Long-term immunosuppressants improve survival for lupus patients with ESKD

Researchers at Albert Einstein College of Medicine of Yeshiva University have shown that close supervision by rheumatologists and the use of immunosuppressant drugs improve the survival of lupus patients with end-stage kidney disease (ESKD)—a finding that could reverse long-standing clinical practice. Their study appeared in the September 1 online edition of the Journal of Rheumatology.

At least 1.5 million Americans (more than 90 percent of them women) have lupus (officially known as lupus erythematosus), a chronic autoimmune disease that can damage many organs of the body. Treatment usually involves using immunosuppressive drugs to blunt the immune system's attack on the body. Kidney disease is a common complication of lupus, and up to 30 percent of patients with lupus-related kidney disease ultimately develop end-stage renal failure.

"The lupus disease process was thought to become inactive once kidney failure develops," said lead author Anna Broder, M.D., assistant professor of medicine at Einstein. "As a result, patients generally haven't been encouraged to continue with immunosuppressant medications or to follow up with their rheumatologists after developing end-stage kidney disease. But recent studies have suggested that lupus can indeed remain active after patients start dialysis or receive a kidney transplant."

"Our research shows for the first time that under-supervising and under-treating these lupus patients was associated with an increased risk of death," said Dr. Broder.

The Einstein researchers reviewed the charts of 80 lupus patients with end-stage renal disease who had been started on renal replacement therapy (i.e., either kidney dialysis or kidney transplant). Twenty-two of the patients had been seen frequently in rheumatology clinics (two or more visits per year), while the other 58 patients had been followed infrequently (fewer than two visits per year).

Four years after beginning renal replacement therapy, patients who continued to be treated with immunosuppressive medications were less likely to have died compared with patients who took only low doses of prednisone or no medication. (In fact, patients receiving no medication were 13 times more likely to have died compared with patients treated with a combination of immunosuppressive therapies.) The study also found that lupus patients who visited their rheumatologist at least twice a year after starting dialysis had significantly higher four-year survival rates compared with patients who went for fewer follow-up visits.

"If these findings are confirmed by future studies," said Dr. Broder, "they may significantly change the way lupus patients with end-stage renal failure are managed while on dialysis or after receiving kidney transplants."