Advertisement
American Journal of Kidney Diseases

Dialysis Outcomes for Children With Lupus Nephritis Compared to Children With Other Forms of Nephritis: A Retrospective Cohort Study

Published:August 27, 2021DOI:https://doi.org/10.1053/j.ajkd.2021.07.013

      Rationale & Objective

      Children with lupus nephritis (LN) are at high risk of developing kidney failure requiring initiation of kidney replacement therapy. This study compared outcomes among children with LN on dialysis with children with non-lupus glomerular disease and investigated risk factors for adverse outcomes among children with LN on dialysis.

      Study Design

      Retrospective cohort study.

      Setting & Participants

      Children and adolescents aged 6-20 years with LN (n = 231) and non-lupus glomerular disease (n = 1,726) who initiated maintenance dialysis 1991-2018 and were enrolled in the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry.

      Exposure

      Lupus nephritis.

      Outcome

      Hospitalization, mortality, and time to transplant.

      Analytical Approach

      Contingency tables were used to compare hospitalizations, and multivariable cause-specific hazards models were used to compare rates of death and transplantation in children with LN compared with those with non-lupus glomerular disease. Using data from children with LN, multivariable logistic regression models were fit to evaluate the risk factors for hospitalization, and multivariable Cox regression models were fit to evaluate factors associated with kidney transplantation.

      Results

      Children with LN were more likely to be hospitalized in the first year after dialysis initiation (63.3% vs 48.6%, P < 0.001) and were less likely to receive a kidney transplant in the first 3 years after dialysis initiation (year 0-1: adjusted hazard ratio [AHR], 0.36 [95% CI, 0.23-0.57], P < 0.001; year 1-3: AHR, 0.73 [95% CI, 0.54-0.98], P = 0.04). Anemia was associated with hospitalization after dialysis initiation (adjusted OR, 4.44 [95% CI, 1.44-13.66], P = 0.01). Non-White race was associated with a lower rate of kidney transplantation (AHR, 0.47 [95% CI, 0.27-0.82], P = 0.01). LN was not associated with death while on dialysis (AHR, 1.21 [95% CI, 0.47-3.11], P = 0.7).

      Limitations

      The NAPRTCS registry does not collect information on lupus disease activity or medication doses and has limited data on medication use.

      Conclusions

      Children and adolescents with LN on dialysis are at higher risk for adverse outcomes including hospitalization and lower rates of kidney transplantation compared with children with non-lupus glomerular disease receiving maintenance dialysis.

