Kidney Transplantation Improves Survival in Lupus Nephritis With End-Stage Kidney Disease

Abstract

Introduction: Lupus nephritis (LN) is a severe complication of systemic lupus erythematosus (SLE) and is associated with high morbidity and mortality rates. Although kidney transplantation (KT) is considered the optimal treatment for end-stage kidney disease (ESKD), its survival benefit, specifically in patients with LN-induced ESKD (LN-ESKD), is not well-established. This study aimed to determine the effects of KT on the survival of a national cohort of patients with LN-ESKD.

Methods: We retrospectively analyzed patients with LN-ESKD registered in the French Renal Epidemiology and Information Network (REIN) registry, who were waitlisted for KT between 2002 and 2022. KT was treated as a time-dependent variable to avoid an immortal time bias. The primary outcome was all-cause mortality, which was assessed using Kaplan-Meier analysis and adjusted Cox proportional hazards models.

Results: Of the 882 patients with LN-ESKD, 636 (72%) were waitlisted for KT, and 470 (74%) received a transplant. After a median follow-up of 80 months, KT was associated with a 60% reduction in the risk of death compared with remaining on dialysis (hazard ratio [HR]: 0.40, 95% confidence interval [CI]: 0.240-0.67, P < 0.001), with consistent benefits across subgroups. Patient survival at 10 years was 83% for transplant recipients and 60% for nontransplant recipients (P < 0.001). Sensitivity analyses, after excluding recipients of living donors and patients who were inactivated from the waitlist, supported these findings. Two years after the onset of ESKD, 38% of the waitlisted patients under went transplantation. The probability of graft failure was 23% at 10 years posttransplant.

Conclusion: Compared with patients who remain on dialysis, KT is associated with improved survival in patients with LN-ESKD. Early evaluation of transplant eligibility and timely referral to transplant centers are crucial for optimizing outcomes.

Keywords: ESKD; death; kidney transplantation; lupus; nephritis; survival.

Graphical abstract

Figure 1

Flowchart of the study. ESKD, end-stage kidney disease; LN, lupus nephritis.

Figure 2

Patient survival according to transplant status among waitlisted patients with LN-ESKD. (a) All waitlisted patients with lupus nephritis. (b) According to donor type (deceased or living donor). Benjamini-Hochberg–adjusted log-rank P-values: deceased donor transplantation versus no transplantation = 0.0072; living donor transplantation versus no transplantation = 0.00055; deceased donor transplantation versus living donor transplantation = 0.16. The total group size was twice that of the transplant group (once for the dialysis period and once for the transplant period).

Figure 3

Graft survival among transplanted patients with LN-ESKD, computed with death as a competitive event. (a) All transplanted patients with lupus nephritis. (b) According to donor type (deceased or living donor). ESKD, end-stage kidney disease; LN, lupus nephritis.