Mortality and causes of death in systemic lupus erythematosus

Causes of mortality among inpatients with systemic lupus erythematosus in a tertiary care hospital in North India over a 10-year period

INTRODUCTION

Systemic lupus erythematosus (SLE) is a systemic autoimmune disorder with significant morbidity and mortality. The present study was undertaken to identify the causes of in-hospital mortality of patients with SLE.

METHODS

This was a retrospective study. The hospital records of patients with SLE who died between 1998 and 2007 were reviewed. Demographic details, organ involvement, treatment received and evidence of infection were recorded. Disease activity was calculated using the SLE Disease Activity Index. The cause of death of each patient was determined and this information was classified into either deaths caused primarily due to SLE, deaths caused due to infection or those that were multi-factorial.

RESULTS

Seventeen patients with SLE who were diagnosed according to the revised American College of Rheumatology criteria died between 1998 and 2007. Fifteen of these patients were female and two were male. The median age was 25 years. The average duration of hospital stay was 10.29 days. Seven patients (41%) died of active SLE (three from pulmonary hemorrhage, two had renal failure, one had myocarditis and one had severe thrombocytopenia with upper gastrointestinal bleed), three patients (18%) died from infections (one contracted Staphylococcal septicemia, another contracted tuberculous meningitis and the third patient had Pseudomonas septicemia) and in seven patients (41%) the etiology was multi-factorial (these showed both active SLE and evidence of infection). In total 10 patients had evidence of infection, two of these were community-acquired and the rest were hospital-acquired.

CONCLUSION

Active SLE and/or infection are the major causes of death in hospitalised patients with SLE. To reduce patient mortality improvements in supportive care for patients with active SLE and measures to prevent hospital-acquired infections are required.

Accelerated atherosclerosis in SLE: mechanisms and prevention approaches

Systemic lupus erythematosus (SLE) is a multi-organ autoimmune disease characterized by increased serum autoantibody levels and tissue damage. With improved diagnosis and more effective treatment of the resultant kidney disease, accelerated atherosclerosis has become a major cause of morbidity in patients suffering from SLE. Although the exact mechanisms for SLE-accelerated atherosclerosis are unknown, multiple factors have been established as potential players in this process. Among these potential players are dysregulation of T and B cell populations and increased circulating levels of inflammatory cytokines. In addition, SLE patients exhibit a proatherogenic lipid profile characterized by low HDL and high LDL and triglycerides. Recent therapeutic approaches have focused on targeting B cells, the producers of autoantibodies, but most studies do not consider the effects of these treatments on atherosclerosis. Evidence suggests that T cells play a major role in SLE-accelerated atherosclerosis. Therefore, therapies targeted at T cells may also prove invaluable in treating SLE and atherosclerosis.

Systemic lupus erythematosus in an African Caribbean population: incidence, clinical manifestations, and survival in the Barbados National Lupus Registry

OBJECTIVE

To assess the epidemiology, clinical features, and outcomes of systemic lupus erythematosus (SLE) in the predominantly African Caribbean population of Barbados.

METHODS

A national registry of all patients diagnosed with SLE was established in 2007. Complete case ascertainment was facilitated by collaboration with the island's sole rheumatology service, medical practitioners, and the lupus advocacy group. Informed consent was required for inclusion.

RESULTS

Between January 1, 2000 and December 31, 2009, there were 183 new cases of SLE (98% African Caribbean) affecting 172 women and 11 men for unadjusted annual incidence rates of 12.21 (95% confidence interval [95% CI] 10.46-14.18) and 0.84 (95% CI 0.42-1.51) per 100,000 person-years, respectively. Excluding pediatric cases (ages <18 years), the unadjusted incidence rate among women was 15.14 per 100,000 person-years. The principal presenting manifestations were arthritis (84%), nephritis (47%), pleuritis (41.5%), malar rash (36.4%), and discoid lesions (33.1%). Antinuclear antibody positivity was 95%. The overall 5-year survival rate was 79.9% (95% CI 69.6-87.1), decreasing to 68% in patients with nephritis. A total of 226 persons with SLE were alive at the end of the study for point prevalences of 152.6 (95% CI 132.8-174.5) and 10.1 (95% CI 5.4-17.2) per 100,000 among women and men, respectively.

CONCLUSION

Rates of SLE in Barbadian women are among the highest reported to date, with clinical manifestations similar to African American women and high mortality. Further study of this population and similar populations of West African descent might assist our understanding of environmental, genetic, and health care issues underpinning disparities in SLE.

Epicardial adipose tissue is increased in patients with systemic lupus erythematosus

OBJECTIVE

Morbidity and mortality secondary to premature cardiovascular disease (CVD) in systemic lupus erythematosus (SLE) remain significant issues. The pathogenesis of CVD in SLE patients has not been fully explored. Epicardial adipose tissue (EAT) is believed to contribute to atherosclerosis development, through a paracrine and systemic inflammatory effect. We measured EAT volume in 162 SLE patients and 86 matched controls to assess the association of EAT with markers of atherosclerosis, cardiovascular risk and immunoactivation.

METHODS

Clinical and laboratory characteristics collected included anthropomorphic measures, disease activity and damage indices, blood pressure measurement, lipid profile, inflammatory indices, adipokine levels and measures of adiposity. Coronary artery calcium (CAC) and EAT volume were measured using non-contrast cardiac computed tomography.

RESULTS

EAT volume was greater in patients with SLE [(mean ± SD) 96.8 ± 45.9 cm(3)] than controls (78.2 ± 40.7 cm(3); P = 0.001). The EAT volume was 31% larger (95% CI, 16.5%-47.4%) in SLE patients than controls (P < 0.001 adjusted for age, sex, and race; after additional adjustment for waist circumference P = 0.007). Within SLE patients, after adjusting for age, race, sex, and waist circumference, EAT volume was associated with cumulative corticosteroid dose (P = 0.007), current corticosteroid use (P < 0.001), HDL cholesterol (P = 0.033), and triglycerides (P = 0.005). EAT was significantly correlated with CAC score (P < 0.001), but the association was attenuated after adjustment for Framingham risk score (P = 0.051).

