Trends of preemptive kidney transplantation in lupus compared to other primary diseases leading to end stage kidney disease in the United States of America

Purpose The proportion of lupus patients with end-stage kidney disease (ESKD) undergoing preemptive kidney transplantation (PKT) is <5%, due to concern for poor outcomes. In this study, we estimate trends and the likelihood of PKT in lupus patients compared to non-lupus patients approaching ESKD. Additionally, we compare kidney allograft failure (KAF) and all-cause mortality in lupus and non-lupus recipients of PKT. Methods We included 33,415 lupus and 3,001,746 non-lupus incident ESKD patients from the United States Renal Data System (USRDS). Patients were stratified in 6 groups: lupus, polycystic kidney disease (PKD), other glomerular diseases (GD), diabetes (DM), hypertension (HTN), and other diseases (OD). Trends of PKT were assessed with Cochran-Armitage tests. KAF and mortality were compared stratifying by primary diagnosis leading to ESKD. Findings PKT trends increased in the lupus (3.02% to 4.65%, p = 0.001), PKD (3.14% to 16.71%, p < 0.001), and GD (3.94% to 5.90%, p < 0.001) groups, but decreased in the DM (2.11% to 0.71%, p < 0.001), HTN (1.15% to 0.92%, p < 0.001) and OD (3.89% to 3.60%, p < 0.001) groups. KAF rate (per 100 patient-years) was similarly low in lupus (4.40), PKD (2.47), GD (4.28) and OD (4.84) recipients, and similarly high in DM (6.24) and HTN (7.42) recipients. Lupus compared to DM recipients of PKT had significantly lower risk of KAF in adjusted Cox models (Hazard Ratio [95% CI] 0.85 [0.76 to 0.95]). Mortality rate was similarly low in lupus (2.59), PKD (2.20), GD (2.62) and OD (2.99) recipients, and similarly high in HTN (6.39) and DM (6.49) recipients. Lupus compared to DM recipients of PKT had significantly lower risk of all-cause mortality in adjusted models (0.56 [0.50 to 0.64]). Conclusion PKT trends increased from 1985 to 2019 in patients with lupus, PKD and GD. PKT patients with lupus have lower risk of KAF and mortality compared to patients with DM.