Effectiveness and persistence of biological and targeted synthetic treatment in patients with rheumatoid arthritis and chronic kidney disease: a multicentre, prospective cohort study.

内容摘要

Chronic kidney disease is a common comorbidity of rheumatoid arthritis. Because there has been scarce and conflicting evidence on the use of biological and targeted synthetic therapy in patients with rheumatoid arthritis and chronic kidney disease, we aimed to examine the effectiveness and persistence of biological and targeted synthetic disease-modifying antirheumatic drugs (DMARDs) for patients with rheumatoid arthritis and chronic kidney disease. This multicentre, prospective cohort study used data from the CorEvitas Rheumatoid Arthritis registry on patients with rheumatoid arthritis who initiated each type of biological and targeted synthetic DMARD (TNF inhibitors, CTLA4 immunoglobulin, IL-6 inhibitors, B-cell depletion therapy, and JAK inhibitors) recruited from 160 rheumatology practices in the USA. Patients were required to have moderate or high disease activity according to the Clinical Disease Activity Index (CDAI; score >10). Chronic kidney disease was defined as an estimated glomerular filtration rate (eGFR) of less than 60 mL/min per 1·73 m2 at biological or targeted synthetic DMARD initiation. The primary outcome was the attainment of remission according to CDAI score. Propensity scores were used for overlap weighting to improve the balance of characteristics for patients with and without reduced eGFR. Cox regressions estimated the unadjusted and adjusted hazard ratio (HR) of reduced eGFR for CDAI-based remission. People with lived experience of rheumatoid arthritis were not involved in the study design or conduct. Between Oct 1, 2001, and Dec 31, 2023, 12 123 biological and targeted synthetic DMARD treatment initiations in 9601 patients with rheumatoid arthritis, with 51 931 person-years of follow-up, were identified. Of 12 123 eligible biological and targeted synthetic DMARD treatment initiations, 10 857 (89·6%) were in patients with preserved eGFR and 1266 (10·4%) were in patients with reduced eGFR. Across both groups, median age was 59·0 years (IQR 50·0-67·0), 9720 (80·2%) of 12 123 treatment initiations were in female patients and 2403 (19·8%) were in male patients, and 9908 (81·7%) were in non-Hispanic White patients. 3025 (27·9%) of 10 857 treatment initiations in patients with preserved eGFR resulted in CDAI-based remission versus 246 (19·4%) of 1266 treatment initiations in patients with reduced eGFR. Reduced eGFR was associated with a lower likelihood of attaining CDAI-based remission (unadjusted HR 0·71 [95% CI 0·62-0·82], adjusted HR 0·76 [0·66-0·88]) compared with preserved eGFR. Although biological and targeted synthetic DMARDs are generally well tolerated and effective options, patients with rheumatoid arthritis and reduced eGFR have lower likelihood of attaining remission. Tailored treatment strategies for this high-risk population should be established. National Institute of Arthritis and Musculoskeletal and Skin Diseases.