April Jorge, MD *; Zachary S. Wallace, MD, MSc *; Na Lu, MPH; Yuqing Zhang, DSc; Hyon K. Choi, MD, DrPH
Acknowledgment: The authors thank Dr. Eliot Heher of the Massachusetts General Hospital Transplant Center for his contributions to overall study design.
Financial Support: Dr. Jorge is supported in part by the Ruth L. Kirschstein Institutional National Research Service Award (T32-AR-007258). Dr. Wallace receives funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health (NIH) (K23AR073334), the Rheumatology Research Foundation (Scientist Development Award), the Executive Committee on Research at Massachusetts General Hospital (Fund for Medical Discovery), and the NIH Loan Repayment Program. Dr. Zhang and Dr. Choi are supported in part by the NIH (P60-AR-047785).
Disclosures: Dr. Jorge reports grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the NIH during the conduct of the study. Dr. Wallace reports personal fees from Teva Pharmaceuticals and Gilead Sciences outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-1570.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Proctor & Gamble, Pfizer, and Johnson & Johnson.
Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Jorge (e-mail, AMJorge@mgh.harvard.edu). Data set: Availability is subject to approval by the USRDS. Interested readers may contact USRDS@usrds.org to place a data request.
Corresponding Author: April Jorge, MD, Instructor in Medicine, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Bulfinch 165, Boston, MA 02114; e-mail, AMJorge@mgh.harvard.edu.
Current Author Addresses: Dr. Jorge and Mr. Lu: Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Bulfinch 165, Boston, MA 02114.
Drs. Wallace, Zhang, and Choi: Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, 100 Cambridge Street, Suite 1600, Boston, MA 02114.
Author Contributions: Conception and design: A. Jorge, Z.S. Wallace, N. Lu, Y. Zhang, H.K. Choi.
Analysis and interpretation of the data: A. Jorge, Z.S. Wallace, N. Lu, Y. Zhang, H.K. Choi.
Drafting of the article: A. Jorge, Z.S. Wallace, N. Lu, H.K. Choi.
Critical revision of the article for important intellectual content: A. Jorge, Z.S. Wallace, N. Lu, Y. Zhang, H.K. Choi.
Final approval of the article: A. Jorge, Z.S. Wallace, N. Lu, Y. Zhang, H.K. Choi.
Statistical expertise: Z.S. Wallace, N. Lu, Y. Zhang, H.K. Choi.
Obtaining of funding: Z.S. Wallace.
Administrative, technical, or logistic support: A. Jorge, Z.S. Wallace, N. Lu, H.K. Choi.
Collection and assembly of data: Z.S. Wallace, H.K. Choi.
Patients with end-stage renal disease (ESRD) due to lupus nephritis (LN) have high rates of premature death.
To assess the potential effect on survival of renal transplant among patients with ESRD due to LN (LN-ESRD) in the United States.
Nationwide cohort study.
United States Renal Data System, the national database of nearly all patients with ESRD.
Patients with incident LN-ESRD who were waitlisted for a renal transplant.
First renal transplant was analyzed as a time-varying exposure. The primary outcomes were all-cause and cause-specific mortality. Time-dependent Cox regression analysis was used to estimate the hazard ratio (HR) of these outcomes associated with renal transplant in the primary analysis. Sequential cohort matching was used in a secondary analysis limited to patients with Medicare, which allowed assessment of time-varying covariates.
During the study period, 9659 patients with LN-ESRD were waitlisted for a renal transplant, of whom 5738 (59%) had a transplant. Most were female (82%) and nonwhite (60%). Transplant was associated with reduced all-cause mortality (adjusted HR, 0.30 [95% CI, 0.27 to 0.33]) among waitlisted patients. Adjusted HRs for cause-specific mortality were 0.26 (CI, 0.23 to 0.30) for cardiovascular disease, 0.30 (CI, 0.19 to 0.48) for coronary heart disease, 0.41 (CI, 0.32 to 0.52) for infection, and 0.41 (CI, 0.31 to 0.53) for sepsis.
Unmeasured factors may contribute to the observed associations; however, the E-value analysis suggested robustness of the results.
Renal transplant was associated with a survival benefit, primarily due to reduced deaths from cardiovascular disease and infection. The findings highlight the benefit of timely referral for transplant to improve outcomes in this population.
National Institutes of Health.
Jorge A, Wallace ZS, Lu N, Zhang Y, Choi HK. Renal Transplantation and Survival Among Patients With Lupus Nephritis: A Cohort Study. Ann Intern Med. [Epub ahead of print 22 January 2019]170:240–247. doi: 10.7326/M18-1570
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Published: Ann Intern Med. 2019;170(4):240-247.
Published at www.annals.org on 22 January 2019
Autoimmune Kidney Disease, Chronic Kidney Disease, Lupus Erythematosus, Nephrology, Renal Replacement Therapy.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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