Renal transplantation linked with reduced mortality in end-stage disease due to GPA

SAN DIEGO — Renal transplantation reduced the mortality risk compared with remaining on a waitlist among patients with end-stage renal disease due to granulomatosis with polyangiitis, according to findings presented at the American College of Rheumatology Annual Meeting.

Zachary S. Wallace, MD, of the division of rheumatology, allergy and immunology at Massachusetts General Hospital and Harvard Medical School in Boston, suggested that previous data have not investigated whether transplantation or remaining waitlisted for transplantation carries the most optimal survival benefit among patients with end-stage renal disease due to granulomatosis with polyangiitis (GPA).

“GPA remains associated with an excess risk of death,” he said. “In a previous general population study conducted by our group, we found that over time there had been some improvement in this risk, but people with GPA remained at over a two-fold higher risk of death compared to their general population controls.”

All waitlisted cases of ESRD due to granulomatosis with polyangiitis in the United States between 1995 and 2014 underwent analysis. Demographic and comorbidity information was investigated, along with data on mortality. Patients were followed until death or through Jan. 1, 2016.

“We know that people who are waitlisted are often similar to each other,” Wallace said. “They have similarly good health status, are often times of a younger age, tend to have a higher socioeconomic status and often have good social support, so whether they get a renal transplant often comes down to luck and whether or not there is a donor for that patient.”

Of the 1,556 patients who met criteria, 63% ultimately underwent transplantation. Onset of ESRD occurred when patients were aged 47.3 ± 16.5 years, while wait listing occurred when patients were aged 49.3 ± 16.4 years and transplantation occurred when patients were aged 47.8 ± 17.2 years.

Patients waited an average duration of 1.5 ± 2.2 years from diagnosis of ESRD to wait listing. Clinicians followed patients for 6.8 ± 4.7years. There were 444 deaths in the final analysis.

Adjusted analysis results showed a 70% lower mortality risk among patients who were transplanted compared with those on the waitlist, according to Wallace.

Transplantation also yielded a lower mortality risk from cardiovascular disease (HR = 0.06) and infection (HR = 0.3). Cancer-related mortality, however, was not impacted by transplantation waitlist status (HR = 0.5).

“Renal transplantation is associated with a significantly decreased risk of death in people with end-stage renal disease attributable to GPA,” Wallace said. “This decrease is largely driven by a reduction in cardiovascular death.”

Wallace suggested that many things may be learned from the study.

“Early referral for transplant is critical,” he said. “It is important to recognize that rheumatologists can refer patients to a renal transplantation program for evaluation. Patients can be referred any time their GFR is less than 20. They don’t have to be on dialysis for referral.” —by Rob Volansky

Reference:
Wallace ZS, et al. Abstract 1789. Presented at: American College of Rheumatology Annual Meeting; Nov. 4-8, 2017; San Diego.

Disclosures: Wallace reports no relevant financial disclosures. Please see the full study for a complete list of all other authors’ relevant financial disclosures.