CONCLUSION

The increased EAT volume seen in SLE patients is associated with corticosteroid use. Corticosteroids could have adverse cardiovascular effects in SLE via an increase in EAT volume, a marker of risk in the general population.

Male versus female lupus: a comparison of ethnicity, clinical features, serology and outcome over a 30 year period

Objective: To review the differences between male and female lupus patients with respect to clinical features, serology and outcome over a thirty year period. Material and methods: An observational study of all SLE patients seen at University College of London Hospital between 1976 and 2005 was performed. Demographic, clinical and serological data and outcome were retrospectively collected from hospital records or questionnaires and reviewed. Comparisons between continuous variables were made using the Kruskal–Wallis test and Student’s t-test. Chi-square test or Fisher´s exact test were used for categorical variables when it was appropriate. Results: A total of 484 patients (439 females and 45 males) were identified between 1976 and 2005. Their mean age at diagnosis was 29.3 years (SD 12.6) with no significant differences between men and women. There were no significant differences between the number of men and women diagnosed over the different decades or in the mean age at diagnosis. Female gender was significantly associated with the presence of oral ulcers (29.2% vs. 13.3%, p < 0.05) and Ig M ACA (9.9% vs. 0%, p < 0.05). There were no significant differences in the comparison of other variables. With respect to outcome, although renal failure and death were higher in females (6.8% vs. 4.4% and 13.2% vs. 6.6% respectively), no statistically significant differences were found. Cardiovascular disease was the commonest cause of death in men. Conclusion: Over this thirty year follow-up period, relatively few differences have emerged comparing the frequencies of clinical and serological features or outcome in male and female lupus patients.

Emerging therapies for systemic lupus erythematosus--focus on targeting interferon-alpha

Current therapies for systemic lupus erythematosus (SLE), a debilitating, potentially lethal, multifactorial systemic autoimmune disease, are limited to suppressing disease activity and are associated with multiple adverse effects. Recent advances in basic and translational sciences have elucidated a crucial role for the interferon-alpha (IFNα) pathway in the pathogenesis of this enigmatic disease. The so-called "type I interferon signature" has emerged as a major risk factor for disease activity of SLE. Multiple genes encoding for molecules within the type I interferon pathway have been associated with SLE in genome wide association studies. In addition, innate immune receptors are thought to be triggered by either endogenous and/or exogenous stimuli that lead to hypersecretion of IFNα. We review the multiple emerging treatment strategies targeting IFNα-related pathways. These include monoclonal antibodies against IFNα, anti-IFNα antibody-inducing vaccines, and inhibitors of Toll-like receptors. We also summarize the current status of these pharmaceutical agents in early clinical trials.

Biological therapy in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a prototypic inflammatory autoimmune disorder characterized by multisystem involvement and fluctuating disease activity. Symptoms range from rather mild manifestations such as rash or arthritis to life-threatening end-organ manifestations. Despite new and improved therapy having positively impacted the prognosis of SLE, a subgroup of patients do not respond to conventional therapy. Moreover, the risk of fatal outcomes and the damaging side effects of immunosuppressive therapies in SLE call for an improvement in the current therapeutic management. New therapeutic approaches are focused on B-cell targets, T-cell downregulation and costimulatory blockade, cytokine inhibition, and the modulation of complement. Several biological agents have been developed, but this encouraging news is associated with several disappointments in trials and provide a timely moment to reflect on biologic therapy in SLE.

Measuring outcomes in systemic lupus erythematosus clinical trials

The recent approval of the biologic therapy, belimumab, for treatment of systemic lupus erythematosus (SLE) by the US FDA has shifted the developmental landscape of therapeutics for this autoimmune disease. Promising therapies are currently in development for the treatment of SLE, with trials designed to emphasize clinically relevant end points. This article will discuss outcome measures that have been utilized including disease activity indices, definitions of flare, measures of damage, global assessments of disease activity and measures of health-related quality of life. Application of these outcome measures in recent trials are highlighted as illustrative examples. Contributions to the recent success of randomized controlled trials in SLE have included use of evidence-based responder indices, clear definitions of treatment failure, predefined management strategies for use of immunosuppressive agents and corticosteroids, sufficient sample sizes and efforts to identify responsive patient populations. Each completed study in SLE promises to better inform trial design and offer further opportunities for success in a field with a continuing unmet therapeutic need.

The problem of accelerated atherosclerosis in systemic lupus erythematosus: insights into a complex co-morbidity

Rheumatic autoimmune diseases, such as rheumatoid arthritis and systemic lupus erythematosus (SLE), are associated with antibodies to "self" antigens. Persons with autoimmune diseases, most notably SLE, are at increased risk for developing accelerated cardiovascular disease. The link between immune and inflammatory responses in the pathogenesis of cardiovascular disease has been firmly established; yet, despite our increasing knowledge, accelerated atherosclerosis continues to be a significant co-morbidity and cause of mortality in SLE. Recent animal models have been generated in order to identify mechanism(s) behind SLE-accelerated atherosclerosis. In addition, clinical studies have been designed to examine potential treatments options. This review will highlight data from recent studies of immunity in SLE and atherosclerosis and discuss the potential implications of these investigations.

Social support and health in patients with systemic lupus erythematosus: A literature review

In the last decades, with the improvement of life expectancies for systemic lupus erythematosus (SLE) patients, the relationship between social support and health in this population has received a considerable amount of attention in behavioural medicine and health psychology. This paper is the first to review research studies which specifically investigated perceived social support in relation to SLE patients’ health outcomes (quality of life, disease activity and damage). Starting with a descriptive approach to social support perceived by patients with SLE, the research evidence on the impact of social support on health is presented. These studies demonstrate that the consideration of social support is critical in predicting disease activity, damage and quality of life (both physical and psychological components) although the precise ways in which social support contributes to health are not yet completely understood. Discussing the results, the authors offer some suggestions which could guide further research in this field. Finally, clinical and non-clinical implications of the findings are discussed.

