Excess atherosclerosis in systemic lupus erythematosus,-A matter of renal involvement: Case control study of 281 SLE patients and 281 individually matched population controls

Choroidal thickness changes in systemic lupus erythematosus patients

Purpose

To compare choroidal thickness (CT) between patients with systemic lupus erythematosus (SLE) without ophthalmologic manifestations and a control group. To study the effects in CT of disease duration, activity index, medication and systemic comorbidities.

Methods

Cross-sectional study where spectral-domain optical coherence tomography with enhanced depth imaging was used to measure CT in 13 locations, subfoveally and at 500-µm intervals along a horizontal and a vertical section from the fovea. Linear regression models were used.

Results

Sixty-eight SLE patients and fifty healthy controls were enrolled. CT multivariable analysis revealed lower values in SLE patients (12.93-26.73 µm thinner) in all locations, except the inferior quadrants (6.48-10.44 µm thicker); however, none of these results reached statistical significance. Contrary to the control group, the normal topographic variation in CT between macular quadrants and from the center to the periphery was not observed in the SLE group. Multivariable analysis in the SLE group alone revealed a significant negative association with anticoagulants (50.10-56.09 µm thinner) and lupus nephritis (40.79-58.63 µm thinner). Contrary to controls, the CT of SLE patients did not respond to changes in mean arterial pressure.

Conclusion

CT in SLE appears to be thinner, particularly in the subset of patients with nephritis and taking anticoagulants, suggesting more advanced systemic vascular disease. Choroidal responses to hemodynamic changes may also be altered in SLE.

The non-haemostatic role of platelets in systemic lupus erythematosus

Dysregulation of lymphocyte function, accumulation of autoantibodies and defective clearance of circulating immune complexes and apoptotic cells are hallmarks of systemic lupus erythematosus (SLE). Moreover, it is now evident that an intricate interplay between the adaptive and innate immune systems contributes to the pathogenesis of SLE, ultimately resulting in chronic inflammation and organ damage. Platelets circulate in the blood and are chiefly recognized for their role in the prevention of bleeding and promotion of haemostasis; however, accumulating evidence points to a role for platelets in both adaptive and innate immunity. Through a broad repertoire of receptors, platelets respond promptly to immune complexes, complement and damage-associated molecular patterns, and represent a major reservoir of immunomodulatory molecules in the circulation. Furthermore, evidence suggests that platelets are activated in patients with SLE, and that they could contribute to the circulatory autoantigenic load through the release of microparticles and mitochondrial antigens. Herein, we highlight how platelets contribute to the immune response and review evidence implicating platelets in the pathogenesis of SLE.

Cardiovascular disease in systemic lupus erythematosus: an update

PURPOSE OF REVIEW

The mechanisms leading to the development of premature atherosclerosis and vascular injury in systemic lupus erythematosus (SLE) remain to be fully elucidated. This is a comprehensive review of recent research developments related to the understanding of cardiovascular disease (CVD) in lupus.

RECENT FINDINGS

SLE patients with lupus nephritis display significantly increased risk of myocardial infarction and CVD mortality than SLE patients without lupus nephritis. SLE disease-related parameters could be taken into consideration when calculating CVD risks. The type I interferon pathway is detrimental to the vasculature and may contribute to the development of insulin resistance. The level of low-density granulocytes, a distinct subset of proinflammatory neutrophils present in SLE, was independently associated with coronary plaque burden and endothelial dysfunction. Invariant natural killer T cells may promote an atheroprotective effect in SLE patients with asymptomatic atherosclerotic plaques. Oxidized lupus high-density lipoprotein promotes proinflammatory responses in macrophages.

SUMMARY

Recent discoveries have further strengthened the critical role of SLE-related immune dysregulation and metabolic disturbances in promoting accelerated CVD. Understanding how these pathogenic factors promote vascular injury may provide better molecular candidates for therapeutic targeting, and ultimately to improve CVD outcomes.

