Frequent follow-up with a rheumatologist and continued immunosuppressive treatment for systemic lupus erythematosus (SLE) in patients with end-stage renal disease (ESRD) improves their chances of survival, according to a study.
The finding suggests that SLE in the ESRD population may be underrecognized and undertreated, said lead investigator Anna R. Broder, MD, Assistant Professor of Medicine at Albert Einstein College of Medicine, Bronx, NY.
“People who followed up with rheumatologists at least twice a year had lower mortality rates compared with people who followed with rheumatologists less than twice a year,” Dr. Broder told Renal & Urology News. “In addition, people who were maintained on immunosuppressive medications had higher survival rates compared with people who were maintained on prednisone alone or on no medications.”
According to Dr. Broder, the SLE disease process was thought to become inactive once kidney failure develops, so patients generally have not been encouraged to continue with immunosuppressant medications or to follow up with the rheumatologists after they progress to ESRD. Recent studies, however, have shown that SLE can remain active after patients start dialysis or receive a kidney transplant.
In a retrospective study, Dr. Broder and her colleagues analyzed data from 80 patients with SLE with ESRD who had started on dialysis or had received a kidney transplant. Of these, 22 made two or more rheumatology visits per year (the frequent group) and 58 made fewer than two rheumatology visits per year (the infrequent group).
For 11 of the 80 patients, the researchers were unable to determine conclusively the time of ESRD onset, so they included only 69 patients in the survival analysis. Subjects with frequent follow-up after starting dialysis had significantly higher four-year survival rates than those who had infrequent follow-up, according to a report in the Journal of Rheumatology (published online ahead of print). This finding is consistent with more recent evidence suggesting that SLE remains active after ESRD onset, the authors noted. Consequently, monitoring disease activity and adjusting immunosuppressive therapy may lead to improved survival after onset of ESRD.
Compared with patients treated with any combination of immunosuppressive medications, patients who were on no medication had a statistically significant 13-fold increased risk of death. Those treated only with prednisone had a statistically significant sixfold increased risk. Patients who received a renal transplant had a statistically significant 92% decreased risk compared with non-transplanted patients.
One of the study’s strengths, Dr. Broder pointed out, was that she and her colleagues were able to capture patients who followed up with rheumatologists and those who did not. Most previous studies in the rheumatologic literature included patients who only followed up with rheumatologists, and, therefore, patients who stop following up with rheumatologists after ESRD onset were underrepresented.
The study’s relatively small sample size and retrospective design were among the limitations, the authors stated.
In addition, the investigators explained that they chose to look at all-cause mortality rather than SLE-related mortality as the main outcome because the cause of death was not known for three patients and causes of death given on death certificates are not always accurate and reliable.