Lupus nephritis and kidney transplantation: A narrative review of patient and graft outcomes

Abstract

Lupus nephritis (LN), a serious manifestation of systemic lupus erythematosus, continues to be a major cause of morbidity and mortality. Despite significant advances in immunosuppressive therapy, many patients progress to end-stage kidney disease (ESKD), for which kidney transplantation (KT) remains the treatment of choice. However, the survival advantage of KT in LN-related ESKD is not yet clearly defined. This narrative review synthesizes current guidelines and recent evidence to address the distinctive challenges of transplantation in patients with autoimmune conditions such as LN, particularly regarding the optimal timing of KT. While existing recommendations emphasize achieving disease quiescence prior to transplantation, emerging data support the benefits of preemptive KT and individualized immunosuppressive regimens in improving both patient and graft outcomes. Advances in immunosuppressive therapies, including newly approved agents such as voclosporin and belimumab, have further enhanced LN management. In addition, novel biomarkers such as urinary monocyte chemoattractant protein-1, B-cell activating factor and matrix metalloproteinase-7 show promise for monitoring disease activity and predicting post-transplant recurrence risk. A comprehensive appraisal of guidelines and contemporary studies is essential to refine management strategies and optimize long-term outcomes for patients with LN undergoing KT.

Keywords: End-stage kidney disease; Graft survival; Immunosuppressive therapy; Kidney transplantation; Lupus nephritis; Outcomes

Core Tip: Kidney transplantation is the preferred treatment for lupus nephritis progressing to end-stage kidney disease, though its survival benefit in lupus nephritis end-stage kidney disease remains uncertain. Achieving disease quiescence before transplantation is critical, yet emerging evidence supports preemptive transplantation and personalized immunosuppressive regimens to enhance outcomes. New therapies such as voclosporin and belimumab, together with biomarkers like urinary monocyte chemoattractant protein-1, matrix metalloproteinase-7, and B-cell activating factor, show promise for improving patient selection, monitoring disease activity, and predicting recurrence. Careful integration of updated guidelines and recent evidence is essential to optimize both patient and graft survival.