Management Of Systemic Lupus ... Health Article

Outcome In Patients With Systemic Lupus Erythematosus

In some patients with lupus nephritis, planning for dialysis or renal transplantation, rather than immunosuppression, is appropriate. Patients who present with serum creatinine levels over 2.4 mg/dl, in whom the creatinine has slowly risen over a period of a few years, often have irreversible kidney lesions. ^{126, 148, 149, 150, 151} Black race and hematocrit levels below 26 percent also predict a high risk for end-stage renal disease. ^{66, 67, 150} The irreversibility of lesions can be confirmed by high chronicity scores and low activity scores on renal biopsy specimens. ¹²⁶ The 2-year survival rate in SLE patients with renal transplants is approximately 85 percent, with renal graft survival rates at 1 and 5 years of 68 and 54 percent, respectively. ^{152, 153} Recent data suggest that patients with SLE have about twice the risk of renal transplant failure than patients with other types of renal disease. ¹⁵³ SLE recurs in approximately 10 percent of transplanted kidneys, and standard laboratory measures of lupus activity may or may not predict this recurrence. ¹⁵⁴ With regard to extrarenal SLE, a decrease in disease activity scores and numbers of disease flares usually occur after initiation of dialysis or transplantation.

Death is caused most frequently by infection or severe nephritis; other manifestations of active SLE and atherosclerotic thrombotic events also account for a substantial proportion of deaths. ^{148, 149, 150, 151, 152} Extrarenal manifestations of SLE that are frequently fatal include carditis, pneumonitis, pulmonary hypertension, diffuse brain disease, stroke, myocardial infarction, intestinal perforations in areas of vasculitis, and extracranial arterial thromboses.

The prognosis of patients with SLE has improved considerably in the past four decades.Older age, male gender, African-American race, lower income without medical insurance, and nephritis are associated with the highest mortality rates. ^{148, 149, 150, 151} Fortunately, the mortality rate in SLE patients has declined steadily over the past 30 years. ¹⁵⁵ Nevertheless, current survival rates are not good enough—a fact that demands more effective approaches to the treatment of SLE.

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