African-American recipients of kidney transplants with lupus have high allograft failure risk. We studied their risk adjusting for: (1) socio-demographic factors: donor age, gender and race-ethnicity; recipient age, gender, education and insurance; donor-recipient race-ethnicity match; (2) immunologic factors: donor type, panel reactive antibodies, HLA mismatch, ABO blood type compatibility, pre-transplant dialysis, cytomegalovirus risk and delayed graft function (DGF); (3) rejection and recurrent lupus nephritis (RLN). Two thousand four hundred and six African-, 1132 Hispanic-, and 2878 Caucasian-Americans were followed for 12 years after transplantation. African- versus Hispanic- and Caucasian-Americans received more kidneys from deceased donors (71.6%, 57.3% and 55.1%) with higher two HLA loci mismatches for HLA-A (50%, 39.6% and 32.4%), HLA-B (52%, 42.8% and 35.6%) and HLA-DR (30%, 24.5% and 21.1%). They developed more DGF (19.5%, 13.6% and 13.4%). More African- versus Hispanic- and Caucasian-Americans developed rejection (41.7%, 27.6% and 35.9%) and RLN (3.2, 1.8 and 1.8%). 852 African-, 265 Hispanic-, and 747 Caucasian-Americans had allograft failure (p < 0.0001). After adjusting for transplant era, socio-demographic-immunologic differences, rejection and RLN, the increased hazard ratio for allograft failure of African- compared with Caucasian-Americans became non-significant (1.26 [95% confidence interval 0.78-2.04]). African-Americans with lupus have high prevalence of risk factors for allograft failure that can explain poor outcomes.

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It has been generally held that once glomerular filtration rate (GFR) falls below approximately 25 ml/min, a relentless progression to end-stage renal disease (ESRD) inevitably ensues, regardless of the original cause of reduced function. There is a paucity of contemporary studies, however, addressing whether the rate of progression can be slowed down with contemporary and comprehensive renal care when chronic kidney disease (CKD) has progressed to stages 4 and 5 (GFRo30 ml/min/1.73 m 2 ). In this review we argue that significant progress is being made already in retarding the progression of advanced CKD thereby delaying the initiation of renal replacement therapy. We propose that CKD clinics, by providing comprehensive management of CKD, will have a decisive role in preventing and delaying the progression to advanced CKD.