To the Editor:
Patients with psoriasis are at an increased risk of chronic kidney disease (CKD) and end-stage renal disease, which may lead to higher risk of death.1 CKD can worsen over time, and patients with progressive decline in estimated glomerular filtration rate (eGFR) and proteinuria are at a higher risk for progression to end-stage renal disease.2 The estimated decline in eGFR in CKD patients is 2.83 and 1.66 mL/min/1.73 m2 per year (8.8% ± 12.9%) in men and women, respectively, and an increased rate of decline is associated with male sex, proteinuria, and high systolic blood pressure.3 Recent studies have shown the benefits of anti–tumor necrosis factor biologics on the stabilization of renal function in CKD patients with rheumatoid arthritis.4 In this retrospective study, we investigated the effects of biologics on renal function in psoriasis patients with CKD.
The study was approved by the Tulane University institutional review board. Patients with psoriasis who were treated at Tulane Medical Center from 2011 to 2019 were analyzed. Patients included in the study had moderate to severe psoriasis and coexisting CKD before initiation of a biologic drug. Any patient with an eGFR persistently lower than 60 mL/min/1.73 m2 during 3 months was categorized as having CKD and included in the study. Patients were excluded if they had been receiving more than 1 biologic drug. Data were analyzed with an equivalence-paired t test.
Of the 533 patients reviewed, 34 (6.53%) met the inclusion criteria. Thirty-two patients were biologic naive, and 2 (5.9%) switched biologic drugs during the examination period and were excluded. The overall mean age at baseline was 63.5 years, 41.2% of patients were men, 88.2% of patients were white, 10% were black, and 1.8% were Hispanic. Fifty-six percent of patients had concomitant diabetes and hypertension (Table I). The overall mean eGFR at baseline was 53.2 mL/min/1.73 m2 per year (SD 10.5), corresponding to stage 3A CKD, whereas the overall mean eGFR after biologic treatment was 54.2 mL/min/1.73 m2 per year (SD 12.1). The average length of biologic use was 3.0 years (SD 2.0 years). Statistical analysis revealed no significant difference between pre- and postbiologic treatment in eGFR measurements (90% confidence interval −2 to 5; P < .001). Eight patients had an improved eGFR over time. Four patients (50%) were treated with infliximab, 2 were treated with ustekinumab, and 1 patient each was treated with adalimumab and ixekizumab.
Table I.
Characteristics of psoriasis patients with chronic kidney disease
| Age, y | eGFR prebiologic use | eGFR postbiologic use | % Change in GFR | Duration of biologic use, y | Medication | Diabetes | HTN |
|---|---|---|---|---|---|---|---|
| 64 | 38 | 38 | 0 | 2 | Adalimumab | Y | Y |
| 68 | 43 | 34 | −21 | 8 | Adalimumab | Y | Y |
| 70 | 57 | 57 | 0 | 2 | Adalimumab | Y | Y |
| 79 | 57 | 57 | 0 | 3 | Adalimumab | Y | N |
| 50 | 57 | 58 | 1.8 | 3 | Adalimumab | Y | Y |
| 72 | 58 | 58 | 0 | 3 | Adalimumab | N | Y |
| 60 | 59 | 55 | −6.7 | 3 | Adalimumab | Y | Y |
| 63 | 60 | 60 | 0 | 2 | Adalimumab | Y | Y |
| 44 | 64 | 59 | −8 | 2 | Adalimumab | Y | Y |
| 57 | 50 | 73 | 46 | 6 | Infliximab | N | Y |
| 69 | 53 | 58 | 9.4 | 8 | Infliximab | Y | Y |
| 72 | 70 | 70 | 0 | 3 | Infliximab | N | Y |
| 63 | 65 | 72 | 10.7 | 3 | Infliximab | N | Y |
| 69 | 19 | 16 | −16 | 2 | Ustekinumab | Y | Y |
| 78 | 69 | 69 | 0 | 1 | Ustekinumab | Y | Y |
| 76 | 51 | 57 | 12 | 3 | Ustekinumab | N | Y |
| 62 | 58 | 58 | 0 | 3 | Ustekinumab | Y | Y |
| 62 | 54 | 54 | 0 | 4 | Ustekinumab | N | Y |
| 57 | 54 | 54 | 0 | 1 | Ustekinumab | N | Y |
| 51 | 58 | 58 | 0 | 2 | Ustekinumab | Y | Y |
| 70 | 45 | 45 | 0 | 3 | Ixekizumab | Y | Y |
| 62 | 41 | 44 | 7.3 | 3 | Ixekizumab | Y | N |
| 63 | 65 | 65 | 0 | 3 | Ixekizumab | N | Y |
| 57 | 50 | 50 | 0 | 3 | Secukinumab | N | Y |
eGFR, Estimated glomerular filtration rate; GFR, glomerular filtration rate; HTN, hypertension; N, no; Y, yes.
This study had limitations, including a small sample size and retrospective study design. The study did not evaluate the level of proteinuria over time, nor the degree of blood pressure or glucose control over time in patients with diabetes, hypertension, or both. The presence of psoriatic arthritis and exposure to long-term nonsteroidal anti-inflammatory drugs was also not assessed. Confounding from selective prescribing and a health adherer effect are both possible limitations to the data interpretation.
This limited-sample retrospective study suggests that biologics do not affect long-term renal function in psoriasis patients with CKD. Additional studies are needed to further investigate whether early intervention with biologics can reduce progression to end-stage renal disease.
Footnotes
Conflicts of interest: Dr Murina is a speaker for AbbVie, Celgene, Eli Lilly and Company, Janssen, and Novartis. She has served on advisory boards for Ortho Dermatologics and Janssen.
IRB approval status: Reviewed and approved by Tulane IRB (2019–183).
REFERENCES
- 1.Abuabara K, Azfar RS, Shin DB, Neimann AL, Troxel AB, Gelfand JM. Cause-specific mortality in patients with severe psoriasis: a population-based cohort study in the U.K. Br J Dermatol. 2010;163(3):586–592. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Chang WX, Arai S, Tamura Y, et al. Time dependent risk factors associated with the decline of estimated GFR in CKD patients. Clin Exp Nephrol. 2016;20(1):58–70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Chang WX, Asakawa S, Toyoki D, et al. Predictors and the subsequent risk of end-stage renal disease - usefulness of 30% decline in estimated GFR over 2 years. PLoS One. 2015;10(7): e0132927. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Kim HW, Lee CK, Cha HS, et al. Effect of anti-tumor necrosis factor alpha treatment of rheumatoid arthritis and chronic kidney disease. Rheumatol Int. 2015;35(4):727–734. 10.1016/j.jaad.2019.12.043 [DOI] [PubMed] [Google Scholar]