Background/Purpose: Lupus nephritis (LN) is an important cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE), leading to end stage renal failure (ESRF) in up to a quarter of the patients and  often necessitating transplantation. Predicting adverse clinical outcomes in such patients remains challenging. We aimed to identify predictors of survival in our cohort of SLE patients undergoing renal transplantation (rTp).

Methods: This was a retrospective analysis of all SLE patients under long term follow up who developed renal failure in the 40 year period (1975-2015) in two tertiary centres. Hospital notes, electronic records and correspondence from Family Physicians and colleagues in other hospitals were reviewed. Cox proportional hazard regression and receiver operator curves (ROC) were used to determine potential predictors. Amongst the factors considered were duration of SLE diagnosis, ethnicity, gender, age at onset of SLE and LN, serology (including dsDNA binding and antiphospholipid antibodies and complement levels), comorbidities (including diabetes, hypertension, dyslipidaemia and cardiovascular disease), class of LN on biopsy, decade of rTp, drugs and  adherence to treatment.

Results: Over the last 40 years, from a total of 361 patients with LN, 40 patients (age 35±11 years, 34 female (85%), of which 15 Caucasian (38%), 15 Afro Caribbean (38%), and 10  Asian (25%)) underwent rTp. During a median follow up of 85 months (IQR 63,127) 6 patients died (15% mortality) and the five year survival was 95% (table 1). Univariate analysis only identified time on dialysis prior to rTp as a predictor of survival with a Hazard Ratio of 1.017 for each additional month spent on dialysis (95%CI= 1.000-1.034, p=0.044). ROC curves were used to calculate the optimal maximum time on dialysis prior to conferring an adverse outcome showing that ≥23 months on dialysis had an adverse effect with sensitivity of 0.800 and specificity 0.430 of death (figure1).

Conclusion: To predict adverse outcomes in rTp remains challenging. The only potential modifiable risk identified is time spent on dialysis prior to rTp with patients spending <23 months on dialysis having a beneficial outcome. Table 1: Cohort characteristics

Figure 1 Area under the curve showing fair accuracy (0.7) and indicating that patients on dialysis prior to rTp for more than 23 months have an adverse outcome (sensitivity 0.8, specificity 0.43).