Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
Divisions of Rheumatology and Nephrology, Department of Medicine, University of California, San Francisco, CA, USA.
Lupus. 2024 Jan;33(1):48-57. doi: 10.1177/09612033231219739. Epub 2023 Nov 29.
For the majority of patients with lupus nephritis-related end-stage kidney disease (LN-ESKD), kidney transplant is associated with better outcomes than dialysis. Access to kidney transplant requires an initial referral to a transplant center and medical evaluation prior to waitlisting. The study's objective was to examine access to these early steps in the kidney transplant process among patients with LN-ESKD.
Adults who began treatment for ESKD in the Southeast, Northeast, New York, or Ohio River Valley U.S. regions from 1/1/2012 to 12/31/2019, followed through 6/30/2021, were identified from the United States Renal Data System. Referral and evaluation start data were collected from 28 of 48 transplant centers across these regions. The exposure was primary cause of ESKD (LN-ESKD vs other-ESKD). The outcomes were referral and evaluation start at a transplant center. Cox models quantified the association between LN-ESKD (vs other-ESKD) and referral and evaluation start.
Among 192,318 patients initiating treatment for ESKD, 0.4% had LN-ESKD. Over half (58%) of LN-ESKD patients were referred before study end, and among those referred, 66% started the evaluation. In adjusted analyses, patients with LN-ESKD were referred (HR: 1.09, 95% CI: 0.99, 1.19) and started the transplant evaluation (HR: 1.13, 95% CI: 1.00, 1.28) at a higher rate than patients with other-ESKD. Among referred patients with LN-ESKD, the median time from ESKD start to referral was 2.9 months (IQR: <1 to 11.7 months), which is similar to patients with other-ESKD (median 2.6 months, IQR: <1 to 8.8 months).
Among incident patients with ESKD, having a primary diagnosis of LN-ESKD versus other-ESKD is associated with higher rates of early transplant access outcomes. Despite this, patients with LN-ESKD (vs other-ESKD) are less likely to be preemptively referred (i.e., referred prior to ESKD start) for kidney transplant. While providers may no longer be delaying the early steps in the kidney transplantation process among this patient population, there is still room for improvement in the rates of preemptive referral. Access to kidney transplant referral prior to ESKD could result in increased transplant rates and better transplant outcomes for patients with LN-ESKD.
对于大多数狼疮性肾炎相关终末期肾病（LN-ESKD）患者来说，与透析相比，肾移植的预后更好。接受肾移植需要先向移植中心转诊，并在等候名单前进行医学评估。本研究的目的是探讨 LN-ESKD 患者在肾移植过程中早期阶段获得这些治疗的机会。
从美国肾脏数据系统中确定了 2012 年 1 月 1 日至 2019 年 12 月 31 日期间，在美国东南部、东北部、纽约州或俄亥俄河谷地区开始接受终末期肾病治疗，并在 2021 年 6 月 30 日之前完成治疗的成年人。转诊和评估启动数据来自这些地区的 28 个 48 个移植中心中的 28 个。暴露因素为终末期肾病的主要病因（LN-ESKD 与其他-ESKD）。结果是在移植中心转诊和评估启动。Cox 模型量化了 LN-ESKD（与其他-ESKD）与转诊和评估启动之间的关联。
在接受终末期肾病治疗的 192318 名患者中，0.4%患有 LN-ESKD。超过一半（58%）的 LN-ESKD 患者在研究结束前已被转诊，在被转诊的患者中，66%已开始接受评估。在调整分析中，与其他-ESKD 患者相比，LN-ESKD 患者的转诊（HR：1.09，95%CI：0.99，1.19）和接受移植评估（HR：1.13，95%CI：1.00，1.28）的比例更高。在接受转诊的 LN-ESKD 患者中，从终末期肾病开始到转诊的中位时间为 2.9 个月（IQR：＜1 至 11.7 个月），与其他-ESKD 患者相似（中位 2.6 个月，IQR：＜1 至 8.8 个月）。
在新诊断的终末期肾病患者中，与其他病因导致的终末期肾病相比，诊断为 LN-ESKD 与更高的早期移植获得率相关。尽管如此，LN-ESKD（与其他-ESKD）患者更不可能被预先转诊（即在终末期肾病开始前转诊）接受肾移植。尽管在该患者群体中，提供者可能不再延迟肾移植过程的早期步骤，但在预先转诊的比例上仍有改进的空间。在终末期肾病之前获得肾移植转诊的机会，可以提高 LN-ESKD 患者的移植率并改善移植结果。
