Systemic Lupus Erythematosus Disease Activity and Clinical Outcomes After Kidney Transplantation for Lupus Nephritis: A Single-Center Study

Objectives Systemic lupus erythematosus (SLE) is frequently complicated by lupus nephritis (LN), a major cause of morbidity and renal failure.[1] Kidney transplantation improves survival and is the preferred treatment for end-stage renal disease secondary to LN.[2] While transplant-related outcomes such as graft survival are well characterized, few studies have examined the broader post-transplant course of SLE. We aimed to characterize post-transplant lupus disease activity, flare frequency, and the prevalence of major comorbidities and adverse events. Methods A retrospective chart review was conducted for patients with SLE followed at The Ottawa Hospital who underwent kidney transplantation for LN between 2006 and 2023. Demographic, clinical, and serologic data were extracted from electronic medical records. Post-transplant disease activity was assessed using the SLE Disease Activity Index (SLEDAI-2k) and cumulative damage using SLICC/ACR Damage Index (SDI). Adverse outcomes, including graft rejection, cardiovascular events, infections, metabolic complications, osteoporotic fractures, avascular necrosis, and malignancy, were recorded. Data were summarized descriptively. Results 13 female patients were identified in our cohort (13/400), with a mean age of 44.8 ± 6.2 years at transplantation and mean follow-up of 8.4 ± 5.1 years. Time spent on dialysis prior to transplantation ranged from 3 months to 13 years. Ethnic distribution of patients was 54% White, 15% Black, 15% East Asian, 8% Indigenous, and 8% Middle Eastern. Deceased kidney donor (54%) was slightly more common than living donor (46%). Most patients received prednisone (92%) and calcineurin inhibitors (85%) as part of maintenance post-transplant immunosuppression. Mean cumulative SDI was elevated at 6.2 ± 2.0 (range 3-10). SLEDAI-2k scores (n=9) ranged from 0-6 (mean 1.2 ± 2.0); most maintained remission or low disease activity, and only 1 patient experienced a lupus flare requiring treatment escalation. Post-transplant adverse outcomes included cardiovascular events (15%), new-onset diabetes (15%), and major infections (38%). Additional complications included cataracts (15%), osteoporotic fractures (15%), and avascular necrosis (8%). One patient experienced biopsy-proven graft rejection, but no malignancies or deaths were observed during the post-transplant period. Conclusion Lupus activity following kidney transplantation for LN remained quiescent, with few flares observed; however, treatment-related complications were more common. While these interim findings are based on a limited cohort, they suggest that post-transplant SLE patients tend to maintain disease control, but they demonstrate the need for ongoing monitoring of complications and organ damage from chronic prednisone use. Continued patient recruitment and longitudinal follow-up are in progress. References [1.] Hanly J. Rheumatology 2016;55;252-62. [2.] Brilland B. Kidney Int Rep 2025;10;1163-74.