Providers recommend waiting to transplant patients with end-stage renal disease (ESRD) secondary to lupus nephritis (LN), to allow for quiescence of systemic lupus erythematosus (SLE)-related immune activity. However, these recommendations are not standardized, and we sought to examine whether duration of time to transplant was associated with risk of graft failure in US LN-ESRD patients.
Using national ESRD surveillance data (United States Renal Data System), we identified 4,743 US patients with LN-ESRD who received a first transplant on or after January 1, 2000 (followup through September 30, 2011). The association of wait time (time from ESRD start to transplant) with graft failure was assessed with Cox proportional hazards models, with splines of the exposure to allow for nonlinearity of the association and with adjustment for potential confounding by demographic, clinical, and transplant factors.
White LN-ESRD patients who were transplanted later (versus at <3 months receiving dialysis) were at increased risk of graft failure (3-12 months: adjusted hazard ratio [HR] 1.23, 95% confidence interval [95% CI] 0.93-1.63; 12-24 months: adjusted HR 1.37, 95% CI 0.92-2.06; 24-36 months: adjusted HR 1.34, 95% CI 0.92-1.97; and >36 months: adjusted HR 1.98, 95% CI 1.31-2.99). However, no such association was seen among African American recipients (3-12 months: adjusted HR 1.07, 95% CI 0.79-1.45; 12-24 months: adjusted HR 1.01, 95% CI 0.64-1.60; 24-36 months: adjusted HR 0.78, 95% CI 0.51-1.18; and >36 months: adjusted HR 0.74, 95% CI 0.48-1.13).
While future studies are needed to examine the potential confounding effect of clinically recognized SLE activity on the observed associations, these results suggest that longer wait times to transplant may be associated with equivalent or worse, not better, graft outcomes among LN-ESRD patients.