|Year : 2016 | Volume
| Issue : 3 | Page : 73-78
Outcome of lupus nephritis after live-donor renal transplantation: single-center experience
Mohamed A Zahab MD 1, Yasser A Elhendy2, Amir M Elokely2, Mohammed A Fouda1, Ayman F Refaie1, Ayman M Nagib1, Mona Abdulrahim3, Mohamed Ghoneim4
1 Department of Dialysis and Transplantation, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
2 Department of Internal Medicine, Zagazig University, Zagazig, Egypt
3 Department of Pathology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
4 Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
|Date of Submission||11-Oct-2016|
|Date of Acceptance||18-Oct-2016|
|Date of Web Publication||2-Jan-2017|
Mohamed A Zahab
Department of General and Transplantation Nephrology, Urology and Nephrology Center, Mansoura, 35511
Source of Support: None, Conflict of Interest: None
Systemic Lupus Erythematosis (SLE) is a systemic autoimmune disease affects multiple organs with clinically heterogeneous outcomes. Lupus Nephritis (LN) is a common complication of systemic lupus erythematosus, and it occurs in 31–65% of SLE patients. kidney transplantation is the best long-term option for patients with End Stage renal Disease. The aim of this work is then to assess the patient and graft outcome for those who reached end stage renal disease and received kidney transplantation at urology and nephrology center, mansoura university.
Subjects and Methods
The material of this section include 23 kidney transplant recipients due to lupus nephritis. A 46 matched kidney transplant patients who were diagnosed as end stage renal disease due to other causes will serve as control group.
Results and Conclusions
Results of the study showed no difference in patient and graft outcome between kidney transplant recipients due to lupus nephritis and kidney transplant recipients due to other causes. The risk of recurrence of lupus nephritis in the graft is very low if compared with FSGS or MPGN. We concluded that kidney transplantation for lupus patients is safe and carries no risk for lower patient or graft survival. The risk of recurrence is much lower if compared with other glomerular diseases.
Keywords: kidney transplantation, lupus nephritis, end stage kidney disease
|How to cite this article:|
Zahab MA, Elhendy YA, Elokely AM, Fouda MA, Refaie AF, Nagib AM, Abdulrahim M, Ghoneim M. Outcome of lupus nephritis after live-donor renal transplantation: single-center experience. J Egypt Soc Nephrol Transplant 2016;16:73-8
|How to cite this URL:|
Zahab MA, Elhendy YA, Elokely AM, Fouda MA, Refaie AF, Nagib AM, Abdulrahim M, Ghoneim M. Outcome of lupus nephritis after live-donor renal transplantation: single-center experience. J Egypt Soc Nephrol Transplant [serial online] 2016 [cited 2017 Dec 18];16:73-8. Available from: http://www.jesnt.eg.net/text.asp?2016/16/3/73/197380
| Introduction|| |
Systemic lupus erythematosus (SLE) is a systemic autoimmune disorder in which multiple autoantibodies against cell nuclear constituents (DNA, histones, and ribonucleoproteins) are produced. The deposition of immune complexes in several organs, mainly kidney, skin, and joints, causes inflammation and tissue damage, producing a broad spectrum of clinical manifestations .
Lupus nephritis (LN) is an immune complex glomerulonephritis that is a common and serious feature of SLE. In LN, glomerular immune complex accumulation leads to an inflammatory response that damages glomeruli and eventually the renal interstitium. After the kidney becomes involved in SLE, the prognosis of the lupus declines. This is partly because of the development of chronic kidney disease or end-stage renal disease (ESRD), possibly along with the increased risk of cardiovascular disease associated with chronic kidney disease. The nephrologist is therefore critical to the SLE care team and requires a strong working knowledge of the treatment options available for LN .
Although kidney transplantation is the best long-term option for patients with ESRD, the vast majority of LN ESRD patients initiate dialysis first, because of both the imbalance of supply and demand of donor organs and the desire to delay transplantation following lupus disease activity .
