Undertreatment of Disease Activity in Systemic Lupus Erythematosus Patients with Endstage Renal Failure Is Associated with Increased All-cause Mortality

Abstract

Objective.

In a cohort of systemic lupus erythematosus (SLE) patients with endstage renal failure, to evaluate whether continuing rheumatology followup visits and immunosuppressive therapy after starting renal replacement were associated with increased survival.

Methods.

We identified all SLE patients over 21 years old who started renal replacement therapy between 2005 and 2011 at an urban tertiary care center. Mortality data were obtained using in-hospital records and the US Social Security Death Index database.

Results.

We identified 80 SLE patients undergoing renal replacement therapy. Twenty-two patients (28%) were followed in rheumatology clinics frequently (2 or more visits per year) after starting renal replacement therapy, and 58 patients (72%) were followed infrequently (fewer than 2 visits per year). Survival rates were significantly higher in transplant patients compared with dialysis patients. Patients with SLE followed frequently after starting dialysis had significantly higher 4-year survival rates compared with patients followed infrequently after starting dialysis (log-rank p = 0.03). In the Cox proportional hazards model, treatment with prednisone alone or with no medication was associated with a hazard ratio (HR) of death = 6.1 (95% CI 1.1, 34; p = 0.04) and HR = 13 (95% CI 1.5, 106; p = 0.02), respectively, compared with patients treated with a combination of immunosuppressive therapy with or without prednisone, adjusted for age at SLE diagnosis, sex, transplant status, and the frequency of rheumatology visits after the development of endstage renal failure.

Conclusion.

Active disease in patients with SLE undergoing renal replacement therapy may be underrecognized and undertreated, leading to increased mortality.