Activity of Systemic Lupus Erythematosus in End-Stage Renal Disease Patients: Study in a Brazilian Cohort

Abstract

Background: Dialysis has been associated with lupus remission. We studied the prevalence of systemic lupus erythematosus (SLE) as a cause of end-stage renal disease (ESRD) in the metropolitan area of Rio de Janeiro and assessed disease activity in SLE patients on dialysis. Methods: Of 3,535 ESRD patients, 63 had SLE (1.8%). Fifty-seven entered the study (54 females, 3 males, 38 ± 10 years). Hemodialysis consisted of 3 sessions per week of about 4 h duration, blood flow of about 400 ml/min, bicarbonate dialysate ([Ca²⁺] = 2.5–3.5 mEq/l) at 500 ml/min and cellulose acetate or polysulfone dialyzers. Activity was initially defined as: non-renal (nr) SLE disease activity index (SLEDAI) of >0; use of at least 20 mg/day of prednisone; and/or any dose of another activity-controlling drug. Fifty-seven ESRD patients without SLE were used as controls. Results:Eighteen SLE patients were under drug treatment; of the remaining, 30 had an nrSLEDAI of >0 totaling 48 patients (84%) initially labeled as active. An apparent activity was also present in 21 controls (37%). Of those, 19 had an nrSLEDAI of <4. With a cutoff of ≧4, figures in each group would be 49 and 4%. Under this criterion, age was the only significant predictor of flare in our SLE ESRD population in a multivariate logistic regression model. Activity remained high in patients who were on dialysis for >5 years (7/18, 39%). Conclusion: SLE accounted for 1.8% of our ESRD patients. Application of SLEDAI to dialysis patients may require consideration of confounding factors related to the ESRD state. Even with a score of ≧4 as a cutoff, SLE activity in dialysis patients was high (49%) and long-lasting. Age was the major determinant of flare.

Disease activity in systemic lupus erythematosus patients with end-stage renal disease: systematic review of the literature

“…Ribeiro et al [20] performed a cohort including 57 patients with SLE and ESRD and compared with a control group of 57 non-lupus individuals all under hemodialysis. Applying the criteria non-renal SLEDAI >0, use of at least 20 mg/day of prednisone, and/or any dose of another activity-controlling drug to define disease activity, it was observed that 48 patients (84%) had an active SLE and 21 controls (37%) exhibited an "apparently active" disease.…”

“…As pointed out above, the diminishing in the disease activity after ESRD was not a universal finding, and there may be various explanations for the great variability of the results found in the studies, such as: (a) adoption of different clinical and serological criteria to define a lupus flare; (b) the follow-up period after dialysis was very distinct and might have over-or underestimated the number of disease reactivations. Some studies excluded from the analysis patients with SLE and ESRD who remained less than 6 months in dialysis [18,[20][21][22], what may have contributed to underestimate the occurrence of lupus flares, as some articles showed greater number of deaths related to SLE activity in the beginning of the dialysis [11,15]; (c) the use of a control group for comparison was not a constant in every study, and among those controlled, there was a large variation in the characteristics of the controls-mainly in respect of the presence or absence of SLE; and (d) the adoption of different types of renal replacement therapy between the studies (hemodialysis, peritoneal dialysis, and renal transplantation), although some authors [4,22] have demonstrated a lack of statistically significant differences in patients undergoing hemodialysis when compared to those treated by peritoneal dialysis. Accordingly, Goo et al [22] found that the disease activity measured by SLEDAI did not significantly differ among the group of patients who were treated by hemodialysis, peritoneal dialysis, or renal transplantation.…”

“…Possible causes for that decrease includes immunodeficiency related to the uremic state or dialysis and a probable natural evolution of the disease [20]. On the other hand, SLE reactivation during dialysis treatment is not rare [20][21][22][23][24][25][26][27][28]. Therefore, as there is a considerable number of patients with SLE who progress to ESRD and need renal replacement therapy, it is relevant to review the evidences of the literature regarding the disease activity in these individuals.…”

Recomendaciones sobre el manejo del compromiso renal del lupus eritematoso sistémico: Documento de Consenso de las Sociedades Chilenas de Nefrología y Reumatología

“…El inicio de TRR suele asociarse a disminución de actividad del LES 31 . La inmunosupresión en este caso estará indicada para el control de enfermedad extra-renal.…”

New-onset systemic lupus erythematosus in a long-term hemodialysis patient with acute pleuritis and pneumonitis

“…In some cases, reactivation of SLE does occur in patients under chronic dialysis treatment [4,5]. However, the onset of SLE long after the initiation of renal replacement treatment has been rarely reported.…”