Factors affecting kidney-transplant outcome in recipients with lupus nephritis.

BACKGROUND: Factors associated with outcome in renal transplant recipients with lupus nephritis have not been studied.

METHODS: Using the data from the United States Renal Data System of patients transplanted between January 1, 1995 through December 31, 2002 (and followed through December 31, 2003) (n = 2882), we performed a retrospective analysis of factors associated with long-term death-censored graft survival and recipient survival.

RESULTS: The number of pretransplant pregnancies incrementally increased the risk of graft failure [hazard ratio (HR) 1.54, p < 0.05] in the entire subgroup of females and in the subgroup of recipients aged 25-35 yr. Recipient and donor age had an association with both the risk of graft failure (HR 0.96, p < 0.001; HR 1.01, p < 0.005) and recipient death (HR 1.04, p < 0.001; HR 1.01, p < 0.05). Greater graft-failure risk accompanied increased recipient weight (HR 1.01, p < 0.001); African Americans compared with whites (HR 1.55, p < 0.001); greater Charlson comorbidity index (HR 1.17, p < 0.05); and greater panel reactive antibody (PRA) levels (HR 1.06, p < 0.001). Pretransplant peritoneal dialysis as the predominant modality had an association with decreased risk of graft failure (HR 0.49, p < 0.001), while prior transplantation was associated with greater risk of graft failure and recipient death (HR 2.29, p < 0.001; HR 3.59, p < 0.001, respectively) compared with hemodialysis (HD). The number of matched human leukocyte antigens (HLA) antigens and living donors (HR 0.92, p < 0.05; HR 0.64, p < 0.001, respectively) was associated with decreased risk of graft failure. Increased risk of graft failure and recipient death was associated with nonuse of calcineurin inhibitors (HR 1.89, p < 0.005; HR 1.80, p < 0.005) and mycophenolic acid (MPA) (including mycophenolate mofetil and MPA) or azathioprine (HR 1.41, p < 0.05; HR 1.66, p < 0.01). Using both cyclosporine and tacrolimus was associated with increased risk of graft failure (HR 2.09, p < 0.05). Using MPA is associated with greater risk of recipient death compared with azathioprine (HR 1.47, p < 0.05).

CONCLUSION: In renal transplant recipients with lupus nephritis, multiple pregnancies, multiple blood transfusions, greater comorbidity index, higher body weight, age and African American race of the donor or recipient, prior history of transplantation, greater PRA levels, lower level of HLA matching, deceased donors, and HD in pretransplant period have an association with increased risk of graft failure. Similarly, higher recipient and donor age, prior transplantations, and higher rate of pretransplant transfusions are associated with greater risk of recipient mortality. Using neither cyclosporine nor tacrolimus or using both (compared with tacrolimus) and neither MPA nor azathioprine (compared with azathioprine) was associated with increased risk of graft failure and recipient death. Using MPA is associated with greater risk of recipient death compared with azathioprine. Testing these results in a prospective study might provide important information for clinical practice.