LUPUS ON DIALYSIS

  End-stage renal disease due to lupus nephritis     Almost 10-30 % of ptns with proliferative LN ( lupus nephritis ) progress...

 

End-stage renal disease due to lupus nephritis

 

 

Almost 10-30 % of ptns with proliferative LN (lupus nephritis) progress to ESRD. Global prognosis has been greatly improved in recent era, owing to the advent of combined immunosuppression (im/m.). The development of ESRD is usually, but not always, accompanied with gradual complete or partial resolution of the extrarenal criteria of lupus, despite the absence of an underlying known mechanism. Ptn survival with either HDX or CAPD seems to be simulating that in the general population of ptns with ESRD, despite there’s higher risk of mortality during the 1^st 3 mo of DX due to sepsis and other sequelae of high-dose im/m therapy. There’s higher risk of peritonitis & non-catheter-related infection among PD ptns.  

 

RTx is an accepted therapeutic option for ptns with LN that’s accompanied with better survival. Global 5- & 10-y graft survival rates are simulating that among ptns with LN compared with rates among ptns with other causes. LN ptns should be screened for the presence of APA before proceeding to KTx as KTx recipients with underlying LN + APA may be at a higher risk for thrombotic events. LN is observed to recur in the Tx kidney in 2-11 % of LN ptns. Ptns with clinically significant recurrence requiring an alteration of therapy generally present with:

1)    Higher SCr above its baseline,

2)    New-onset proteinuria, &

3)    New-onset hematuria.

Episodes of recurrence are mostly seen in the 1^st 10 ys. Recurrent LN is usually milder than the original disease observed in the native kidney and promotes a good prognosis. The incidence of graft loss due to recurrent LN is < 2-4 %.  

 

Dgx of recurrent LN can be suspected among ptns recently developing proteinuria, hematuria, or a higher SCr. Dgx can be established by biopsy. Before proceeding to an allograft biopsy, among all TR (transplant recipients) presenting with a high SCr, we should keep:

1)    Adequate hydration,

2)    Optimize serum CNI levels, &

3)    Perform abdominal US.

Moreover, among TR who showed a PH of LN, we perform a kidney biopsy in the setting of abnormal urinary protein excretion or hematuria.  

 

Therapy of recurrent lupus nephritis rely primarily on the clinical presentation & the histology findings. Among all ptns who have recurrent LN & proteinuria >300 mg/d, > add either ACEi or ARB, as much tolerated with monitoring of S.K⁺, Cr, and the fall in BP. Certain ptns may need dose modification of the im/m. protocol. Ptns showing a histologic Dgx of recurrent LN & a rapid decline in eGFR or with proteinuria >500 mg/d or those showing severe proliferative lesions on biopsy, they should be ttt with im/m. agents targeted to manage LN. Options for im/m. modification may include one of the following agents:

 

1)    Higher dose of MMF to 2-3 g/d.  or

2)    Cph (cyclophosphamide) & hold current antimetabolite (MMF or azathioprine). This can be done by the older National Institutes of Health (NIH) monthly protocol or by the newer Euro-Lupus protocol.

3)    There’re insufficient data in regard to rituximab therapy in ptns with allograft recurrence who were failing both MMF & Cph therapy.

4)    Ptns treated with a higher dose MMF or with adding Cph should also be ttt with Steroids. Methylprednisolone 7 mg/kg or 500 mg IV/D./3 d. followed by a tapered  oral steroid regimen.