Maintenance Hemodialysis in End-Stage Lupus Nephritis

Clinically significant renal involvement occurs in about 11% of patients with systemic lupus erythematosus (SLE) and may progress to uremia (1). In the past renal disease was one of the main cause of death in lupus (2) and patients with end-stage nephritis were generally denied maintenance dialysis because of limited facilities and of the prevailing belief that the extrarenal lupus would progress inexorably. According to Coplon et aI. , once the serum creatinine exceeds 4 mg/dl the patient with SLE will progress to uremia despite aggressive immunosuppressive therapy (3). These and other investigators further noted frequent serious and often fatal infections in patients with renal failure receiving immunosuppressive therapy (3, 4). Because of this they advocated an alternative approach consisting of the least amount of immunosuppressive regimen necessary to control extra-renal manifestations and use of maintenance dialysis when renal failure ensued. In their initial communication Coplon et al reported a marked reduction in the intensity of the serological and clinical manifestations of SLE in ten patients with endstage lupus nephritis after an average of 14.3 months of hemodialysis. They also noted a high incidence of severe infections, leading to three deaths early in the course of maintenance dialysis. These patients had received large doses of prednisone during this period and the incidence of life threatening infections later fell considerably as the dose of steroids was reduced (3). In 1974 Fries et al reported on 13 patients with active lupus and end-stage nephritis, who exhibited a gradual reduction in the clinical and serological manifestations of the disease once hemodialysis was begun, despite a substantial reduction in the dose of steroids. Three patients died in this group during an average period of 18 months of maintenance hemodialysis; and only one patient exhibited active SLE at the end of the study (5). Recently Kimberly et al reported their experience with 39 patients with end-stage lupus nephritis treated with maintenance hemodialysis for four months to nine years (6). Despite withdrawal of immunosuppressive therapy, 24 patients in this group were clinically and serologically quiescent and in only four did the disease become reactivated during maintenance dialysis. Of the fifteen deaths in this group, eight occurred during the first 3 months all from active SLE or of infectious complications of immunosuppressive therapy. Of the seven late deaths one was due to systemic infection associated with steroid administration. No evidence of active SLE was present in the remaining six cases who had died of causes unrelated to SLE. More recently Coplon et al published another report describing their findings on 28 patients with end-stage lupus nephritis. They demonstrated marked improvement of clinical and serological manifestations of SLE despite withdrawal or marked reduction of immunosuppressive regimens (7). Only three of their patients had middly active SLE exhibiting arthralgias and moderately elevated titers of antinuclear antibodies. Six deaths occurred in these series primarily associated with the complications of high dose steroid administration. Our own experience with 12 lupus patients maintained on hemodialysis for a period averaging 31 months is consistent with these other groups (8). All of our patients exhibited marked reduction in the clinical and serological activities of SLE, but one half continued to have mild extra-renal manifestations including arthralgia and skin rash. Only 25% of our patients required low dose steroids « 15 mg prednisone/daily) at some point after the institution of maintenance hemodialysis. The mortality in our series was limited to an early death within one week from the onset of hemodialysis and a late death after 3 years of hemodialysis with no evidence of active SLE. Several groups have observed marked improvement of renal function in some of their patients after variable periods of maintenance dialysis and withdrawal or reduction of immunosuppressive medications. Kimberly et al