Mycophenolate mofetil in the treatment of lupus nephritis

Lupus nephritis is a complication of systemic lupus erythematosus, which has significant morbidity and mortality. The accepted standard of treatment for severe lupus nephritis is cyclophosphamide for induction of remission. This has significant adverse effects including severe infection and amenorrhea. In addition, although cyclophosphamide induces remission, long-term mortality does not seem to be altered. Mycophenolate mofetil (MMF) is an immunosuppressive agent originally used in solid organ transplantation, which has been compared with cyclophosphamide in trials for lupus nephritis. Randomized trials with MMF have been relatively small, although pooled data seem to suggest that it is at least as effective as cyclophosphamide in inducing remission. In addition, MMF has also been associated with a reduced risk of infection and amenorrhea, although this finding is not universal. MMF appears to be associated with more diarrhea compared with cyclophosphamide. MMF is likely to be a useful treatment for lupus nephritis, although available trial data are limited due to the small size of previous studies. A large trial (the Aspreva Lupus Management Study) is currently underway to attempt to establish the place of MMF in treatment of lupus nephritis.

Damage accrual, cumulative glucocorticoid dose and depression predict anxiety in patients with systemic lupus erythematosus

The burden of anxiety in patients with systemic lupus erythematosus (SLE) compared to those with other inflammatory rheumatological conditions is unclear. We aimed to compare the frequency and level of anxiety between patients with SLE, rheumatoid arthritis (RA), and gout and healthy individuals and explore independent predictors for anxiety in SLE patients. Consecutive patients with SLE, RA and gout and healthy individuals who were age and sex matched with the SLE group were evaluated for anxiety using the Hospital Anxiety and Depression Scale (HADS). Sociodemographic and disease-related variables were compared between all groups. Predictors for anxiety were studied by regression models, with construction of a prediction model for the presence of anxiety in SLE patients by the receiver operating characteristic (ROC) analysis. Amongst 271 subjects studied, 60 had lupus, 50 had gout, 100 had RA and 61 were healthy controls. The frequency and level of anxiety were significantly higher in SLE patients than patients with gout, RA and healthy controls. SLE per se was independently associated with higher HADS-anxiety score after controlling for potential confounders. Logistic regression model showed that higher damage accrual, higher cumulative glucocorticoid dose, depression and fewer regular medications predicted anxiety in SLE patients, with an accuracy of 90% by the ROC analysis.

Lupus organ damage: what is damaged in Asian patients?

Assessment of organ damage has become the standard outcome measure for morbidity and mortality in patients with lupus. Ethnicity is thought to be a marker for genetic, environmental, behavioral, and other variables that may affect disease outcomes. Previous studies suggest that Asians residing in western countries had significantly higher prevalence of damage compared with Whites. In contrast, studies performed in Chinese, Korean and Arab patients showed that the overall prevalence of damage and the most commonly involved organs (neuropsychiatric and musculoskeletal) were similar to Whites. Compared with their Asian counterparts, Pakistani and Jewish patients appeared to have a higher prevalence of damage, most likely secondary to longer disease duration. Chinese patients had an increased prevalence of premature gonadal failure, whereas patients residing in western and southern Asia had more skin damage. When compared with Whites, Asian patients had more renal damage but less ocular and cardiovascular damage. Risk factors associated with organ damage in Asian lupus patients included older age, higher disease activity, and the use of cyclophosphamide and steroids. Further investigations into other determinants such as genetic predisposition, socioeconomic factors, prevalence and severity of disease manifestations, and treatment, is needed in order to understand the variation in damage accrual in lupus patients from different ethnicities.

New and emerging treatment approaches to lupus

The main goal in systemic lupus erythematosus (SLE) is to achieve remission, as this has a major impact on patient and renal survival. Furthermore, early treatment success has been shown to improve long-term prognosis. Treatment in severe SLE, especially in lupus nephritis, has traditionally been a standardized schematic therapy with cyclophosphamide and prednisolone followed by azathioprine. However, animal and human studies have increased our pathogenetic knowledge of this autoimmune disease with emerging new treatment targets. New and future therapeutic approaches are focused on B-cell depletion, T-cell downregulation and co-stimulatory blockade, cytokine inhibition, or the modulation of complement. Many different biological agents have been used in recent and ongoing studies, but up to now breakthroughs emerging from randomized Phase III trials have been rare. However, the future remains exciting with progress towards safe treatments with which to control the disease in the long run.

Factors predictive of thrombotic events in LUMINA, a multi-ethnic cohort of SLE patients (LXXII)

OBJECTIVE

Thrombosis is an important cause of morbidity and mortality in SLE. We have explored the factors associated with time to the occurrence of thrombotic events in SLE patients to expand our cohort's previous observations.

METHOD

SLE patients (ACR criteria), age >or=16 years, disease duration

RESULTS

A total of 643 patients were studied; mean (s.d.) age was 36.4 (12.6) years and disease duration at T0 was 1.4 (1.3) years; 90% were female. After T0, 81 (12.6%) patients had developed a thrombotic event. In the MV model, age [hazard ratio (HR) = 1.06; 95% CI 1.03, 1.08; P < 0.0001], health insurance (HR = 0.53; 95% CI 0.30, 0.94; P = 0.029), smoking (HR = 1.85; 95% CI 1.01, 3.40; P = 0.048), damage (T0) (HR = 1.44; 95% CI 1.20, 1.71; P < 0.0001), aPL (HR = 2.12; 95% CI 1.19, 3.76; P = 0.011) and glucocorticoid (highest dose) (HR = 1.01; 95% CI 1.01, 1.02; P < 0.0001) were significant.

