Renal Replacement Therapy in Lupus Nephritis–Related End-Stage Kidney Disease: A Systematic Review and Meta-Analysis

Objective: To assess the impact of renal replacement therapy in people with lupus nephritis (LN)–associated end-stage kidney disease (ESKD) and support the development of the 2024 American College of Rheumatology LN treatment guidelines. Methods: We conducted a systematic literature review and meta-analysis to address three Population, Intervention, Comparison, and Outcome (PICO) questions related to renal replacement therapy for ESKD due to LN, including comparisons of kidney transplant versus dialysis, hemodialysis versus peritoneal dialysis, and preemptive kidney transplant versus no preemptive kidney transplant. Outcomes of interest included mortality, cardiovascular (CV) events, infections, lupus flares, disease-related damage, graft failure, and quality of life. We conducted a meta-analysis and analyzed hazard ratios for time-to-event analyses and risk ratios for dichotomous outcomes, as well as absolute risk estimates. Results: Sixteen comparative observational studies addressed at least one of the three PICO questions. Kidney transplant was found to reduce the risks of all-cause mortality, CV mortality, infection-related mortality, and CV events compared with dialysis (high certainty). Dialysis modality (peritoneal vs hemodialysis) was not associated with mortality (high certainty) or with other outcomes of infection, CV complications, and systemic lupus erythematosus flares (low certainty). Preemptive kidney transplant was associated with lower risks of graft failure and mortality (low certainty). Conclusion: This systematic review identified improved outcomes with kidney transplant versus dialysis for people with LN-associated ESKD and potential benefits of preemptive kidney transplant. This evidence supports the use of kidney transplant as a preferred renal replacement therapy for people with LN-ESKD.