Although dialysis can reduce systemic lupus erythematosus (SLE) disease activity by removing immune complexes, flares still occur in a proportion of patients receiving renal replacement therapy (RRT), a new study finds. A second study finds comparable mortality risks among patients receiving hemodialysis vs peritoneal dialysis.
In their paper published in the Journal of Rheumatology, Seokchan Hong, MD, PhD, of the University of Ulsan College of Medicine in Seoul, South Korea and colleagues stated “careful follow-up is required to detect SLE flare even after RRT initiation, particularly in patients who had high nonrenal SLE activity prior to dialysis.”
Among 121 patients with lupus nephritis on dialysis (79.3% hemodialysis; 20.7% peritoneal dialysis), 32 (26.4%) patients experienced an SLE flare at a median of 17 months after dialysis initiation. Nonrenal SLE disease activity index (SLEDAI) score before dialysis initiation was significantly associated with a 24% increased risk for SLE flare during dialysis. The most common features of SLE flare were hematologic (40.6%), including thrombocytopenia (31.2%) and leukopenia (21.8%). The same proportion of patients (40.6%) experienced constitutional manifestations, most commonly fever (34.3%).
The investigators distinguished SLE flare by symptom improvement following corticosteroid treatment. Of the 32 patients who experienced a flare, 15 received high-dose corticosteroids, 9 corticosteroid pulse therapy, and 8 medium-dose corticosteroids. One third of patients who flared (34.3%) required additional immunosuppressants, including cyclophosphamide, cyclosporine, tacrolimus, mycophenolate mofetil, rituximab, or intravenous immunoglobulin. The most common complication was cytopenia that improved after drug withdrawal; no patient died.
The risk of SLE flare did not differ between dialysis modalities. Among patients receiving peritoneal dialysis, 44% experienced peritonitis.
Death After Dialysis Initiation
In a meta-analysis of 6 observational studies involving 3405 patients with lupus nephritis on dialysis (2841 on hemodialysis; 564 on peritoneal dialysis), Wenjun Gou, MBBS, and Yan Hong Tuo, MBBS, found no significant difference in mortality risk between patients treated with hemodialysis vs peritoneal dialysis, according to results published in Medicine.
The investigators also found no significant differences between dialysis modalities in cause of death, whether SLE flare, cardiovascular problems, infection, respiratory problems, or other causes.
Kim YE, Choi SJ, Lim DH, et al. Disease flare of systemic lupus erythematosus in patients with end-stage renal disease on dialysis. J Rheum. 49(10):1131-1137. doi:10.3899/jrheum.220101
Gou W, Tuo YH. Comparison of mortality and its causes in patients with complicated systemic lupus erythematosus on hemodialysis versus peritoneal dialysis: A meta-analysis. Medicine. Published online August 12, 2022. doi:10.1097/MD.0000000000030090