CONCLUSIONS

Age, poverty, smoking, damage accrual, aPL and higher doses of glucocorticoids were independently associated with a shorter time to the first thrombotic event; health insurance had a protective effect. Acting upon modifiable risk factors at the personal (smoking, high-dose glucocorticoids) and societal (poverty, health insurance) levels may prevent these events and improve the long-term outcome of SLE patients.

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Key Words

• systemic lupus erythematosus
• thrombotic events
• risk factors

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MESH Headings

• Adult
• Black or African American
• Female
• Hispanic or Latino
• Humans
• Longitudinal Studies
• Lupus Erythematosus, Systemic/complications
• Lupus Erythematosus, Systemic/ethnology
• Lupus Erythematosus, Systemic/mortality
• Male
• Middle Aged
• Proportional Hazards Models
• Risk Factors
• Severity of Illness Index
• Socioeconomic Factors
• Thrombosis/ethnology
• Thrombosis/etiology
• Thrombosis/mortality
• United States
• White People
• Young Adult

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Grants

• P20 RR011126 NCRR NIH HHS
• P01 AR049084 NIAMS NIH HHS
• M01-RR00032 NCRR NIH HHS
• P01 AR49084 NIAMS NIH HHS
• M01-RR02558 NCRR NIH HHS
• M01 RR002558 NCRR NIH HHS
• 1P20RR11126 NCRR NIH HHS
• M01 RR000032 NCRR NIH HHS

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Affiliation(s)

Paula I. Burgos Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA, Department of Clinical Immunology and Rheumatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Department of Surgery, Department of Epidemiology, Schools of Medicine and Public Health, University of Alabama at Birmingham, Birmingham, AL, Department of Medicine, Division of Rheumatology, University of Texas Health Science Center at Houston, Houston, TX, USA and Department of Medicine, Division of Rheumatology, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
Gerald McGwin Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA, Department of Clinical Immunology and Rheumatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Department of Surgery, Department of Epidemiology, Schools of Medicine and Public Health, University of Alabama at Birmingham, Birmingham, AL, Department of Medicine, Division of Rheumatology, University of Texas Health Science Center at Houston, Houston, TX, USA and Department of Medicine, Division of Rheumatology, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
John D. Reveille Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA, Department of Clinical Immunology and Rheumatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Department of Surgery, Department of Epidemiology, Schools of Medicine and Public Health, University of Alabama at Birmingham, Birmingham, AL, Department of Medicine, Division of Rheumatology, University of Texas Health Science Center at Houston, Houston, TX, USA and Department of Medicine, Division of Rheumatology, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
Luis M. Vilá Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA, Department of Clinical Immunology and Rheumatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Department of Surgery, Department of Epidemiology, Schools of Medicine and Public Health, University of Alabama at Birmingham, Birmingham, AL, Department of Medicine, Division of Rheumatology, University of Texas Health Science Center at Houston, Houston, TX, USA and Department of Medicine, Division of Rheumatology, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
Graciela S. Alarcón Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA, Department of Clinical Immunology and Rheumatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Department of Surgery, Department of Epidemiology, Schools of Medicine and Public Health, University of Alabama at Birmingham, Birmingham, AL, Department of Medicine, Division of Rheumatology, University of Texas Health Science Center at Houston, Houston, TX, USA and Department of Medicine, Division of Rheumatology, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico

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Childhood-onset disease as a predictor of mortality in an adult cohort of patients with systemic lupus erythematosus

OBJECTIVE

To examine childhood-onset disease as a predictor of mortality in a cohort of adult patients with systemic lupus erythematosus (SLE).

METHODS

Data were derived from the University of California Lupus Outcomes Study, a longitudinal cohort of 957 adult subjects with SLE that includes 98 subjects with childhood-onset SLE. Baseline and followup data were obtained via telephone interviews conducted in 2002-2007. The number of deaths during 5 years of followup was determined and standardized mortality ratios (SMRs) for the cohort, and across age groups, were calculated. Kaplan-Meier life table analysis was used to compare mortality rates between childhood- (defined as SLE diagnosis at <18 years of age) and adult-onset SLE. Multivariate Cox proportional hazard models were used to determine predictors of mortality.

RESULTS

During the median followup period of 48 months, 72 deaths (7.5% of subjects) occurred, including 9 deaths (12.5%) in subjects with childhood-onset SLE. The overall SMR was 2.5 (95% confidence interval [95% CI] 2.0-3.2). In Kaplan-Meier survival analysis, after adjusting for age, childhood-onset subjects were at increased risk for mortality throughout the followup period (P< 0.0001). In a multivariate model adjusting for age, disease duration, and other covariates, childhood-onset SLE was independently associated with an increased mortality risk (hazard ratio [HR] 3.1, 95% CI 1.3-7.3), as was low socioeconomic status measured by education (HR 1.9, 95% CI 1.1-3.2), and end stage renal disease (HR 2.1, 95% CI 1.1-4.0).

CONCLUSION

Childhood-onset SLE was a strong predictor of mortality in this cohort. Interventions are needed to prevent early mortality in this population.

Systemic Lupus Erythematosus, Rheumatoid Arthritis, and Postarthroplasty Mortality: A Cross-sectional Analysis from the Nationwide Inpatient Sample

Objective.

Systemic lupus erythematosus (SLE) is a disease of considerable morbidity, and this may place patients at greater risk for poor in-hospital postoperative outcomes for procedures such as arthroplasty. Our aim was to test this hypothesis.

Methods.

We compared the in-hospital postoperative mortality risk for patients with SLE undergoing hip and knee arthroplasty to those with rheumatoid arthritis (RA) and the general population without either condition, using data from the Nationwide Inpatient Sample (1993–2006). We performed parallel, weighted, multivariable logistic regressions to calculate mortality risk stratified by joint site, type of admission, hospital type, income category, race, length of stay, surgical indication, and medical comorbidities.

Results.

