Background/Purpose: Lack of evidence-based recommendations about pre-emptive renal transplantation in systemic lupus erythematosus (SLE) patients with end stage renal disease (ESRD) may be unnecessarily delaying transplantation in these patients.  We compared rates and factors associated with pre-emptive transplantation between incident ESRD patients with and without SLE enrolled in the United States Renal Disease Systems (USRDS).

Methods: There were 561,038 individuals in the US with new onset ESRD of any cause between 1/1/2005 and 12/31/2009.   Adult patients with incident ESRD SLE 2005-2009 were identified from the ICD-9 code 710.0 for SLE in the Medical Evidence report.  They were frequency matched by age, sex and race to 4,830 patients with incident non-SLE ESRD (type 1 diabetes, type 2 diabetes, hypertension, and other causes). Pre-emptive transplantation was defined as the initial renal replacement modality without any intervening dialysis.  Multivariable logistic regression models, adjusted for socio-demographic factors and comorbidities, were used to compare the odds of pre-emptive renal transplantation in SLE and non-SLE, and to evaluate associated factors in each group.

Results:  

4,830 SLE subjects and 4,830 matched non-SLE subjects were included in the final analysis. SLE patients were less likely to have atherosclerotic heart disease, congestive heart failure (CHF), peripheral vascular disease (PVD), and chronic obstructive pulmonary disease (COPD). The proportions of patients with past cerebrovascular accidents (CVA) or transient ischemic attacks (TIA) were similar (p=0.12).  SLE patients were more likely to be employed, and to have private insurance.    

The overall adjusted odds ratio of pre-emptive transplantation were similar in SLE and non-SLE: OR = 0.85 (95% CI: 0.67, 1.01), p=0.2.  However, when comparing specific non-SLE causes of ESRD to SLE, the adjusted OR for pre-emptive transplantation was 0.19 (95% CI: 0.09, 0.42) for type 2 diabetes, 0.42 (95% CI: 0.23, 0.75) for hypertension, 1.67 (95% CI: 1.10, 2.54) in type 1 diabetes, and 2.06 (95% CI: 1.55, 2.74) for “others” (Table). Over 70% of all pre-emptive transplants were form living donors. The rates of pre-emptive transplantation were significantly higher among patients with pre-ESRD nephrology care. In contrast to non-SLE, younger SLE patients were less likely to receive a pre-emptive kidney transplant.

Conclusion: The odds of pre-emptive transplantation vary by ESRD cause.  Improving pre-ESRD nephrology care and access to living donor transplants, as well as addressing disease-specific barriers to pre-emptive transplantation, may increase a likelihood of pre-emptive transplantation.

Table:   Adjusted Odds Ratios (OR) and 95% Confidence Intervals (95%CI) from the Logistic Regression Model for Pre-emptive Transplantation among ESRD patients with and without SLE.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/pre-emptive-renal-transplantation-among-end-stage-renal-disease-patients-with-and-without-sle/