A proportion of patients with proliferative lupus nephritis (LN) in systemic lupus erythematosus (SLE) progress to end-stage renal disease (ESRD), with transplantation being a suitable option for some patients after careful consideration of several factors, including factoring in any potential increased risk of graft thrombosis associated with antiphospholipid antibody syndrome.1
Dialysis has a large impact on the quality of life of patients with ESRD. Studies have shown that patients who underwent renal transplantation have improvements in health-related quality of life as compared to patients who are maintained on dialysis and listed for renal transplant.2 This review article will cover topics related to renal transplantation for ESRD secondary to LN, and address unique factors that need to be addressed in this patient population.
Development of Renal Disease in SLE
Patients should have their renal function tested at regular intervals during follow-up, as renal involvement is a common manifestation of SLE.3 Renal evaluation can include urinalysis with sediment examination, urine protein excretion, serum creatinine, and estimated glomerular filtration rate (GFR) in addition to any lupus-specific laboratory testing indicative of disease activity such as complement factors. A renal biopsy may be indicated to diagnose and guide treatment in patients with SLE who develop signs of renal involvement. Histopathologic testing on the renal biopsy can help categorize LN into classes, as treatment guidelines are influenced by the histological subtype found on biopsy.3 A classification system formulated and published in 2004 divides the glomerular disorders into 6 different patterns or classes based upon biopsy findings.
Progression of SLE to ESRD
Despite improvements in medication management, approximately 10% to 30% of patients with proliferative LN will still progress to ESRD, necessitating dialysis, with some patients becoming candidates for renal transplantation.1 In recent years, patients with both LN and ESRD have had survival rates equal to other patients receiving dialysis.4 However some studies report that during the first 3 months after dialysis initiation there appears to be an increased mortality rate.5 This increased risk has been at least partially attributed to increased risk secondary to complications from receiving high-dose glucocorticoid therapy.5
Upon initiation of dialysis, LN clinical and serological activity appears to decrease.5 Oftentimes, initiation of dialysis improves LN to the point that medication may be adjusted and even discontinued.
Evaluation for Renal Transplantation & Timing of Transplant
The current practice of initiating hemodialysis prior to renal transplantation is based on the thought that dialysis can help suppress any residual LN activity and allow for a period of quiescence, especially in patients who had an especially rapid decline in kidney function.6 In the past, a common practice was to delay renal transplantation until a patient received dialysis for several months to a year1,5, based on the thought that dialysis can help a patient recover some level of renal function as well as let fulminant LN subside.
However a study looking retrospectively at outcomes in patients with LN undergoing renal transplant from a large ESRD surveillance data from the United States Renal Data System through September 2011 found that longer wait times to transplant were actually associated with equivalent or worse graft outcomes.7
Antiphospholipid Antibody and Allograft Vascular Thrombosis
An area of major concern has always been a previous history of antiphospholipid antibody (APA) syndrome because of the risk of graft or other vascular thrombosis. One study found that the survival rate and postsurgical outcomes after kidney transplantation in patients with APA was lower than those without APA.8 It was also found that patients with APA had faster declines in GFR at one year post-transplant when compared to those without the presence of APA.8