Activated T-effector seeds: cultivating atherosclerotic plaque through alternative activation

Atherosclerosis is a chronic inflammatory pathology that precipitates substantial morbidity and mortality. Although initiated by physiological patterns of low and disturbed flow that differentially prime endothelial cells at sites of vessel branch points and curvature, the chronic, smoldering inflammation of atherosclerosis is accelerated by comorbidities involving inappropriate activation of the adaptive immune system, such as autoimmunity. The innate contributions to atherosclerosis, especially in the transition of monocyte to lipid-laden macrophage, are well established, but the mechanisms underpinning the infiltration, persistence, and effector dynamics of CD8 T cells in particular are not well understood. Adaptive immunity is centered on a classical cascade of antigen recognition and activation, costimulation, and effector cytokine secretion upon recall of antigen. However, chronic inflammation can generate alternative cues that supplant this behavior pattern and promote the retention and activation of peripherally activated T cells. Furthermore, the atherogenic foci that activated immune cell infiltrate are unique lipid-laden environments that offer a diverse array of stimuli, including those of survival, antigen hyporesponsiveness, and inflammatory cytokine expression. This review will focus on how known cardiovascular comorbidities may be influencing CD8 T-cell activation and how, once infiltrated within atherogenic foci, these T cells face a multitude of cues that skew the classical cascade of T-cell behavior, highlighting alternative modes of activation that may help contextualize associations of autoimmunity, viral infection, and immunotherapy with cardiovascular morbidity.

Low plasma concentrations of apolipoprotein M are associated with disease activity and endothelial dysfunction in systemic lupus erythematosus

BACKGROUND

Apolipoprotein M (apoM) is a 25-kDa apolipoprotein present in 5% of high-density lipoprotein (HDL) particles. It is suggested to be anti-atherogenic and to play a key role in sustaining endothelial barrier integrity. SLE patients have increased cardiovascular disease risk, and we aimed to investigate if apoM levels reflect endothelial function in SLE. Since apoM plasma levels decrease during inflammatory conditions, our aim was also to determine the impact of SLE disease activity on apoM plasma levels.

METHODS

Plasma concentrations of apoM were measured by ELISA in two patient groups with systemic lupus erythematosus (SLE) and in 79 healthy control individuals. In patient group I (n = 84), evaluation time points were selected with the objective to include a wide range of clinical and laboratory variables reflecting disease activity which was measured as SLEDAI. In patient group II consisting of 140 consecutive patients, endothelial function was measured by a finger plethysmograph. A low Reactive Hyperemia Index (RHI) value indicates endothelial dysfunction.

RESULTS

SLE patients had decreased levels of apoM compared to healthy controls (p < 0.01), with apoM levels correlating inversely with SLEDAI (r = - 0.31, p < 0.01) as well as with levels of CRP (r = - 0.26, p = 0.02) and positively with levels of C3 (r = 0.29, p < 0.01). ApoM levels were particularly low in patients with active disease from the kidney and skin and in patients with leukopenia or positive anti-dsDNA antibody test (p < 0.05). ApoM levels correlated with RHI values in young SLE patients (r = 0.32, p = 0.01), consistent with the important role of apoM in regulating endothelial integrity.

CONCLUSIONS

ApoM levels may be regulated by SLE-related inflammatory processes and could be a marker of disease activity and endothelial dysfunction, in particular in young SLE patients. Further studies are needed to investigate the predictive value of apoM in the development of a cardiovascular disease.

Renal Transplantation and Survival Among Patients With Lupus Nephritis: A Cohort Study

Background

Patients with end-stage renal disease (ESRD) due to lupus nephritis (LN) have high rates of premature death.

Objective

To assess the potential effect on survival of renal transplant among patients with ESRD due to LN (LN-ESRD) in the United States.

Design

Nationwide cohort study.

Setting

United States Renal Data System, the national database of nearly all patients with ESRD.

Participants

Patients with incident LN-ESRD who were waitlisted for a renal transplant.

Measurements

First renal transplant was analyzed as a time-varying exposure. The primary outcomes were all-cause and cause-specific mortality. Time-dependent Cox regression analysis was used to estimate the hazard ratio (HR) of these outcomes associated with renal transplant in the primary analysis. Sequential cohort matching was used in a secondary analysis limited to patients with Medicare, which allowed assessment of time-varying covariates.

