End-stage renal disease mortality fell from 1995 to 2014 in lupus nephritis

All-cause mortality among white, African-American and Hispanic patients with end-stage renal disease related to lupus nephritis decreased considerably between 1995 and 2014, according to findings published in Arthritis & Rheumatology.

Perspective from Amanda Mixon, PA-C

“Lupus nephritis (LN) affects up to 50% of adults with [systemic lupus erythematosus], and despite the introduction of improved, lower toxicity treatments in the past 15 years, including mycophenolate and low dose cyclophosphamide regimens, up to 30% of patients with lupus nephritis progress to end-stage renal disease (ESRD),” April Jorge, MD, of Massachusetts General Hospital, and colleagues wrote. “Mortality among SLE patients is highest among this subgroup. The premature mortality among patients with LN-ESRD persisted in the U.S. between 1995 and 2006, but it is unknown whether there has since been a significant change in survival.”

To extend the 1995-2006 analysis of LN-ESRD–related mortality to 2014, and to evaluate various cause-specific trends, the researchers reviewed data from the United States Renal Data System. After identifying 20,974 individuals with incident LN-ESRD between Jan. 1, 1995, and Dec. 31, 2014, the researchers divided the patients into four groups based on the year of disease onset.

All-cause mortality among white, African-American and Hispanic patients with end-stage renal disease related to lupus nephritis decreased considerably between 1995 and 2014, according to findings.

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Each of the groups represented a 5-year period: 1995 to 1999, 2000 to 2004, 2005 to 2009 and 2010 to 2014. The researchers then determined the mortality rates within each group, analyzing temporal trends in allcause, and cause-specific mortality, adjusting for covariates. Each patient’s demographic information, BMI, U.S. Census region of residence, baseline comorbidities, initial ESRD therapy, race, ethnicity and, in the event of death, cause of mortality were collected using the registry.

According to the researchers, mortality among patients with LN-ESRD declined from 11.1 per 100 patientyears (95% CI, 10.411.8) during 1995 to 1999, to 6.7 per 100 patientyears (95% CI, 6.27.2) during 2010 to 2014 (P < .01). Adjusted HRs for all-cause mortality during 2010 to 2014, compared with 1995 to 1999, were 0.68 (95% CI, 0.580.78) for white patients, 0.67 (95% CI, 0.570.78) for African-American patients and 0.51 (95% CI, 0.380.69) for Hispanic patients. In addition, deaths caused by cardiovascular disease decreased by 44%, and infection-related mortality decreased by 63% (both P < .01).

“Among nearly all patients with incident LN-ESRD in the U.S. from 1995 to 2014, we found substantial improvements in all-cause mortality in recent years,” Jorge and colleagues wrote. “Although African-Americans with LN-ESRD have been previously shown to have higher mortality than white patients, they had a similar level of temporal improvement in all-cause mortality as whites, and Hispanics also had considerable mortality reductions. Overall rates of death due to CVD and infection considerably improved, suggesting improved ESRD care as well as improved management of immunosuppression and underlying SLE might have minimized these complications.” – by Jason Laday

Disclosure: Jorge reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Perspective

Amanda Mixon, PA-C

As we all know, systemic lupus is a complex illness. As noted in the study by Jorge and colleagues, up to 50% of patients with systemic lupus can later develop lupus nephritis and up to 30% of those patients then proceed to develop end stage renal disease. Over the past several years, newer, less toxic agents have been developed.

In their analysis, Jorge and colleagues evaluated if the overall mortality rates have decreased and found that there was a considerable reduction in all-cause mortality rates among white, African American, and Hispanic patients in recent years.

Of course, there are still many areas within this disease that we can improve on; however, I believe this tells us that rheumatology providers as a whole are making advancements in what was once thought to be a very fatal disease. Education and close follow-up with our lupus patients — particularly those in a higher risk category — is crucial to ensure we keep moving in the right direction.

Amanda Mixon, PA-C

Physician Assistant Board Liaison

Rheumatology Nurses Society

Physician assistant

Arthritis and Rheumatology Clinic of Northern Colorado

Disclosures: Mixon reports reports she serves on the speakers bureau for AbbVie, Celgene, Eli Lilly and Novartis, and is a consultant for AbbVie, Eli Lilly and Regeneron.

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Sources/Disclosures

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Source:

Jorge A, et al. Arthritis Rheumatol. 2018;doi:10.1002/art.40729.