The rate of allograft loss due to recurrent LN is lowest among recipients of living-related kidneys with increasing haplotype match. The underlying ‘protective’ factors against allograft loss due to RLN among recipients of living-related kidneys remain to be elucidated .
Pre-emptive kidney transplantation is associated with superior outcomes. Patients who have kidney failure due to SLE may not receive a pre-emptive kidney transplant because of concern for disease activity and risk of recurrence in the transplanted kidney that may lead to shortened graft and patient survival .
The aim of this work was to assess the patient and graft outcomes for those who reached ESRD and received kidney transplantation at Urology and Nephrology Center, Mansoura University, Egypt.
| Patients and methods|| |
This study included 23 patients who were diagnosed as having ESKD due to LN and underwent living donor kidney transplantation at the Urology and Nephrology Center, Mansoura University between 1976 and 2013. A total of 46 matched kidney transplant patients who were diagnosed as having ESKD due to non glomerular causes served as the control group. All the patients received live donor allografts between March 1976 and December 2013. All patients underwent thorough clinical and laboratory investigations.
The data extracted from the study were analyzed using SPSS for windows, release 16 SPSS Inc. (Chicago, Illinois, USA). Qualitative data were displayed in cross-tabulation and quantitative data were described in terms of arithmetic mean and SD. Bivariate techniques were used for initial evaluation of contrast. Thus, the χ2 and Fisher’s exact test were used for comparison of frequencies of qualitative variables, and the unpaired t-test was used for comparisons of means of two quantitative variables. Patient and graft survival were analyzed using Kaplan–Meier curves. A P value of less than 0.05 was considered significant.
| Results|| |
Demographic characteristics of recipients and donors are matched between lupus and nonlupus groups ([Table 1]). Human leukocyte antigen and DR mismatch are comparable in both groups ([Table 2]). All of the lupus patients received hemodialysis before transplantation ([Table 3]). All lupus patients versus 91% from nonlupus group received induction therapy. Most of them received basiliximab. Most of the lupus patients received triple maintenance therapy (steroid+calcineurin inhibitor+mycophenolate mofetil) ([Table 4]). Early postoperative complications are comparable in both groups ([Table 5]). Post-transplant acute rejection episodes were comparable between both groups ([Table 6]). There is no difference between both groups regarding post-transplant hypertension, diabetes mellitus, malignancy, and incidence of both viral and bacterial infections ([Table 6]). Serum creatinine and condition at last follow-up are comparable between both groups ([Table 7] and [Table 8]). Graft and patient survival at 5, 10, and 15 years are comparable in both groups ([Figure 1] and [Figure 2]).
|Table 1 Demographic data of the recipients and donors among both lupus nephritis patients and control group|
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|Table 2 Immunological data of recipients among both lupus nephritis patients and control group|
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|Table 3 Pretransplant dialysis and comorbid conditions among both lupus nephritis patients and control group|
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|Table 4 Induction therapy, maintenance therapy, and total dose of steroid in the first 3 months post transplantation among both lupus nephritis patients and control group|
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|Table 5 Early post-transplant surgical complications among both lupus nephritis patients and control group|
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|Table 6 Frequency of acute rejection episodes among both lupus nephritis patients and control group|
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|Table 7 Mean serum creatinine (mg/dl) at different time points post-transplant among both lupus nephritis patients and control group|
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|Table 8 Condition at last follow-up among both lupus nephritis patients and control group|
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| Discussion|| |
Graft survival at 1 and 5 years after transplant were comparable between both groups. We found that graft survival rates among the lupus group were 95% at 1 year, 85% at 5 years, 84% at 10 years, and 75% at 15 years, whereas patient survival rates were 100% at 1 and 5 years and 87% at 10 and 15 years. These observations are similar to those of Cairoli et al. , and Oliveira et al. , who reported that patient and graft survival rates among LN patients who received kidney transplantation are similar to those of ESRD caused by other diseases. These concepts are also supported by the results of the European Transplant Registry . However, Chelamcharla et al. , describe different results with lower graft survival and increased mortality in patients with SLE. This difference may be explained partly, by the differences between studies in terms of prospective or retrospective design, inclusion criteria, control group, and different time of renal transplantation period.
