Children with lupus-related kidney disease have more hospitalizations, fewer transplants
For children and adolescents initiating dialysis, lupus nephritis conferred a higher hospitalization risk, as well as a lower likelihood of transplantation, compared with other glomerular causes of end-stage kidney disease.
The study, which was published in the American Journal of Kidney Diseases, included nearly 2,000 participants who began dialysis treatments between 1991 and 2018.
Lupus nephritis vs other causes of ESKD
“Despite the significant morbidity and mortality associated with [lupus nephritis] LN, few studies have focused specifically on the outcomes of children with resulting ESKD. Furthermore, the studies that have evaluated outcomes among patients with ESKD due to LN compared patients with LN to those with all other causes of ESKD, which may be inappropriate as glomerular disease is associated with an increased prevalence of comorbidities including uncontrolled hypertension, severe anemia, and effects of immunosuppression compared to children with congenital urologic disease,” Heather Wasik, MD, MHS, of the division of pediatric nephrology at SUNY Upstate Medical University, and colleagues wrote. “In addition, little is known about the risk factors for hospitalization, prolonged time on dialysis prior to kidney transplantation, and death among children on dialysis with LN.
Identifying specific risk factors for adverse outcomes among pediatric dialysis patients with LN is a crucial first step in developing targeted interventions to reduce the occurrence of these outcomes.”
Using the North American Pediatric Renal Trials and Collaborative Studies registry, Wasik and colleagues identified 231 patients who had lupus nephritis listed as the primary cause of kidney disease and 1,726 patients with non-lupus glomerular disease; all participants were aged between 6 and 20 years (mean age in lupus nephritis group was 15.3 years vs. 13.9 years for those with non-lupus glomerular disease), with researchers noting participants with lupus nephritis were more likely to be Black and to be taking more medications.
Primary outcomes of the study were hospitalization within 12 months following dialysis initiation, patient survival on dialysis (ie, time to mortality) and time from dialysis initiation to kidney transplantation.
Patients were followed for a median of 1.23 years.
Findings indicated that participants with lupus nephritis were more likely to be hospitalized in the first year following dialysis initiation (63.3% vs. 48.6%), causes of which included infection, access complications, hypertension and other cardiovascular disease. Anemia demonstrated a strong association with increased hospitalization risk, leading to an adjusted odds ratio of 4.44.
Patients with lupus nephritis were also less likely to receive a kidney transplant in the first 3 years following dialysis initiation, which remained true even after adjustments were made for age, race, sex, index dialysis modality, hypertension, anemia and dialysis initiation era (the adjusted HRs were 0.36 and 0.73 in the year following dialysis initiation and in years 1 to 3 from initiation, respectively). “Non-white” race was associated with a lower rate of transplantation (aHR = 0.47) and was, according to the researchers, “the only independent risk factor associated with a decreased likelihood of receiving a kidney transplant in pediatric dialysis patients,” highlighting the need for interventions to reduce racial disparities.
No associations were observed between lupus nephritis and mortality while on dialysis.
“In this retrospective study of children with LN initiating dialysis over a nearly 30-year period, we have shown that LN confers an increased risk for adverse outcomes beyond those typical of children with other glomerular causes of ESKD,” Wasik and colleagues concluded. “ ... Further study must be done to identify risk factors for adverse outcomes and to assess targeted interventions to decrease morbidity and mortality in this vulnerable population.”