Results

During the study period, 9659 patients with LN-ESRD were waitlisted for a renal transplant, of whom 5738 (59%) had a transplant. Most were female (82%) and nonwhite (60%). Transplant was associated with reduced all-cause mortality (adjusted HR, 0.30 [95% CI, 0.27 to 0.33]) among waitlisted patients. Adjusted HRs for cause-specific mortality were 0.26 (CI, 0.23 to 0.30) for cardiovascular disease, 0.30 (CI, 0.19 to 0.48) for coronary heart disease, 0.41 (CI, 0.32 to 0.52) for infection, and 0.41 (CI, 0.31 to 0.53) for sepsis.

Limitation

Unmeasured factors may contribute to the observed associations; however, the E-value analysis suggested robustness of the results.

Conclusion

Renal transplant was associated with a survival benefit, primarily due to reduced deaths from cardiovascular disease and infection. The findings highlight the benefit of timely referral for transplant to improve outcomes in this population.

Primary Funding Source

National Institutes of Health.

MicroRNA-145 attenuates IL-6-induced enhancements of sensitivity to UVB irradiation by suppressing MyD88 in HaCaT cells

MicroRNAs (miRNAs/miRs) play vital roles in various immune diseases including systemic lupus erythematosus (SLE). The current study aimed to assess the role of miR-145 in interleukin-6 (IL-6)-treated HaCaT cells under ultraviolet B (UVB) irradiation and further explore the potential regulatory mechanism. HaCaT cells were pretreated with IL-6 and then exposed to UVB to assess the effect of IL-6 on sensitivity of HaCaT cells to UVB irradiation. The levels of miR-145 and MyD88 were altered by transfection and the transfected efficiency was verified by quantitative reverse transcription polymerase chain reaction (qRT-PCR)/western blot analysis. Cell viability, percentage of apoptotic cells and expression levels of apoptosis-related factors were measured by trypan blue assay, flow cytometry assay, and western blot analysis, respectively. In addition, the levels of c-Jun N-terminal kinases (JNK) and nuclear factor-κB (NF-κB) signaling pathway-related factors were assessed by western blot analysis. IL-6 treatments significantly aggravated the reduction of cell viability and promotion of cell apoptosis caused by UVB irradiation in HaCaT cells. Interestingly, miR-145 level was augmented by UVB exposure and miR-145 mimic alleviated IL-6-induced increase of sensitivity to UVB irradiation in HaCaT cells, as dramatically increased cell viability and reduced cell apoptosis. Opposite effects were observed in miR-145 inhibitor-transfected cells. Meanwhile, MyD88 was negatively regulated by miR-145 and MyD88 mediated the regulatory effect of miR-145 on IL-6- and UVB-treated cells. In addition, miR-145 mimic inhibited the JNK and NF-κB pathways by down-regulating MyD88. In conclusion, the present study demonstrated that miR-145 alleviated IL-6-induced increase of sensitivity to UVB irradiation by down-regulating MyD88 in HaCaT cells.

Subclinical parameters of arterial stiffness and arteriosclerosis correlate with QRISK3 in systemic lupus erythematosus

It is well known that cardiovascular diseases (CVD) are a major contributor of death in systemic lupus erythematosus (SLE) as well in other rheumatic illness. In the last decades, there has been a growing development of different methodologies with the purpose of early detection of CVD. Objective: The aim of this study is to correlate the usefulness of subclinical parameters of vascular aging and QRISK 3–2017 score for early detection of CVD in SLE. Methods: Clinical assessment including systemic lupus erythematosus disease activity index (SLEDAI) and systemic lupus international collaborating clinics / american college of rheumatology damage index (SLICC/ACR DI), laboratory measurements, carotid ultrasound examination, carotid intima media thickness (cIMT) measurement, carotid distention and diameter analysis, arterial stiffness measurement measured by tonometry and QRISK 3–2017 were done. All results were analyzed by SPSS 24 software. Results: We observed correlation between QRISK3 and mean cIMT (rs = 0.534, P < 0.001), PWV (rs = 0.474, P < 0.001), cfPWV (rs = 0.569, P < 0.001) and distensibility (rs = -0.420, P = 0.006). Consistent with above, SLE patients in middle and high risk QRISK 3–2017 showed increased arterial stiffness versus low risk group. Conclusions: We encourage to the rheumatology community to assess cardiovascular risk in SLE patients with QRISK 3–2017 risk calculator as an alternative method at the outpatient clinic along a complete cardiovascular evaluation when appropriate.

