Improving ESRD care among lupus nephritis patients: a socioeconomic and geographic perspective Pubblico

Abstract

Patients with systemic lupus erythematosus (SLE) are at risk for lupus nephritis (LN), which can progress to end-stage renal disease (ESRD). Adequate, timely identification and treatment of LN and ESRD across sociodemographic groups and geographic areas is essential for achieving equitable outcomes in the predominantly young, minority U.S. SLE population.

First, ESRD incidence in SLE patients was estimated via linkage of national ESRD surveillance data to a lupus registry including 345 incident Atlanta SLE patients (Aim 1). The overall ESRD incidence rate among newly diagnosed SLE patients was 11.1 per 1000 patient-years, and 5.2% initiated ESRD treatment within 5 years. Young age, black race, and early diagnosis of LN were associated with 2-, 4-, and 7-fold higher ESRD incidence, respectively.

Next, associations of quality-of-ESRD-care indicators with sociodemographics and U.S. region were explored among 6,594 incident LN-ESRD patients (Aim 2). Black vs. white patients were less likely to receive pre-ESRD care (OR=0.73, 95% CI 0.63-0.85) and be waitlisted for a kidney transplant in the first year of dialysis (HR=0.78, 95% CI 0.68-0.81). Only 24% had a permanent dialysis access, and those with no vs. private insurance were 40% less likely to have a permanent access. Quality of ESRD care varied 2- to 3-fold across U.S. regions, but patterns were not consistent across indicators.

Finally, the association of duration of time to transplant with risk of graft failure was examined in 4,743 incident kidney transplant recipients with LN-ESRD (Aim 3). White LN-ESRD patients transplanted later (vs. <3 months on dialysis) were at increased risk of graft failure [HR (95% CI): 3-12 months, 1.23 (0.93-1.63); 12-24 months, 1.37 (0.92-2.06); 24-36 months, 1.34 (0.92-1.97); and >36 months, 1.98 (1.31-2.99)]. However, no such association was seen among black recipients [3-12 months, 1.07 (0.79-1.45); 12-24 months, 1.01 (0.64-1.60); 24-36 months, 0.78 (0.51-1.18); and >36 months, 0.74 (0.48-1.13)].

These results could be used to inform shared decision-making for SLE patients and their providers. Additionally, these results identify targets for interventions at the patient, provider, and health system levels to improve care overall, as well as reduce sociodemographic and geographic disparities in delivered care, among SLE patients.

Table of Contents

1. Introduction and Overview - 1

1.1 Background - 1

1.2 Study Motivation - 2

1.3 Aims - 3

1.4 Data Sources - 4

1.5 Public Health Importance - 5

2. Background and Literature Review - 7

2.1 Systemic Lupus Erythematosus (SLE) - 7

2.2 Lupus Nephritis (LN) - 10

2.3 Lupus Nephritis-Associated End-Stage Renal Disease (LN-ESRD) - 14

2.4 U.S. Population Incidence of LN-ESRD - 15

2.5 Incidence of LN-ESRD among SLE Patients - 19

2.6 U.S. ESRD Quality-of-Care Indicators - 24

2.7 Translation of ESRD Quality-of-Care Indicators in LN-ESRD Patients - 35

2.8 Barriers to Kidney Transplantation in LN-ESRD Patients - 38

2.9 Waiting Time To Kidney Transplantation in LN-ESRD Patients - 40

3. Methods - 46

3.1 Data Sources - 46

3.2 Analytic Methods - 55

4. Aim 1: Incidence of End-Stage Renal Disease among Newly Diagnosed Systemic Lupus Erythematosus Patients - 91

4.1 Manuscript Information - 91

4.2 Abstract - 92

4.3 Introduction - 93

4.4. Patients and Methods - 95

4.5 Results - 100

4.6 Discussion - 105

4.7 Acknowledgements and Financial Support - 112

4.8 Tables and Figures - 113

4.9 Supplementary Tables - 122

5. Aim 2: Sociodemographic and Geographic Predictors of Quality of Care in U.S. Patients with End-Stage Renal Disease due to Lupus Nephritis - 123

5.1 Manuscript Information - 123

5.2 Abstract - 124

5.3 Introduction - 125

5.4. Patients and Methods - 126

5.5 Results - 130

5.6 Discussion - 135

5.7 Acknowledgements and Financial Support - 141

5.8 Tables and Figures - 142

5.9 Supplementary Tables and Figures - 151

6. Aim 3: Association of Time to Kidney Transplantation with Graft Failure among U.S. Patients with End-Stage Renal Disease Due to Lupus Nephritis - 157

6.1 Manuscript Information - 157

6.2 Abstract - 158

6.3 Introduction - 159

6.4 Patients and Methods - 160

6.5 Results - 164

6.6 Discussion - 168

6.7 Acknowledgements and Financial Support - 173

6.8 Tables and Figures - 175

6.9 Supplementary Tables and Figures - 186

7. Summary and Future Directions - 189

7.1 Summary of Findings - 189

7.2 Strengths and Limitations - 193

7.3 Future Directions - 195

8. Bibliography - 200

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School	Laney Graduate School
Department	Epidemiology
Degree	PhD
Submission	Dissertation
Language	English
Research Field	Health Sciences, Epidemiology
Parola chiave	end-stage renal disease quality of care lupus
Committee Chair / Thesis Advisor	McClellan, William, Emory University
Committee Members	Drenkard, Cristina M, Emory University Kramer, Michael R, Emory University Klein, Mitchel, Emory University Patzer, Rachel Elizabeth, Emory University

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