Persistent lupus activity in end-stage renal disease.

Clinical and serological activity of systemic lupus erythematosus (SLE) has been reported to dramatically improve in patients who develop end-stage renal disease (ESRD). At Tulane University Medical Center, most patients with SLE and ESRD continue to have evidence of disease activity. A retrospective study of lupus activity was therefore performed in 19 patients with SLE, who were either undergoing dialysis or had undergone transplantation between 1988 and 1994, to determine disease activity before and a mean follow-up of 3 years after ESRD. There were seven hemodialysis patients, five peritoneal dialysis patients, and seven transplant recipients in the study population. Clinical events recorded to evaluate disease activity as indicators of serological activity were malar rash, ulcers, alopecia, arthritis, myositis, pleuritis, pericarditis, fever, cerebritis, and vasculitis. The following studies were recorded as measures of serological activity: leukocyte count, platelet count, serum complement 3 level, and anti-double-stranded DNA level. Disease activity was measured by using the SLE Disease Activity Index and the requirement for immunosuppressive medications. Clinical event rates for alopecia, arthritis, myositis, pleuritis, pericarditis, fever, and vasculitis were greater after ESRD but not to statistical significance. Serological studies showed little change in the dialysis patients before and after ESRD; however, there was a tendency for lupus serological results to improve after transplantation. When all event rates were combined, there was a statistically significant greater incidence of lupus activity after both hemodialysis and peritoneal dialysis (P < 0.01) but not after renal transplantation. Fifty-eight percent of the patients undergoing dialysis died, either during the study period or within a 5-year follow-up, all of whom had clinically active lupus. This study therefore shows that lupus activity may persist in patients with ESRD. It is speculated that the study population, 84% of whom were black women, may represent a subgroup of patients with lupus in whom the disease remains active, even after they have developed ESRD.