Elevation of serum proprotein convertase subtilisin/kexin type 9 (PCSK9) concentrations and its possible atherogenic role in patients with systemic lupus erythematosus

Background

Systemic lupus erythematosus (SLE) patients have tendencies of accelerated atherosclerosis (AS) which can only partly be explained by traditional cardiovascular disease (CVD) risk factors. Imbalanced inflammation also plays a vital role. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a new therapeutic target for AS for its dual mechanisms in lipids and inflammation. We aimed to assess serum PCSK9 concentrations in SLE patients and its possible role in atherogenesis of SLE.

Methods

Ninety SLE patients and 50 healthy controls were included. SLE patients were further divided into SLE-AS and SLE-NonAS subgroups, according to the carotid intima-media thickness (cIMT). Traditional CVD risk factors, inflammatory biomarkers and PCSK9 concentrations were compared between: (I) SLE patients and controls; (II) SLE-AS subgroup and SLE-NonAS subgroup; (III) SLE patients with and without lupus nephritis (LN). Correlational analysis, univariate and multivariate linear regression analysis were applied to analyze the association between PCSK9 levels and disease parameter in SLE patients. Effects on PCSK9 concentrations by monotherapy with hydroxychloroquine (HCQ), which is thought having protective effects against AS in SLE, were investigated by follow-up analysis in 15 SLE patients.

Results

We found that SLE patients had significantly elevated serum PCSK9 levels than controls, especially in SLE-As subgroup or those with LN, accompanied with higher ratio of cIMT thickening. Correlational analysis showed PCSK9 concentrations correlated with C-reactive protein (CRP) levels, age and erythrocyte sedimentation rate (ESR). Univariate and multivariate linear regression revealed that only CRP, but not age or ESR was positive predictors of PCSK9. Interestingly, monotherapy with HCQ for three months significantly reduced PCSK9 and CRP levels in inactive SLE patients.

Conclusions

Our results suggested that elevated PCSK9 levels in SLE are probably associated with atherogenic inflammation in SLE. HCQ, which is thought having protective effects against AS in SLE, can effectively reduce PCSK9 levels in SLE patients.

Stratification of Systemic Lupus Erythematosus Patients Into Three Groups of Disease Activity Progression According to Longitudinal Gene Expression

OBJECTIVE

The highly heterogeneous clinical presentation of systemic lupus erythematosus (SLE) is characterized by the unpredictable occurrence of disease flares and organ damage. Attempts to stratify lupus patients have been limited to classification based on clinical information, leading to unsuccessful clinical trials and controversial research results. This study was undertaken to develop and validate a robust method to stratify patients with lupus according to longitudinal disease activity and whole-genome gene expression data in order to establish subgroups of patients who share disease progression mechanisms.

METHODS

We used a cluster-based approach to stratify SLE patients based on the correlation between disease activity scores and longitudinal gene expression information. Clustering robustness was evaluated by the bootstrap method, and the clusters were characterized in terms of clinical and functional features.

RESULTS

We observed a clear partition into 3 different disease clusters in 2 independent sets of patients, one pediatric and one adult, which was not influenced by treatment, race, or other source of bias. Two of the clusters differentiated into a group showing a correlation between the percentage of neutrophils and disease activity progression and a group showing a correlation between the percentage of lymphocytes and disease activity progression. The third cluster, in which the percentage of neutrophils correlated to a lesser degree with disease activity, was functionally more heterogeneous. Patients in the neutrophil-driven clusters had an increased risk of developing proliferative nephritis.

CONCLUSION

Our findings indicate that SLE patients can be stratified into 3 subgroups of patients who show different mechanisms of disease progression and are clinically differentiated. Our results have important implications for treatment options, the design of clinical trials, our understanding of the etiology of the disease, and the prediction of severe glomerulonephritis.

