Approximately 10 to 30 percent of patients with proliferative lupus nephritis progress to end-stage renal disease (ESRD), depending upon the severity of the disease, ancestral and socio-economic factors, noncompliance, and the response to initial treatment [1,2]. Overall prognosis has improved in recent decades, perhaps due to the use of combined immunosuppression . However, a report using data from the United States Renal Data System from 1995 to 2006 found increases in the standardized incidence of ESRD due to lupus nephritis in younger individuals (ie, age <40 years), in African Americans and American Indians, and in individuals from the southeastern United States .
Issues related to ESRD in patients with lupus nephritis are reviewed here. These include complete or partial resolution of lupus activity in most patients and issues related to dialysis and renal transplantation.
The treatment of lupus nephritis is discussed elsewhere. (See "Therapy of diffuse or focal proliferative lupus nephritis" and "Clinical features and therapy of membranous lupus nephritis", section on 'Therapeutic approach'.)
LUPUS ACTIVITY IN END-STAGE RENAL DISEASE PATIENTS
The development of ESRD is, in many patients, associated with gradual complete or partial resolution of the extrarenal manifestations of lupus [5-9]. How this occurs is not well understood.
In a review of the literature, the percentage of patients with active (eg, arthritis/arthralgias, rash, and serositis) clinical lupus fell from 55 percent at the onset of dialysis to 6.5 percent in the 5th year and, in a small number of patients, to 0 percent in the 10th year . During this time span, the incidence of serologic activity (defined as the percentage of patients with two or more abnormal studies for ANA, anti-dsDNA, CH50, or C3) fell from 80 to 22 percent. In addition, most patients in whom the disease remains active have only mild to moderate symptoms. As an example, in one study, the number of patients with severe extrarenal disease activity (defined by a Systemic Lupus Erythematosus Disease Activity Index [SLE-DAI] >10) declined from 17 to 3 after the initiation of dialysis and to 0 after transplantation .