse outcome predictor in renal transplantation (rTp). We investigated whether non-adherence is associated with increased rTp graft rejection and/or failure in patients with LN. Methods: Patients with LN undergoing rTp in two major London hospitals were retrospectively included. Medical and electronic records were reviewed for documented concerns of non-adherence as well as laboratory biochemical drug levels. The role of non-adherence and other potential predictors of graft rejection/failure including demographics, comorbidities, age at systemic lupus erythematosus and LN diagnosis, type of LN, time on dialysis prior to rTp and medication use were investigated using logistic regression. Results: Out of 361 patients with LN, 40 had rTp. During a median follow-up of 8.7 years, 17/40 (42.5%) of these patients had evidence of non-adherence. A total of 12 (30.0%) patients experienced graft rejection or failure or both. In the adherent group 2/23 (8.7%) had graft rejection, whilst in the non-adherent this rose to 5/17 (29.4%, p = 0.11). Graft failure was seen in 5/23 (21.7%) patients from the adherent group and 4/17 (23.5%) in the non-adherent group (p = 0.89). Non-adherent patients had a trend towards increased graft rejection, hazard ratio 4.38, 95% confidence interval = 0.73–26.12, p = 0.11. Patients who spent more time on dialysis prior to rTp were more likely to be adherent to medication, p = 0.01. Conclusion: Poor adherence to immunosuppressive therapy is common and has been shown to associate with a trend towards increased graft failure in patients with LN requiring rTp. This is the first paper to report that shorter periods on dialysis prior to transplantation might lead to increased non-adherence in lupus patients

Impact of pre-transplant time on dialysis on survival in patients with lupus nephritis

Lupus nephritis (LN) is an important cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE) often leading to end-stage renal failure (ESRF) and necessitating renal transplantation (rTp). Optimal timing of rTp in SLE patients with ESRF is uncertain and could potentially affect survival. We investigated the time spent on dialysis before rTp and survival following rTp in a cohort of SLE patients. Retrospective analysis of all adult SLE patients receiving rTp over a 40-year period (1975–2015) in two tertiary UK centres. Cox proportional hazard regression and receiver operator curves (ROC) were used to determine the risk associated with time on dialysis before rTp and other potential predictors. Forty patients (age 35 ± 11 years, 34 female, 15 Caucasian, 15 Afro–Caribbean and 10 South Asian) underwent rTp. During a median follow-up of 104 months (IQR 80,145), eight (20%) patients died and the 5-year survival was 95%. Univariate analysis identified time on dialysis prior to rTp as the only potentially modifiable risk predictor of survival with a hazard ratio of 1.013 for each additional month spent on dialysis (95% CI = 1.001–1.026, p = 0.03). ROC curves demonstrated that > 24 months on dialysis had an adverse effect with sensitivity of 0.875 and specificity 0.500 for death. No other modifiable predictors were significantly associated with mortality, indicating that time on dialysis had an independent effect. Increased time on dialysis pre-transplantation is an independent modifiable risk factor of mortality in this cohort of patients with lupus nephritis