Long non-coding RNA TUG1 protects renal tubular epithelial cells against injury induced by lipopolysaccharide via regulating microRNA-223

BACKGROUND

Lupus nephritis (LN) is a serious complication of systemic lupus erythematosus (SLE). Long non-coding RNA taurine upregulated gene 1 (lncRNA TUG1) exerted critical regulatory effects on inhibiting cell injury and inflammation. However, its role in LN is still unclear.

METHODS

HK-2 cells were treated with lipopolysaccharide (LPS) to simulate cell inflammatory injury. Cell viability and apoptosis, as well as pro-inflammatory factors expression were measured, respectively. Then, HK-2 cells were transfected with pEX-TUG1 or sh-TUG1 to explore the effects of TUG1 on LPS-induced cell injury. Potential binding effects between TUG1 and microRNA-223 (miR-223), as well as between miR-223 and Sirtuin 1 (Sirt1) were verified. miR-223 mimic or miR-223 inhibitor was transfected to assess the effects of miR-223 on cell injury. Finally, the roles of Sirt1 in LPS-induced HK-2 cell injury and activation of phosphatidylinositol 3-kinase/protein kinase 3 (PI3K/AKT) and nuclear factor kappa B (NF-κB) pathways were explored.

RESULTS

LPS administration inhibited HK-2 cell viability and proliferation, increased expression of pro-inflammatory factors, and promoted cell apoptosis. TUG1 overexpression protected HK-2 cells against LPS-induced injury via negatively regulating miR-223 expression. TUG1 suppression had opposite effects. Sirt1 was a direct target gene of miR-223 in HK-2 cells, which participated in the effects of miR-223 on HK-2 cells and was related with the activation of PI3K/AKT and NF-κB pathways.

CONCLUSION

TUG1 protected HK-2 cells against LPS-induced inflammatory injury by regulating miR-223 and Sirt1 expression, and then activating PI3K/AKT and inactivating NF-κB pathways. TUG1 might be a potential therapeutic target for LN treatment.

Secondary Sjögren syndrome: A case report using silver diamine fluoride and glass ionomer cement

BACKGROUND AND OVERVIEW

The authors describe dental treatment for a patient with a complex medical history of secondary Sjögren syndrome with systemic lupus erythematosus and rheumatoid arthritis.

CASE DESCRIPTION

An 18-year-old woman's rheumatology group referred her for oral evaluation; she had secondary Sjögren syndrome, systemic lupus erythematosus, and rheumatoid arthritis. The patient had multiple advanced carious lesions, extreme sensitivity, and hyposalivation. The patient selected a minimally invasive treatment plan that focused on silver diamine fluoride (SDF), partial caries removal, and glass ionomer cement (GIC) restorations. The SDF treatment and GIC restorations were successful in arresting carious lesions and restoring form and function but may not completely prevent new carious lesions from forming in the future.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The case shows that using less invasive treatments, such as SDF and GIC restorations can be used to manage complex cases involving extreme caries risk and be preferable to endodontic treatment and extractions.

Novel gene variants associated with cardiovascular disease in systemic lupus erythematosus and rheumatoid arthritis

Objectives

Patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) have increased risk of cardiovascular disease (CVD). We investigated whether single nucleotide polymorphisms (SNPs) at autoimmunity risk loci were associated with CVD in SLE and RA.

Methods

Patients with SLE (n=1045) were genotyped using the 200K Immunochip SNP array (Illumina). The allele frequency was compared between patients with and without different manifestations of CVD. Results were replicated in a second SLE cohort (n=1043) and in an RA cohort (n=824). We analysed publicly available genetic data from general population, performed electrophoretic mobility shift assays and measured cytokine levels and occurrence of antiphospholipid antibodies (aPLs).

