OUTCOME OF RENAL-TRANSPLANTATION IN SYSTEMIC LUPUS-ERYTHEMATOSUS

Objectives: (1) To provide an overview of the world's experience with renal transplantation in systemic lupus erythematosus (SLE), and to co nsider the most important studies in detail. (2) To examine four speci fic questions raised by the review, including (a) the frequency of rec urrent lupus glomerulonephritis (GN); (b) the effect of pretransplanta tion dialysis on transplantation outcome; (c) the method of monitoring lupus activity in transplant patients; and (d) the frequency of early graft loss among lupus patients. Methods: We performed a MEDLINE sear ch of the world's literature from 1975 to 1997 on the subject of renal transplantation in SLE, using the search terms ''lupus,'' ''SLE,'' '' kidney,'' ''renal transplantation,'' and ''outcome.'' We included in t his review 20 original reports that devoted significant attention to t he outcome of renal transplantation among patients with lupus. Results : Of the nine studies that compared the transplantation outcomes of lu pus patients with those of transplant patients with other causes of en d-stage renal disease, the allograft survival rates were superior in t he comparison groups in six, and approximately equivalent in three. Th e 1-year allograft survival rate of lupus patients with cadaveric rena l transplants (CRTs) was 67% in the largest multicenter study, signifi cantly lower than the rate for the other 14 diseases examined (77%; P =.009). In most studies, the lupus groups were significantly younger t han their comparison groups, but they frequently included larger perce ntages of black patients. Lupus patients who received living-related r enal transplants (LRRTs) generally had superior graft survival rates c ompared with those who received CRTs. In the largest single-center rep ort, the 5-year graft survival rate in the cyclosporine era was 89% fo r LRRTs, compared with 41% for CRTs. Recurrence of lupus nephritis in the allograft is relatively rare, approximately 2%; this estimate is p robably low. However, recurrent lupus glomerular nephritis (GN) did no t invariably result in allograft failure. Short length of pretransplan tation dialysis tie, less than 6 months) had no adverse effect on tran splantation outcome in 10 of 11 studies that examined the relationship . Pretransplantation serological parameters, such as complement and an ti-double-stranded DNA antibody levels, appear to be unreliable predic tors of the likelihood of recurrence, and also may be inaccurate measu res of disease activity in the posttransplantation period. Finally, 9 of the 20 studies reviewed noted an increased risk of early graft loss among lupus transplant patients, possibly because of an increased fre quency of acute rejection reactions and thrombotic events associated w ith antiphospholipid antibodies. Conclusions: Despite the fact that ma ny lupus patients have excellent renal transplantation outcomes, subst antial evidence indicates that renal transplant patients with lupus do not fare as well as patients with other causes of end-stage renal dis ease, Lupus patients may be particularly susceptible to adverse events occurring in the first year after transplantation. Further investigat ion is needed to improve renal transplantation outcomes for patients w ith lupus. Copyright (C) 1997 by W.B. Saunders Company.