      Index Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Wenderfer S.E.
        • Ruth N.M.
        • Brunner H.I.
        Advances in the care of children with lupus nephritis.
        Pediatr Res. 2017; 81: 406-414https://doi.org/10.1038/pr.2016.247
        • Lee B.S.
        • Cho H.Y.
        • Kim E.J.
        • et al.
        Clinical outcomes of childhood lupus nephritis: a single center’s experience.
        Pediatr Nephrol. 2007; 22: 222-231https://doi.org/10.1007/s00467-006-0286-0
        • Sule S.
        • Fivush B.
        • Neu A.
        • Furth S.
        Increased risk of death in African American patients with end-stage renal disease secondary to lupus.
        Clin Kidney J. 2014; 7: 40-44https://doi.org/10.1093/ckj/sft157
        • Rianthavorn P.
        • Buddhasri A.
        Long-term renal outcomes of childhood-onset global and segmental diffuse proliferative lupus nephritis.
        Pediatr Nephrol. 2015; 30: 1969-1976https://doi.org/10.1007/s00467-015-3138-y
        • Askenazi D.
        • Myones B.
        • Kamdar A.
        • et al.
        Outcomes of children with proliferative lupus nephritis: the role of protocol renal biopsy.
        Pediatr Nephrol. 2007; 22: 981-986https://doi.org/10.1007/s00467-007-0447-9
        • Sule S.
        • Fivush B.
        • Neu A.
        • Furth S.
        Increased risk of death in pediatric and adult patients with ESKD secondary to lupus.
        Pediatr Nephrol. 2011; 26: 93-98https://doi.org/10.1007/s00467-010-1640-9
        • Copelovitch L.
        • Warady B.A.
        • Furth S.L.
        Insights from the chronic kidney disease in children (CKiD) study.
        Clin J Am Soc Nephrol. 2011; 6: 2047-2053https://doi.org/10.2215/CJN.10751210
        • Wong C.J.
        • Moxey-Mims M.
        • Jerry-Fluker J.
        • Warady B.A.
        • Furth S.L.
        CKiD (CKD in children) prospective cohort study: a review of current findings.
        Am J Kidney Dis. 2012; 60: 1002-1011https://doi.org/10.1053/j.ajkd.2012.07.018
        • Carter S.A.
        • Lightstone L.
        • Cattran D.
        • et al.
        Standardized Outcomes in Nephrology–Glomerular Disease (SONG-GD): establishing a core outcome set for trials in patients with glomerular disease.
        Kidney Int. 2019; 95: 1280-1283https://doi.org/10.1016/j.kint.2019.01.047
        • Grambsch P.M.
        • Therneau T.M.
        Proportional hazards tests and diagnostics based on weighted residuals.
        Biometrika. 1994; 81: 515-526https://doi.org/10.1093/biomet/81.3.515
        • Garris C.
        • Jhingran P.
        • Bass D.
        • Engel-Nitz N.M.
        • Riedel A.
        • Dennis G.
        Healthcare utilization and cost of systemic lupus erythematosus in a US managed care health plan.
        J Med Econ. 2013; 16: 667-677https://doi.org/10.3111/13696998.2013.778270
        • Tanzer M.
        • Tran C.
        • Messer K.L.
        • et al.
        Inpatient health care utilization by children and adolescents with systemic lupus erythematosus and kidney involvement.
        Arthrit Care Res. 2013; 65: 382-390https://doi.org/10.1002/acr.21815
        • Pisoni R.L.
        • Bragg-Gresham J.L.
        • Young E.W.
        • et al.
        Anemia management and outcomes from 12 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS).
        Am J Kidney Dis. 2004; 44: 94-111https://doi.org/10.1053/j.ajkd.2004.03.023
        • Servilla K.S.
        • Singh A.K.
        • Hunt W.C.
        • et al.
        Anemia management and association of race with mortality and hospitalization in a large not-for profit dialysis organization.
        Am J Kidney Dis. 2009; 54: 498-510https://doi.org/10.1053/j.ajkd.2009.05.007
        • Ebben J.P.
        • Gilbertson D.T.
        • Foley R.N.
        • Collins A.J.
        Hemoglobin level variability: associations with comorbidity, intercurrent events, and hospitalizations.
        Clin J Am Soc Nephrol. 2006; 1: 1205-1210https://doi.org/10.2215/CJN.01110306
        • Staples A.O.
        • Wong C.S.
        • Smith J.M.
        • et al.
        Anemia and risk of hospitalization in pediatric chronic kidney disease.
        Clin J Am Soc Nephrol. 2009; 4: 48-56https://doi.org/10.2215/CJN.05301107
        • Warady B.A.
        • Ho M.
        Morbidity and mortality in children with anemia at initiation of dialysis.
        Pediatr Nephrol. 2003; 18: 1055-1062https://doi.org/10.1007/s00467-003-1214-1
        • Sule S.
        • Fivush B.
        • Neu A.
