Would you proceed with renal transplant in a patient with lupus nephritis who has progressed to ESRD and is clinically stable, but has persistently elevated dsDNA and low complements despite appropriate doses of hydroxychloroquine and mycophenolate?

Short answer: Yes—if the patient’s clinical lupus is quiescent for at least 6 months, it is reasonable to proceed with kidney transplantation even in the presence of persistent serologic activity (e.g., low complement, elevated anti-dsDNA).

Why this matters:

• Transplant > Dialysis: Patients with LN-ESRD have better long-term survival and quality of life after kidney transplantation compared with remaining on dialysis.
• Serology ≠ Contraindication: Abnormal serologies alone should not delay listing. A systematic review from the Toronto Lupus Cohort, has shown that persistent anti-dsDNA positivity or hypocomplementemia at the time of transplantation is not associated with increased risk of graft failure.
• Pushback possible: Some transplant teams ...

I would consider labs to be a helpful guide; however, the decision to inc/fail immunosuppressant and get a transplant of a kidney is a major decision. Given the patient is ESRD, they have chronic inflammation. I would be doing UA, urine protein/creatinine to look for activity of the disease in that organ, guiding transplant. If it is > 500 mg daily, would co-manage with nephrology to repeat biopsy as it would change management: active urine sediment/UA AND LABS would trial change of meds: rituxan, lupkynis, or benlysta. Generally, if a patient is on HCQ, MMF, the next agent to add is Benlysta, and guidelines push toward triple therapy. If, however, just spilling protein/ bland urine sediment biopsy and CNI tacro/lupkynis could be trialed pe...

I agree with Dr. @Dr. First Last's comments that getting patients transplanted as soon as possible enhances QoL and survival, and that elevated adsDNA or low C4 (due to the presence of possible null alleles) does not necessarily imply active nephritis.

The referenced Toronto cohort study reported the outcome was graft failure leading to dialysis but not episodes of disease recurrence, and considered 'positive' serology to be either +adsDNA or low C4 or low C3.

Having attended to a number patients who had disease recurrence in an allograft in the context of having been transplanted while still serolgically active with noted persistent low C3, I have favored efforts to achieve at least normalization of C3 (if low) with success doing so initia...

I think it really depends on the quiescence of the lupus. As long as they are on <10 mg prednisone, with no clinical evidence of activity, we will transplant. They can also be on belimumab; the key is clinical quiescence.