Results

We identified two new putative risk loci associated with increased risk for CVD in two SLE populations, which remained after adjustment for traditional CVD risk factors. An IL19 risk allele, rs17581834(T) was associated with stroke/myocardial infarction (MI) in SLE (OR 2.3 (1.5 to 3.4), P=8.5×10⁻⁵) and RA (OR 2.8 (1.4 to 5.6), P=3.8×10⁻³), meta-analysis (OR 2.5 (2.0 to 2.9), P=3.5×10⁻⁷), but not in population controls. The IL19 risk allele affected protein binding, and SLE patients with the risk allele had increased levels of plasma-IL10 (P=0.004) and aPL (P=0.01). An SRP54-AS1 risk allele, rs799454(G) was associated with stroke/transient ischaemic attack in SLE (OR 1.7 (1.3 to 2.2), P=2.5×10⁻⁵) but not in RA. The SRP54-AS1 risk allele is an expression quantitative trait locus for four genes.

Conclusions

The IL19 risk allele was associated with stroke/MI in SLE and RA, but not in the general population, indicating that shared immune pathways may be involved in the CVD pathogenesis in inflammatory rheumatic diseases.

Protective Effects of Hydroxychloroquine against Accelerated Atherosclerosis in Systemic Lupus Erythematosus

Cardiovascular (CV) morbidity and mortality are a challenge in management of patients with systemic lupus erythematosus (SLE). Higher risk of CV disease in SLE patients is mostly related to accelerated atherosclerosis. Nevertheless, high prevalence of traditional cardiovascular risk factors in SLE patients does not fully explain the increased CV risk. Despite the pathological bases of accelerated atherosclerosis are not fully understood, it is thought that this process is driven by the complex interplay between SLE and atherosclerosis pathogenesis. Hydroxychloroquine (HCQ) is a cornerstone in treatment of SLE patients and has been thought to exert a broad spectrum of beneficial effects on disease activity, prevention of damage accrual, and mortality. Furthermore, HCQ is thought to protect against accelerated atherosclerosis targeting toll-like receptor signaling, cytokine production, T-cell and monocyte activation, oxidative stress, and endothelial dysfunction. HCQ was also described to have beneficial effects on traditional CV risk factors, such as dyslipidemia and diabetes. In conclusion, despite lacking randomized controlled trials unambiguously proving the protection of HCQ against accelerated atherosclerosis and incidence of CV events in SLE patients, evidence analyzed in this review is in favor of its beneficial effect.

Atherosclerotic Heart Disease in Women With Autoimmune Rheumatologic Inflammatory Conditions

Women have a higher prevalence of several inflammatory rheumatologic conditions. These include systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and systemic sclerosis (SSc) to name a few. These conditions are all associated with higher rates of cardiovascular (CV) morbidity and mortality, which is driven primarily by atherosclerotic heart disease. Traditional risk factors are important considerations in the assessment of CV risk in the rheumatologic patient; however, these factors do not appear to impart a similar weight of risk in women with inflammatory autoimmune rheumatologic conditions. In addition, even when controlling for traditional risk factors, patients with RA or SLE continue to have a higher risk of CV events, which has been linked to the burden of systemic inflammation. Currently, the CV risk scoring systems available for the general population underestimate the burden of the problem in these complex patients. The increased CV risk in patients with rheumatologic diseases has been reported in the literature for years but remains underrecognized by internists and cardiologists. Although these conditions themselves are relatively rare, the further study of inflammation and its treatment in CV disease will be beneficial to the general population.

Lupus nephritis with preserved kidney function associated with poorer cardiovascular risk control: A call for more awareness

BACKGROUND

Despite the improvement in the prognosis of lupus nephritis (LN), the cardiovascular morbimortality remains high. The early recognition and remission of flares, while trying to avoid the metabolic adverse effects of medication, must be mandatory.

AIM

The aim of our study was to assess the cardiovascular (CV) risk profile in a cohort of lupus patients with preserved kidney function after a nephritis episode, compared to patients without a nephritis flare.

METHODS

130 patients diagnosed of SLE (32 with previous nephritis flare and 98 without) were studied in order to evaluate the CV risk profile, despite the preserved kidney function.

