Kidney transplant outcomes in children and adolescents with systemic lupus erythematosus

Abstract

Background: Literature supports equivalent kidney transplant outcomes in adults with systemic lupus erythematosus (SLE) compared with those without SLE. However, there are conflicting and scant data on kidney transplant outcomes, as well as controversy over optimal timing of transplantation, in children and adolescents with SLE. Methods: Analysis included kidney-only transplant recipients aged 2-21 years from 2000 to 2017 enrolled in the Organ Procurement and Transplant Network (OPTN). The relationship between diagnosis (SLE n = 457, non-SLE glomerular disease n = 4492, and non-SLE non-glomerular disease n = 5605) and transplant outcomes was evaluated. The association between dialysis time and outcomes was analyzed in the SLE group only. Results:In adjusted models, SLE had higher mortality compared with non-SLE glomerular recipients (HR 1.24 CI 1.07-1.44) and non-glomerular recipients (HR 1.42 CI 1.20-1.70). SLE was associated with higher graft failure compared with non-SLE glomerular (HR 1.42 CI 1.20-1.69) and non-glomerular disease (HR 1.67 CI 1.22-2.28). SLE had a higher risk of acute rejection at 1 year compared with non-glomerular disease (HR 1.39 CI 1.03-1.88). There was a decreased risk of delayed graft function compared with non-SLE glomerular disease (HR 0.54, CI 0.36-0.82). There were no significant associations between dialysis time and transplant outcomes in the SLE group. Conclusion: SLE in children and adolescents is associated with worse patient and graft survival compared with non-SLE diagnoses. Outcomes in children and adolescents with SLE are not associated with dialysis time. Further studies are needed to assess implications of potential earlier transplantation and shorter time on dialysis prior to transplantation.

Predicting wait time for pediatric kidney transplant: a novel index

“…It has been thought that allowing for disease remission and symptom quiescence via an extended waiting period would prevent post-transplantation complications and allograft loss [ 41 – 43 ]. This practice is a likely contributor to our finding however, evidence that this longer wait time provides any benefit has been mixed, with some studies showing an increased risk of graft failure [ 42 – 44 ].…”

Kidney transplantation in pediatric patients with rheumatologic disorders

“…In their study comparing 40 children with SLE to 1048 children with dysplasia/hypoplasia from the European Society of Paediatric Nephrology and European Renal Association and European Dialysis and Transplant Association (ESPN/ERA-EDTA) registry, Van Stralen et al [2] found a three-fold increased risk of graft loss in patients with lupus nephritis when adjusting for the lower rate of living donation and preemptive transplant. Mai et al [19 ▪▪ ] recently corroborated these results in their study comparing 457 children with SLE to 4492 children with non-SLE-related glomerular disease and 5605 children with nonglomerular disease in the Organ Procurement and Transplant Network/Scientific Registry of Transplant Recipients (OPTN/SRTR). Children with SLE had higher risk of allograft failure (hazard ratio 1.67, P = 0.001 and 1.42, P = 0.03, respectively) and mortality (hazard ratio 1.42, P < 0.001 and 1.24, P = 0.005, respectively) than both of the other two groups.…”

“…Unlike adults where allograft survival in SLE patients is similar to other causes of ESKD [9,10,18,19 ▪▪ ], allograft survival in pediatric patients with SLE appears to be significantly lower. In their study comparing 40 children with SLE to 1048 children with dysplasia/hypoplasia from the European Society of Paediatric Nephrology and European Renal Association and European Dialysis and Transplant Association (ESPN/ERA-EDTA) registry, Van Stralen et al [2] found a three-fold increased risk of graft loss in patients with lupus nephritis when adjusting for the lower rate of living donation and preemptive transplant.…”