Our study showed that we have one case with biopsy-proven recurrent LN (4.3%). This was higher than that reported by Cairoli et al. , who reported that recurrence rate of LN is 2%. Ponticelli et al. , reported that the risk of recurrence of LN after renal transplantation has been quite variable. Some found that the recurrence rate was quite low, 5%, whereas others reported that about 10% of patients with LN experienced recurrence. The recurrence of LN is very low if compared with other glomerulonephritis. A study from our center by Akl et al. , reported that the rate of recurrence of focal segmental glomerulosclerosis is 44.5% and recurrence of membranoproliferative glomerulonephritis is 22.2%.
In our study, post-transplant acute rejection episodes were comparable between both groups. In addition, 17.4% of the lupus cohort developed acute rejection versus 19.6% of the other group (P 0.23). This is in agreement with the study by Moroni et al. , who reported that the risk of acute and chronic rejection are similar between lupus cohort and patients who received kidney transplantation because of other causes. Chelamcharla et al. , found that there is no difference in the incidence of acute rejection between lupus and nonlupus cohorts; however, they found that the lupus cohort showed significantly worse graft survival, especially those who received kidney from deceased donors.
Thrombotic events have been reported more frequently in renal transplantation recipients, with antiphospholipid syndrome worsening their functional prognosis . The presence of lupus anticoagulant at the time of renal transplantation was associated with a high rate of allograft nephropathy associated with antiphospholipid syndrome and poor transplantation outcomes . Regarding thrombotic events, we found that none of the patients in both groups developed graft artery or graft vein thrombosis. Fuentes et al. , reported that there is no significant difference between lupus and nonlupus groups regarding vascular thrombosis post transplantation, although it may be interesting to analyze a larger series and determine the influence of the antiphospholipid syndrome.
Regarding post-transplant medical complications, we found that both groups are comparable as regards post-transplant hypertension and diabetes mellitus. Costenbader et al. , recorded an increased trend toward cardiovascular risk factors, namely smoking, obesity, diabetes mellitus, and hypertension, among SLE-related ESRD patients. Several small, mostly retrospective, single-center studies with limited numbers of patients indicate cardiovascular disease as the leading cause of morbidity and mortality in transplanted patients secondary to LN . A retrospective analysis of data from the United States Renal Data System and the United Network for Organ Sharing was conducted between 1990 and 1999. Among 2886 patients with LN undergoing a renal transplant, cardiac events and cerebrovascular disease were the main causes of death. However, non-SLE recipients (n=89 958) exhibited a higher rate of these comorbidities, probably because they were older, with a higher prevalence of pre-existing cardiovascular disease and diabetes mellitus .Post-transplant infections and malignancies are comparable between lupus and nonlupus groups. Infections (sepsis, pneumonia, viral infections, fungal infections, tuberculosis, urinary tract infections) have been reported as causes of morbidity and mortality after KTX due to LN . One could hypothesize that prolonged exposure to immunosuppressive agents before ESRD, as well after ESRD and KTX, predisposes to infections. However, published data are contradictory, as the prevalence of serious infections is not always higher in SLE recipients compared with non-SLE patients . Malignancies, orthopedic complications, such as avascular necrosis of the femur head, and osteoporosis have been rarely reported in various studies as late complications in kidney transplant SLE recipients .
| Conclusion|| |
Finally, we can conclude that kidney transplantation for lupus patients is safe and carries no risk for lower patient or graft survival. The risk of recurrence is much lower if compared with other glomerular diseases.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Grammatikos AP, Tsokos GC. Immunodeficiency and autoimmunity: lessons from systemic lupus erythematosus. Trends Mol Med 2012; 18:101–108.