RESULTS

The most prevalent risk factors were sedentary lifestyle (57.6%), overweight/obesity (38.3%) and dyslipidemia (36%), followed by smoking (32%) and hypertension (16%). Though more than a half (53.1%) was taking CV medication, a high percentage did not reach a therapeutic target value, especially regarding obesity (11.5%) and cholesterol levels (LDL-C of 16%). The prevalence of dyslipidemia (53.1% vs 30.6%), smoking (46.6% vs 27.5%), left ventricular hypertrophy (LVH) (21.4% vs 6.4%) and lower HDL-C (48.6mg/dL vs 55.4mg/dL) were significantly different in the group with previous nephritis flare. Moreover, young patients with lupus nephritis, received more pulses of corticosteroids and cyclophosphamide, had higher prevalence of hypertension, LVH, higher proteinuria, hospital admissions and waist circumference, constituting the subgroup of patients with greater aggregation of CV risk factors.

CONCLUSIONS

Patients with previous nephritis flare showed a poor control of CV risk factors despite the preserved renal function, these patients would require a closer therapeutic management.

Assessment of subclinical atherosclerosis in systemic lupus erythematosus: A systematic review and meta-analysis

OBJECTIVES

To determine whether subclinical atherosclerosis is increased in patients with systemic lupus erythematosus (SLE) compared to healthy individuals, using carotid intima-media thickness (CIMT), carotid plaque (CP) presence or flow-mediated dilatation (FMD).

METHODS

A systematic literature search was performed using MedLine, Embase and Cochrane databases. Two reviewers independently screened the articles to identify studies that compared the rates of atherosclerosis in SLE patients versus healthy controls. The results were pooled in a meta-analysis. Factors influencing the CIMT, CP or FMD results were collected.

RESULTS

Of the 203 articles initially identified, 68 were selected for the meta-analysis. Compared to healthy controls, SLE patients had a significantly increased CIMT (mean difference [MD] of 0.08mm, 95% CI [0.06-0.09], P<0.05), more CP (odds ratio 2.01, 95% CI [1.63-2.47], P<0.05) and decreased FMD (MD -3.96%, 95% CI [-5.37 to -2.54)], P<0.05). There was marked heterogeneity among the studies. However, the results of the meta-analysis that included only the CIMT per new international recommendations also showed an increased CIMT in SLE patients, but the heterogeneity was low (MD 0.04mm, 95% CI [0.02-0.06], P<0.05; I²=23%).

CONCLUSION

SLE patients exhibit increased subclinical atherosclerosis compared to healthy controls. CIMT is a promising measure for cardiovascular risk evaluations because non-invasive, non-radiation-based, reproducible. Thus, CIMT can be proposed as an alternative to the reliable CP evaluation and to FMD, which is influenced by independent factors such as smoking. Future studies should focus on reducing the heterogeneity of these measures using standardized procedures.

Cardiovascular disease in systemic lupus erythematosus: A comprehensive update

Heightened rates of both cardiovascular (CV) events and subclinical atherosclerosis, documented by imaging and vascular function techniques are well established in systemic lupus erythematosus (SLE). While traditional CV factors such as smoking, dyslipidemia, diabetes mellitus (DM), hypertension, central obesity and hyperhomocysteinemia have been reported to be prevalent in lupus patients, they do not fully explain the high rates of ischemic events so far reported, implying that other factors inherent to disease itself could account for the enhanced risk, including disease duration, activity and chronicity, psychosocial factors, medications, genetic variants and altered immunological mechanisms. Though the exact pathogenesis of atherosclerosis in the setting of lupus remains ill defined, an imbalance between endothelial damage and atheroprotection seems to be a central event. Insults leading to endothelial damage in the setting of lupus include oxidized low density lipoprotein (oxLDL), autoantibodies against endothelial cells and phospholipids, type I interferons (IFN) and neutrophil extracellular traps (NETs) directly or through activation of type I IFN pathway. Increased oxidative stress, reduced levels of the normally antioxidant high density lipoprotein (HDL), increased levels of proinflammatory HDL (piHDL) and reduced paraoxonase activity have been related to increased oxLDL levels. On the other hand, impaired atheroprotective mechanisms in lupus include decreased capacity of endothelial repair-partly mediated by type I IFN- and dampened production of atheroprotective autoantibodies. In the present review, traditional and disease related risk factors for CV disease (CVD) in the setting of chronic autoimmune disorders with special focus on SLE will be discussed.