The unadjusted mortality rates (per 1000 procedures) for patients with SLE, patients with RA, and controls were 7.4, 3.0, and 6.5, respectively, for nonelective procedures and 2.4, 1.3, and 1.8 for elective procedures. After adjustment for potential confounders, patients with SLE had an OR of 4.0 (95% CI 1.9–8.0) for postoperative mortality with hip replacements and an OR of 1.2 (95% CI 0.2–7.5) for mortality with knee replacements. Mortality risk of patients with RA was not different from that of controls. The adjusted risk estimates for those who underwent arthroplasty before and after 2002 and those who underwent surgery for nonfracture indications were similar.

Conclusion.

Arthroplasty, especially of hips, in patients with SLE is associated with relatively higher postoperative mortality risk.

Prevalence of community-acquired and nosocomial infections in hospitalized patients with systemic lupus erythematosus

Infections are an important cause of morbidity and mortality in systemic lupus erythematosus. We aimed to determine the incidence and characteristics of infections in patients hospitalized because of systemic lupus erythematosus, and to identify which factors influence their outcome. The medical records of patients with systemic lupus erythematosus hospitalized between January 2002 and December 2007 were reviewed according to a standardized case form including demographic, clinical, and therapeutic data. The diagnosis of infection was based on clinical findings, the identification of the causative agent or response to antibiotic treatment. The study included 473 patients (mean age 30 +/- 11 years; 421 (89%) female) who were hospitalized for a mean of 13 +/- 9 days. A community-based infection was suspected in 268 (57%) at admission; the diagnosis was confirmed in 96 patients (22%) and ruled out in 20 (4.2%); nevertheless, 152 patients (32%) received antibiotics on an empirical basis. A nosocomial infection was suspected in 63 (13.3%) of 453 patients and was confirmed in 59 (12.5%). The two most common community-acquired and nosocomial infections affected the respiratory and genitourinary tracts. Gram-negative bacteria were major etiological agents isolated. In the multivariate analysis, community-based infections associated with mucocutaneous, renal, or central nervous system disease activity as well as fever, and Mex-SLEDAI at admission and nosocomial infections to azathioprine use, infection at admission, disease duration, and hospitalization >7 days. We conclude that infections are an important cause of hospitalization of systemic lupus erythematosus patients. Risk factors include disease activity, use of immunosuppressants, disease duration, and length of hospital stay.

The socioeconomic burden of SLE

Systemic lupus erythematosus (SLE) is a chronic, relapsing-remitting, multisystemic autoimmune inflammatory disorder that predominantly affects women of childbearing age. Much has been written about the clinical course and long-term damage associated with SLE, as well as the reduced life expectancy of patients with this condition. In addition, studies have emphasized the socioeconomic and psychosocial impact of SLE, although the monetary cost of caring for patients with the disorder has only been evaluated in a modest number of studies and a restricted number of countries. SLE has a negative impact on quality of life and is associated with high health-care costs and significant productivity loss. Factors associated with increased cost of SLE include long disease duration, high disease activity and damage, poor physical and mental health, and high education and employment levels. Similarly, high disease activity and damage, poor physical health, certain disease manifestations, as well as poor family and social support are associated with poor health-related quality of life outcomes. SLE incurs a great burden on both the patient and society. Long-term prospective studies should be encouraged to monitor the costs and psychosocial impact of this condition, and to better understand the factors that are associated with poor outcomes.

Apolipoprotein H promoter polymorphisms in relation to lupus and lupus-related phenotypes

OBJECTIVE

Sequence variation in gene promoters is often associated with disease risk. We tested the hypothesis that common promoter variation in the APOH gene (encoding for ss(2)-glycoprotein I) is associated with systemic lupus erythematosus (SLE) risk and SLE-related clinical phenotypes in a Caucasian cohort.

METHODS

We used a case-control design and genotyped 345 women with SLE and 454 healthy control women for 8 APOH promoter single-nucleotide polymorphisms (SNP; -1284C>G, -1219G>A, -1190G>C, -759A>G, -700C>A, -643T>C, -38G>A, and -32C>A).Association analyses were performed on single SNP and haplotypes. Haplotype analyses were performed using EH (Estimate Haplotype-frequencies) and Haploview programs. In vitro reporter gene assay was performed in COS-1 cells. Electrophoretic mobility shift assay (EMSA) was performed using HepG2 nuclear cells.

RESULTS

Overall haplotype distribution of the APOH promoter SNP was significantly different between cases and controls (p = 0.009). The -643C allele was found to be protective against carotid plaque formation (adjusted OR 0.37, p = 0.013) among patients with SLE. The -643C allele was associated with a ~2-fold decrease in promoter activity as compared to wild-type -643T allele (mean +/- standard deviation: 3.94 +/- 0.05 vs 6.99 +/- 0.68, p = 0.016). EMSA showed that the -643T>C SNP harbors a binding site for a nuclear factor. The -1219G>A SNP showed a significant association with the risk of lupus nephritis (age-adjusted OR 0.36, p = 0.016).

CONCLUSION

Our data indicate that APOH promoter variants may be involved in the etiology of SLE, especially the risk for autoimmune-mediated cardiovascular disease.

Poor outcomes after acute myocardial infarction in systemic lupus erythematosus

OBJECTIVE

Systemic lupus erythematosus (SLE) is associated with higher risk for acute myocardial infarction (MI); but the post-infarction outcomes among these patients are unknown. Our objective was to compare post-acute MI outcomes in patients with SLE to those with diabetes mellitus (DM) and those with neither condition.

METHODS

We analyzed the risk for prolonged hospitalization and in-hospital mortality following acute MI in the 1993-2002 US Nationwide Inpatient Sample. We used logistic regression to calculate odds ratios (OR) for prolonged hospitalization and Cox proportional hazards regression to calculate hazard ratios (HR) for in-hospital mortality with and without adjustments for age, sex, race/ethnicity, socioeconomic status, and presence of congestive heart failure.