        • Furth S.
        Increased hospitalizations and death in patients with ESKD secondary to lupus.
        Lupus. 2012; 21: 1208-1213https://doi.org/10.1177/0961203312451506
        • Hiraki L.T.
        • Lu B.
        • Alexander S.R.
        • et al.
        End-stage renal disease due to lupus nephritis among children in the US, 1995-2006.
        Arthritis Rheum. 2011; 63: 1988-1997https://doi.org/10.1002/art.30350
        • Ye H.
        • Cao P.
        • Lin J.
        • et al.
        Long-term clinical outcomes of lupus nephritis patients undergoing peritoneal dialysis: a matched, case-control study.
        Perit Dial Int. 2019; 39: 570-573https://doi.org/10.3747/pdi.2019.00041
        • Proença de Moraes T.
        • Massignan B.
        • et al.
        Systemic lupus erythematous and clinical outcomes in peritoneal dialysis.
        Lupus. 2015; 24: 290-298https://doi.org/10.1177/0961203314555353
        • Bartosh S.M.
        • Fine R.N.
        • Sullivan E.K.
        Outcome after transplantation of young patients with systemic lupus erythematosus: a report of the North American Pediatric Renal Transplant Cooperative Study.
        Transplantation. 2001; 72: 973-978https://doi.org/10.1097/00007890200109150-00047
        • Tsai W.T.
        • Chang H.C.
        • Wang C.T.
        • Chiang B.L.
        • Lin Y.T.
        Long-term outcomes in lupus patients receiving different renal replacement therapy.
        J Microbiol Immunol. 2019; 52: 648-653https://doi.org/10.1016/j.jmii.2018.12.010
        • Jorge A.
        • Wallace Z.S.
        • Lu N.
        • Zhang Y.
        • Choi H.K.
        Renal transplantation and survival among patients with lupus nephritis: a cohort study.
        Ann Intern Med. 2019; 170: 240-247https://doi.org/10.7326/m18-1570
        • Gipson D.S.
        • Ferris M.E.
        • Dooley M.A.
        • et al.
        Renal transplantation in children with lupus nephritis.
        Am J Kidney Dis. 2003; 41: 455-463https://doi.org/10.1053/ajkd.2003.50056
        • Furth S.L.
        • Garg P.P.
        • Neu A.M.
        • et al.
        Racial differences in access to the kidney transplant waiting list for children and adolescents with end-stage renal disease.
        Pediatrics. 2000; 106: 756-761https://doi.org/10.1542/peds.106.4.756
        • Amaral S.
        • Patzer R.
        Disparities, race/ethnicity and access to pediatric kidney transplantation.
        Curr Opin Nephrol Hypertens. 2013; 22: 336https://doi.org/10.1097/mnh.0b013e32835fe55b
        • Freeman M.A.
        • Myaskovsky L.
        An overview of disparities and interventions in pediatric kidney transplantation worldwide.
        Pediatri Nephrol. 2015; 30: 1077-1086https://doi.org/10.1007/s00467-014-2879-3
        • Inda-Filho A.
        • Neugarten J.
        • Putterman C.
        • Broder A.
        Improving outcomes in patients with lupus and end-stage renal disease.
        Semin Dialysis. 2013; 26: 590-596https://doi.org/10.1111/sdi.12122
        • Hiraki L.T.
        • Feldman C.H.
        • Liu J.
        • et al.
        Prevalence, incidence, and demographics of systemic lupus erythematosus and lupus nephritis from 2000 to 2004 among children in the US Medicaid beneficiary population.
        Arthritis Rheum. 2012; 64: 2669-2676https://doi.org/10.1002/art.34472
        • Lionaki S.
        • Skalioti C.
        • Boletis J.N.
        Kidney transplantation in patients with systemic lupus erythematosus.
        World J Transplant. 2014; 4: 176https://doi.org/10.5500/wjt.v4.i3.176
        • Demas K.L.
        • Costenbader K.H.
        Disparities in lupus care and outcomes.
        Curr Opin Rheumatol. 2009; 21: 102-109https://doi.org/10.1097/bor.0b013e328323daad

      Linked Article

      • Kidney Failure in Systemic Lupus Erythematosus: A Fraught Complication in a Fraught Disease
        American Journal of Kidney DiseasesVol. 79Issue 5
        • Preview
          Lupus nephritis (LN) is the most common serious organ manifestation of systemic lupus erythematosus (SLE), and significantly increases the morbidity and mortality of the patients in whom it develops.1 An intense effort by lupus patients, clinician-scientists, and the pharmaceutical industry has resulted in the approval of 2 new therapies for LN, with more on the way, leading to a sense of elation in the lupus community. However, the reality for patients who have already developed kidney failure from LN is not as optimistic.
        • Full-Text
        • PDF