‘Lupus does not universally burn out’: More than 35% of patients flare after dialysis
Key takeaways:
- Meta-analysis revealed an overall 35.9% incidence of at least one lupus flare after initiating dialysis.
- Flares were significantly less common with kidney transplant than dialysis.
More than one-third of patients with systemic lupus erythematosus experience a flare after starting dialysis for end-stage renal disease, according to data published in Arthritis Care & Research.
The systematic literature review and meta-analysis also found that flares were “relatively uncommon” after kidney transplant, while rates were higher with either peritoneal dialysis or hemodialysis, wrote Ansaam Daoud, MD, a rheumatologist at Case Western Reserve University, and colleagues.
“It is known that SLE activity diminishes after [end-stage renal disease (ESRD)], a concept known as the ‘burnout state,’” Daoud told Healio. “However, recent studies have challenged these assumptions, with reports showing ESRD patients still experience lupus flares. This systematic review aimed to assess the risk for lupus flares in patients with ESRD and determine how flare rates differ based on the type of renal replacement therapy.”
The systematic review and meta-analysis ultimately included 57 studies evaluating patients with SLE who received one of three different types of renal replacement therapy due to lupus nephritis. These were hemodialysis, peritoneal dialysis and kidney transplant.
The studies varied in their definition of flare, and the reviewers accepted each individual study’s definition for their analysis. Odds ratios for SLE flares were determined using forest plots and random effect models.
Pooling the studies together, the analysis revealed an overall 35.9% incidence (95% CI, 33.3-38.9) of at least one lupus flare after initiating dialysis, according to the researchers.
“A significant proportion of dialysis patients continue to experience flares,” Daoud said. “The high rate of flares in dialysis patients demonstrates that SLE can remain active in ESRD patients.”
Flare risk was significantly higher with either dialysis type (OR = 4.36; 95% CI, 1.66-11.47) compared with kidney transplantation. Meanwhile, lupus nephritis recurred after transplantation at a rate of 3.39% (95% CI, 3.01-3.81) in 29 studies evaluating lupus nephritis and kidney transplants.
In seven studies that compared dialysis types, SLE flare rates were similar between peritoneal dialysis (25.6%) and hemodialysis (25.3%). Comparing the two with a Mantel-Haenszel test revealed a non-statistically significant odds ratio of 1.05 (95% CI, 0.57-1.94) for flares, the researchers wrote.
“Although some studies reported differences in lupus flare rates between [hemodialysis] and [peritoneal dialysis], our meta-analysis found no significant difference between dialysis modalities,” Daoud said.
“This study reinforces that lupus does not universally burn out in ESRD, and dialysis patients remain at risk for lupus disease activity,” she added. “Our findings highlight the importance of continued rheumatologic monitoring and individualized immunosuppressive strategies for SLE patients on renal replacement therapy. Health care providers should closely monitor patients with lupus for active flares, particularly during the first five years after starting dialysis.”
Daoud additionally emphasized the role of racial and ethnic health care disparities in lupus nephritis and ESRD outcomes.
“Disparities in access to kidney transplantation and specialized care may contribute to differences in flare risk and overall disease burden,” she said. “Addressing these gaps through improved health care access, earlier intervention and equitable treatment strategies is essential to improving outcomes for all lupus patients.”
For more information:
Ansaam Daoud, MD, can be reached at ansaam.daoud@uhhospitals.org; X (Twitter): @DaoudAnsaam.
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