RESULTS

For the SLE (n = 2192), DM (n = 236,016), SLE/DM (n = 474), and control (n = 667,956) groups, the in-hospital mortality rates were 8.3%, 6.2%, 5.7%, and 4.7%, respectively. In multivariable regression models, all 3 disease groups had higher adverse outcome risk compared to control. The OR for prolonged hospitalization was higher for those with SLE (OR 1.48, 95% CI 1.32-1.79) compared to those with DM (OR 1.30, 95% CI 1.28-1.32). A similar pattern was observed for hazard ratios for in-hospital mortality as well (SLE, HR 1.65, 95% CI 1.33-2.04; DM, HR 1.11, 95% CI 1.07-1.14).

CONCLUSION

SLE, like DM, increases risk of poor outcomes after acute MI. These patients need to be triaged appropriately for aggressive care.

Non-infectious lupus pericarditis: a retrospective hospital-based observation in Yaoundé-Cameroon

To determine the frequency of non-infectious lupus pericarditis in patients with systemic lupus erythematosus (SLE) seen in the Yaoundé Central and General Hospitals. A descriptive retrospective study was carried out in Rheumatology Units of Yaoundé Central and General Hospitals, from January 2001 to January 2004.

INCLUSION CRITERIA

patients fulfilling the American College of Rheumatology criteria for SLE and presenting with pericarditis. The study consisted of 22 female and one male SLE patients with a mean age of 26 years (range=13-65). Ten out of 23 patients (43%) presented pericarditis with a mean duration of illness before the diagnosis of pericarditis of 2 years. Pericardial rub was the commonest sign (seven cases), followed by dyspnea (six cases) and chest pain (six cases). The diagnosis of pericarditis was proven by echocardiography in all cases. Typical serological findings included anti-nuclear antibodies, anti-double-stranded DNA, and anti-Sm antibodies. Chest X-ray revealed cardiomegaly in all the patients. Electrocardiogram showed abnormal repolarization (seven patients) and low voltage QRS complexes (three cases). Treatment consisted of steroids administration. Four patients had relapse of pericarditis during subsequent lupus flares. This short series shows that non-infectious pericarditis is common in SLE patients in Africa.

Understanding the epidemiology and progression of systemic lupus erythematosus

OBJECTIVES

This review examines the burden and patterns of disease in systemic lupus erythematosus (SLE) and the influence and interactions of gender, ethnicity, age, and psychosocial attributes with respect to disease progression, focusing on issues relevant to clinical practice and research.

METHODS

PubMed literature search complemented by review of bibliographies listed in identified articles.

RESULTS

An increased risk among reproductive age women is clearly seen in African Americans in the United States. However, in other populations, a different pattern is generally seen, with the highest age-specific incidence rates occurring in women after age 40 years. The disease is 2 to 4 times more frequent, and more severe, among nonwhite populations around the world and tends to be more severe in men and in pediatric and late-onset lupus. SLE patients now experience a higher than 90% survival rate at 5 years. The less favorable survival experience of ethnic minorities is possibly related to socioeconomic status rather than to ethnicity per se, and adequate social support has been shown to be a protective factor, in general, in SLE patients. Discordance between physician and patient ratings of disease activity may affect quality of care.

CONCLUSIONS

Our understanding of ways to improve outcomes in SLE patients could benefit from patient-oriented research focusing on many dimensions of disease burden. Promising research initiatives include the inclusion of community-based patients in longitudinal studies, use of self-assessment tools for rating disease damage and activity, and a focus on self-perceived disease activity and treatment compliance.

Systemic lupus erythematosus features in rheumatoid arthritis and their effect on overall mortality

OBJECTIVE

Features of systemic lupus erythematosus (SLE) are commonly observed in patients with rheumatoid arthritis (RA). However, their frequency and clinical significance are uncertain. We examined the frequency of SLE features in RA and their effect on overall mortality.

METHODS

We assembled a population-based incidence cohort of subjects aged >or=18 years first diagnosed with RA [1987 American College of Rheumatology (ACR) criteria] between 1955 and 1995. Information regarding disease characteristics, therapy, comorbidities, and SLE features (1982 ACR criteria) were collected from the complete inpatient and outpatient medical records. Cox regression models were used to estimate the mortality risk associated with lupus features.

RESULTS

The study population comprised 603 subjects with incident RA (mean age 58 yrs, 73% women) with a mean followup time of 15 years. By 25 years after RA incidence, >or=4 SLE features were observed in 15.5% of the subjects with RA. After adjustment for age and sex, occurrence of >or=4 SLE features was associated with increased overall mortality [hazard ratio (HR) 5.54, 95% confidence interval (CI) 3.59-8.53].With further adjustment for RA characteristics, therapy, and comorbidities, the association weakened but remained statistically significant (HR 2.56, 95% CI 1.60-4.08). After adjustment for age, sex, RA characteristics, therapy, and comorbidities, thrombocytopenia (2.0, 95% CI 1.2, 3.1) and proteinuria (1.8, 95% CI 1.3, 2.6) were significantly associated with mortality.

CONCLUSION

SLE features were common in RA, given sufficient observation time. Subjects with RA who developed >or=4 SLE features had an increased risk of death. Proteinuria and thrombocytopenia were individually associated with an increased mortality risk.

Risk and protective factors for thrombosis in systemic lupus erythematosus: results from a large, multi-ethnic cohort

OBJECTIVES

Few studies have examined thrombosis in systemic lupus erythematosus (SLE), none have included Asian-Americans, and most have had small sample sizes. We analysed risk factors for thrombosis in a large, multi-ethnic SLE cohort.

METHODS

We studied 1930 SLE subjects, including Caucasians, African-Americans, Asian-Americans and Hispanics. Data were derived from questionnaires and medical records. Documented history of thrombosis was the primary outcome. Explanatory variables included age at SLE diagnosis, gender, ethnicity, disease duration, smoking, antiphospholipid antibody (aPL) status, nephritis and specific medications.