Skamra C, Ramsey-Goldman R. Management of cardiovascular complications in systemic lupus erythematosus. Int J Clin Rheumtol 2010; 5:75–100.
Devlin A, Waikar S, Solomon DH, Lu B, Shakevich T, Alarcón GS et al.
Variation in initial kidney replacement therapy for end-stage renal disease due to lupus nephritis in the U.S. Arthritis Care Res (Hoboken) 2011; 63:1642–1653.
Phuong-Thu T, Phuong-Chi T. Graft loss due to recurrent lupus nephritis in living-related kidney donation. Clin J Am Soc Nephrol 2011; 6:2296–2299.
Nilubol NC, Melancon JK, Girlanda R, Johnson L, Javaid B. Preemptive kidney transplantation in systemic lupus erythematosus. Transplant Proc 2011; 43:3713–3714.
Cairoli E, Sanchez-Marcos C, Espinosa G, Glucksmann C, Ercilla G, Oppenheimer F, Cervera R. Renal transplantation in systemic lupus erythematosus: outcome and prognostic factors in 50 cases from a single centre. Biomed Res Int 2013; 2014:746192–.
Oliveira CS, d Oliveira I, Bacchiega AB, Klumb EM, Albuquerque EM, Souza E et al.
Renal transplantation in lupus nephritis: a Brazilian cohort. Lupus 2012; 21:570–574.
Briggs JD, Jones E. Renal transplantation for uncommon diseases. Scientific Advisory Board of the ERA-EDTA Registry. European Renal Association-European Dialysis and Transplant Association. Nephrol Dial Transplant 1999; 14:570–575.
Chelamcharla M, Javaid B, Baird BC, Goldfarb-Rumyantzev AS. The outcome of renal transplantation among systemic lupus erythematosus patients. Nephrol Dial Transplant 2007; 22:3623–3630.
Ponticelli C, Moroni G, Glassock RJ. Recurrence of secondary glomerular disease after renal transplantation. Clin J Am Soc Nephrol 2011; 6:1214–1221.
Akl AI, Adel H, Rahim MA, Wafa EW, Shokeir AA. Outcome of glomerulonephritis in live-donor renal transplant recipients: a single-centre experience. Arab J Urol 2015; 13:295–305.
Moroni G, Tantardini F, Gallelli B, Quaglini S, Banfi G, Poli F et al.
The long-term prognosis of renal transplantation in patients with lupus nephritis. Am J Kidney Dis 2005; 45:903–911.
Ghafari A, Etmadi J, Adrdalan MR. Renal transplantation in patients with lupus nephritis: a single-center experience. Transplant Proc 2008; 40:143–144.
Canaud G, Bienaimé F, Noël LH, Royal V, Alyanakian MA, Dautzenberg MD et al.
Severe vascular lesions and poor functional outcome in kidney transplant recipients with lupus anticoagulant antibodies. Am J Transplant 2010; 10:2051–2060.
Fuentes L, Hernandez D, Ruiz P, Blanca L, Lopez V, Sola E et al.
Survival of lupus nephritis patients after renal transplantation in Malaga. Transplant Proc 2012; 44:2067–2068.
Costenbader KH, Desai A, Alarcón GS, Hiraki LT, Shaykevich T, Brookhart MA et al.
Trends in the incidence, demographics, and outcomes of end‐stage renal disease due to lupus nephritis in the US from 1995 to 2006. Arthritis Rheum 2011; 63:1681–1688.
Vaidya S. Ten‐year renal allograft survival of patients with antiphospholipid antibody syndrome. Clin Transplant 2012; 26:853–856.
Kang SH, Chung BH, Choi SR, Lee JY, Park HS, Sun IO et al.
Comparison of clinical outcomes by different renal replacement therapy in patients with end-stage renal disease secondary to lupus nephritis. Korean J Intern Med 2011; 26:60–67.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]