Background/Purpose:

Substantial progress has been made in the treatment of rheumatoid arthritis (RA) and life expectancy has increased. As the population of patients with RA continues to age, they may be more likely to suffer from diseases of aging, including ESRD. However, the characteristics of patients with RA and ESRD, treatment patterns for RA in the setting of ESRD and the impact of RA on mortality in ESRD have not been previously been examined. The purpose of this study was to determine the prevalence of ESRD and reasons for dialysis in RA, treatment modalities for RA in the setting of ESRD and five year cardiovascular mortality in patients with RA and ESRD compared to those with ESRD without RA.

Methods:

Retrospective cohort study of adult ESRD patients with RA without HIV in the United States Renal Data System (USRDS) beginning in calendar year 2011. Medicare Part D beneficiary data was used to determine filled prescriptions for medications that might be used to treat RA including corticosteroids, DMARDs and biologics. Cox proportional hazard models were estimated to determine five year cardiovascular-related mortality in patients with RA compared to all others with ESRD without RA.

Results:

There were 28,589 patients with RA and ESRD in 2011. Based on population estimates of the frequency of RA in adults in the United States, approximately 2% of adult patients with RA have ESRD. Patients with ESRD and RA are more likely to be female, to have hypertension, diabetes, atrial fibrillation and cardiovascular events (p<0.01 for all) than those with ESRD without RA. Hypertensive renal disease (30%) and type II diabetes (25%) are the most common causes of ESRD in RA; amyloidosis, vasculitis and analgesic nephropathy are uncommon, accounting for less than 5% of all cases. More than half of ESRD patients with RA had a filled prescription for a medication for RA treatment; most commonly prednisone (42% of all prescriptions). Ten percent of all filled prescriptions were for hydroxychloroquine; 2.63% for leflunomide and 1.39% for sulfasalazine. Biologics were a rare class of filled prescription therapies (etanercept 1.59%;adalimumab 1.07%; golimumab, infliximab, anakinra and abatacept each comprised <1% of total filled prescriptions in this population). After adjustment for covariates, compared to patients without RA with ESRD, five year cardiovascular mortality in patients with RA and ESRD was significantly increased (HR 1.42 (95%CI 1.38-1.47).

Conclusion:

ESRD is infrequent in patients with RA but has a significant impact on cardiovascular mortality. Similar to the general ESRD population, hypertension and diabetes mellitus are the most common causes of dialysis. Prednisone and hydroxychloroquine are the most frequent prescriptions filled that could be used to treat RA; use of biologics appears uncommon in this population. Further prospective studies of the impact of ESRD on outcomes in RA and optimal treatments for RA in the setting of ESRD are needed.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/end-stage-renal-disease-esrd-in-patients-with-rheumatoid-arthritis/