RESULTS

Smoking (OR 1.26, p = 0.011), longer disease duration (OR 1.26 per 5 years p = 0.027 x 10(-7)), nephritis (OR 1.35, p = 0.036), aPL positivity (OR 3.22, p<10(-9)) and immunomodulating medication use (OR 1.40, p = 0.011) were statistically significant risk factors for thrombosis. Younger age at SLE onset was protective (OR 0.52 for age </=20, p = 0.001). After adjusting for disease severity and incorporating propensity scores, hydroxychloroquine use remained significantly protective for thrombosis (OR 0.62, p = 4.91 x 10(-4)).

CONCLUSIONS

This study confirms that older age at onset, longer disease duration, smoking, aPL positivity, history of nephritis and immunomodulating medication use are risk factors for thrombosis in SLE. These data are the first to confirm in a large and ethnically diverse SLE cohort that hydroxychloroquine use is protective for thrombosis.

Two aspects of the clinical and humanistic burden of systemic lupus erythematosus: mortality risk and quality of life early in the course of disease

OBJECTIVE

To evaluate mortality risk and predictors among recently diagnosed systemic lupus erythematosus (SLE) patients.

METHODS

The vital status of 265 SLE patients and 355 controls enrolled in the Carolina Lupus Study (median time since diagnosis 13 months) was determined approximately 5 years after enrollment. We also assessed the utility of an 8-item quality of life instrument, derived from the standard 36-item Medical Outcomes Study Short Form 36, as an additional measure of disease impact.

RESULTS

Five years after diagnosis, 9.7% of patients compared with 0.3% of controls had died (P < 0.0001). Increased mortality risk was seen among older patients (adjusted hazard ratio [HR] 1.03, 95% confidence interval [95% CI] 1.01-1.06 per 1-year increment in age) and among men, African Americans, patients with lupus nephritis, and patients with anti-double-stranded DNA antibodies (adjusted HR approximately 2.0 for each of these factors). In addition, patients who did not provide a blood sample at study enrollment experienced increased mortality risk (age-, sex-, and race-adjusted HR 3.7, 95% CI 1.5-9.1). Similar results were seen in analyses limited to time from study enrollment. Physical component scores of the quality of life measure were 7.7 points lower (P < 0.0001) and mental component scores were 1.8 points lower (P = 0.07) in patients compared with controls.

CONCLUSION

The mortality risk among SLE patients is significant, particularly among African Americans, even early in the disease process and even with currently available treatments. Differences between cases and controls in health-related quality of life using the Short Form 8 also demonstrate the multidimensional burden of SLE.

Case report: disseminated dermatophytosis by microsporum gypseum in a systemic lupus erythematosus patient

Mycosis is a major contributor to morbidity and mortality in patients with systemic lupus erythematosus and frequent exposition to an infectious source could enhance the development of dermatophytic infections. A case of disseminated dermatophytosis by Microsporum gypseum is reported in a systemic lupus erythematosus (SLE) patient.

Adherence with advice and prescriptions in SLE is mostly good, but better follow up is needed: a study with a questionnaire

The objective was to evaluate the efficacy of the information policy given to all systemic lupus erythematosus (SLE) patients. One hundred consecutive SLE patients were asked to answer anonymously a questionnaire covering demographic issues including education, adherence with prescriptions and advice given and methods of sourcing information. Seventy-three females and ten males responded. The demographic data showed that 34 had a university education, 29 high school and 19 primary school education. An inability to work due to disease was increased compared with the matched population (P < 0.001). Forty-two reported that they had received advice about physical training and forty of them followed this advice. Only 28 out of 46 smokers reported that they had got any advice about smoking, and out of these only 13 followed the advice. The patients with university background were less likely to smoke (P < 0.05) and followed the advice more often (P < 0.05). Most patients followed given advice about exposure to sunlight. Thirty-five percent of those prescribed glucocorticoids reported that they varied from the prescribed dosages without consultation with their specialist. This behaviour was more common in the university group (P < 0.05), this grouping also had a higher median dosage. Seventy-three patients had read the booklet about SLE provided by the clinic. Accessing internet information was more common for those with university education (P < 0.01). This study shows that on the whole SLE patients follow given advice, but adherence varies. Aside from the issue of glucocorticoid dosage adherence, educational level seems to be the most important predictor for adherence to advice. Thus, we conclude that a more individualized approach to delivery of information is required and better follow up is needed.

[Systemic lupus erythematosus--activity and outcome]

Both clinically and scientifically, the variable organ manifestations of systemic lupus erythematosus (SLE) pose a particular challenge to rheumatologists. Validated scores for disease activity (BILAG, ECLAM, SIS, SLAM, SLEDAI), damage (SLICC/ACR damage index) and health-related quality of life (MOS SF-36) have been successfully used for years. New therapies, however, need to show improvement on outcome parameters for defined organ systems--and these are mostly ill-defined. For proliferative lupus nephritis, well designed studies have been available for years. However, these use very severe outcome parameters (renal failure, death), and therefore take at least 5 years for definitive results. Of the surrogate markers which were devised, none has proven reliable for determining outcome. The combination of shorter studies for defining hopeful strategies followed by long definitive studies, appears to be the best option at present.

Risk factors associated with the death of patients hospitalized for juvenile systemic lupus erythematosus

We assessed the risk factors associated with death in patients hospitalized for juvenile systemic lupus erythematosus (JSLE) and evaluated the autopsy reports. A total of 57,159 hospitalizations occurred in our institution from 1994 to 2003, 169 of them involving 71 patients with JSLE. The most recent hospitalization of these patients was evaluated. Patients were divided into two groups based on mortality during hospitalization: those who survived (N = 53) and those who died (N = 18). The main causes of hospitalization were JSLE activity associated with infection in 52% and isolated JSLE activity in 44%. Univariate analysis showed that a greater risk of death was due to severe sepsis (OR = 17.8, CI = 4.5-70.9), systemic lupus erythematosus disease activity index (SLEDAI) >or=8 (OR = 7.6, CI = 1.1-53.8), general infections (OR = 6.1, CI = 1.5-25), fungal infections (OR = 5.4, CI = 3.2-9), acute renal failure (OR = 5.1, CI = 2.5-10.4), acute thrombocytopenia (OR = 3.9, CI = 1.9-8.4), and bacterial infections (OR = 2.3, CI = 1.2-7.5). Stratified analysis showed that severe sepsis and SLEDAI >or=8 were not confounder variables. In the multivariate analysis, logistic regression showed that the only independent variable in death prediction was severe sepsis (OR = 98, CI = 16.3-586.2). Discordance between clinical diagnosis and autopsy was observed in 6/10 cases. Mortality of hospitalized JSLE patients was associated with severe sepsis. Autopsy was important to determine events not detected or doubtful in dead patients and should always be requested.

