Background/Purpose: It has been observed that systemic lupus erythematosus (SLE) activity often goes into remission in patients with end-stage kidney disease (ESKD) on dialysis or after a kidney transplant, although the exact mechanism remains elusive. Greater than a quarter of these patients can experience an SLE flare, with patients on dialysis having higher flare rates compared to transplant recipients. This study aims to characterize and identify the clinical phenotypes and risk factors of patients with SLE who continue to flare on dialysis or after transplant. Furthermore, this study analyzes flare manifestations and timing of flares from initial SLE diagnosis, as well as the impact of medications, dialysis modality, and transplant on SLE activity.

Methods: A single-center retrospective chart review was performed using the inclusion criteria of patients 18 years and older diagnosed with SLE who have ESKD on dialysis or after transplant, with records searched between 2015 and 2022. The proportion of patients who met the ACR classification criteria for SLE was 100%. SLE flare was defined as increased disease activity requiring a change in management and flare confirmation by a rheumatologist or nephrologist. For included patients, demographics, clinical phenotypes, and medical characteristics were recorded and analyzed between flare and no-flare groups.

Results: A total of 144 patients with SLE were included; there was a mean age of 48.5 years, 86.8% female, and 60.4% African American (Table 1). Lupus flare occurred in 20.8% of the study population. Flare rates were similar in patients on PD and HD, although this was not statistically significant (Table 1; p = 0.47). Of the patients who experienced a flare, 43.3% occurred within one year of dialysis initiation or after transplant. The most common flare manifestations included hematologic (66.7%), hypocomplementemia (56.7%), and kidney involvement (46.7%) (Figure 1). Mortality rates were similar in the flare group (31.6%) and no-flare group (30.0%). Lastly, patients in the flare group had lower rates of calcineurin inhibitor use (16.7%) than the no-flare group (29.8%) (Table 1; p = 0.17). The use of immunosuppression agents, including prednisone, cDMARDs, and hydroxychloroquine, was similar between the groups.

Conclusion: Greater than 20% of patients experience an SLE flare while on renal replacement therapy or after transplant. Common manifestations include hematologic abnormalities, hypocomplementemia, and kidney involvement. Only about half of the flare group had elevated anti-dsDNA or hypocomplementemia, and providers must look beyond the numbers during diagnosis. Lastly, flares frequently occur within the first year, therefore, patients should be monitored closely after dialysis initiation or transplantation.

Demographic and clinical differences in patients with ESKD secondary to SLE on dialysis or after transplant in flare and no-flare groups

Flare manifestations in patients with ESKD secondary to SLE on dialysis or after transplant

« Back to ACR Convergence 2025

ACR Meeting Abstracts - https://acrabstracts.org/abstract/systemic-lupus-erythematosus-flares-in-patients-with-end-stage-kidney-disease-on-renal-replacement-therapy-or-after-transplant/