Systemic lupus erythematosus

Systemic lupus erythematosus is an autoimmune connective-tissue disorder with a wide range of clinical features, which predominantly affects women, especially from certain ethnic groups. Diagnosis is based on clinical assessment supported by investigations, including the finding of autoantibodies. Treatments range from antimalarial agents to corticosteroids and immunosuppressive agents. This Seminar draws attention to advances in the epidemiology, genetics, cardiovascular risks, lupus nephritis, CNS disease, the antiphospholipid syndrome, assessment of disease activity and damage, and pregnancy related and quality of life issues. New therapeutic approaches, such as biological agents and mycophenolate mofetil, will also be discussed.

Development of additional autoimmune diseases in a multiethnic cohort of patients with systemic lupus erythematosus with reference to damage and mortality

OBJECTIVES

To determine the prevalence of other autoimmune diseases (AID) in black, Caucasian and South Asian patients with systemic lupus erythematosus (SLE) compared with the prevalence of these AID in the UK population, and to assess the impact of these additional AID on damage scores and mortality.

METHODS

The prevalence and chronology of development of additional AID in SLE patients was determined by case note review. Comparisons were made with prevalence data for AID in the general UK population. The impact of additional AID on mortality and damage scores at up to 10 years was determined in the index cases (patients who developed another AID either in the same year or within 5 years of onset of SLE) compared with controls matched for sex, age, ethnicity and year of onset of SLE.

RESULTS

There was no significant difference in the total number of AID that developed in patients from each ethnic group but differences in the frequency of some AID were noted. Mortality and damage scores were worse at 5 years in the study cases than the controls, particularly in the peripheral vascular category.

CONCLUSION

Patients with SLE might develop other AID that could complicate management of SLE by having an adverse impact on damage scores and mortality.

Skin damage occurs early in systemic lupus erythematosus and independently of disease duration in Brazilian patients

To determine if skin damage is related to disease duration in Brazilian patients with SLE followed in a tertiary reference center through the application of standardized damage index (SLICC/ACR-DI). Sixty SLE patients were enrolled in this study. Relevant data were obtained through patients' interview, physical and laboratory examinations and review of the hospital records. The frequency and the different types of organ damage were determined using de SLICC/ACR-DI. Statistics were performed through chi-square and Student's t tests. Multivariate regression was used to correlate damage with disease duration. Forty-one (68.3%) patients presented any type of cumulative organ damage. The skin (35%), renal (23.3%) and neuropsychiatric (18.3%) systems were the most frequently involved, followed by peripheric vascular, ocular and cardiovascular systems. Non-Caucasoid patients and patients with longer disease duration had a slight tendency for greater organ damage (P = 0.05). Skin damage occurred independently of disease duration, whereas cardiovascular (P = 0.051), peripheral vascular (P = 0.057) and pulmonary damage (P = 0.06) had a tendency to occur more frequently in patients with longer disease duration. In this study, 68.3% of permanent damage was observed. An elevated frequency of skin damage was observed in this population which occurred independently of disease duration. Non-Caucasian patients had a tendency to present higher scores, but more studies are necessary to determine if ethnic or economic factors are involved.

Atherosclerosis and systemic lupus erythematosus

Large increases in mortality related to premature atherosclerosis with coronary artery disease have been reported in patients with systemic lupus erythematosus (SLE). The current pathogenic hypothesis for atherosclerosis involves not only the classic factors identified in the Framingham study, but also includes chronic inflammation, corticosteroid therapy, excess of traditional risk factors, autoantibodies, immune complexes (containing antibodies to phospholipids, to oxidized low-density lipoproteins, and to endothelial cells), and cytokine-producing activated T cells. Early risk factor intervention and effective control of inflammation should be incorporated into the management of SLE to protect against atherosclerosis.

Short-term prediction of mortality in patients with systemic lupus erythematosus: classification of outcomes using random forests

OBJECTIVE

To identify demographic and clinical characteristics that classify patients with systemic lupus erythematosus (SLE) at risk for in-hospital mortality.

METHODS

Patients hospitalized in California from 1996 to 2000 with a principal diagnosis of SLE (N = 3,839) were identified from a state hospitalization database. As candidate predictors of mortality, we used patient demographic characteristics; the presence or absence of 40 different clinical conditions listed among the discharge diagnoses; and 2 summary indexes derived from the discharge diagnoses, the Charlson Index and the SLE Comorbidity Index. Predictors of patients at increased risk of mortality were identified and validated using random forests, a statistical procedure that is a generalization of single classification trees. Random forests use bootstrapped samples of patients and randomly selected subsets of predictors to create individual classification trees, and this process is repeated to generate multiple trees (a forest). Classification is then done by majority vote across all trees.

RESULTS

Of the 3,839 patients, 109 died during hospitalization. Selecting from all available predictors, the random forests had excellent predictive accuracy for classification of death. The mean classification error rate, averaged over 10 forests of 500 trees each, was 11.9%. The most important predictors were the Charlson Index, respiratory failure, SLE Comorbidity Index, age, sepsis, nephritis, and thrombocytopenia.

CONCLUSION

Information on clinical diagnoses can be used to accurately predict mortality among hospitalized patients with SLE. Random forests represent a useful technique to identify the most important predictors from a larger (often much larger) number and to validate the classification.