Long-term prognosis and causes of death in systemic lupus erythematosus

Panax notoginseng saponins attenuate atherogenesis accelerated by zymosan in rabbits

Panax notoginseng saponins (PNS) are highly valued traditional Chinese medicine. The effects of PNS (120 mg/kg, once daily administrated intragastrically (i.g.)) on atherosclerosis induced by a high-cholesterol diet and chronic inflammation, which was derived through zymosan (10 mg/kg, once every 2 d) administration intraperitoneally, were evaluated in rabbits for 8 weeks. A normal group, a simple high-fat diet group, and a zymosan plus high-cholesterol diet group (Zym) were used as controls. Typical pathologic changes associated with atherosclerosis in rabbits following induction by zymosan were alleviated by PNS treatment. After 2, 4, 6, and 8 weeks of treatment, PNS decreased the serum levels of total cholesterol, triglyceride, low-density lipoprotein cholesterol, interleukin-6 and C-reactive protein as well as increased high-density lipoprotein cholesterol level significantly in comparison with those in the Zym group, except for triglycerides at week 2. In addition, PNS treatment significantly decreased the mRNA expression levels of monocyte chemoattactant protein-1 and nuclear factor-kappaB/p65 in the aorta wall after 8 weeks of treatment compared with the Zym group. In conclusion, PNS attenuates atherogenesis through an antiinflammatory action and regulation of the blood lipid profile.

Protective molecules and their cognate antibodies: new players in autoimmunity

Impairment of the clearance of apoptotic material seems to contribute to autoantigen exposure, which can initiate or maintain an autoimmune response in predisposed individuals. Complement component C1q, Creactive protein (CRP), serum amyloid P (SAP), mannose-binding lectin (MBL), apolipoprotein A-1 (Apo A-1) and long pentraxin 3 (PTX3) are molecules involved in the removal of apoptotic bodies and pathogens, and in other antiinflammatory pathways. For this reason they have been called "protective" molecules. C1q has a key role in the activation of the complement cascade and acts as a bridging molecule between apoptotic bodies and macrophages favouring phagocytosis. In addition to other functions, CRP, SAP and MBL bind to the surface of numerous pathogens as well as cellular debris and activate the complement cascade, thus stimulating their clearance by immune cells. The role of PTX3 is more controversial. In fact, PTX also promotes the clearance of microorganisms, but the activation of the complement cascade through C1q and removal of apoptotic material can be either stimulated or inhibited by this molecule. Antibodies against protective molecules have been recently reported in systemic lupus erythematosus and other autoimmune rheumatic diseases. Some of them seem to be pathogenetic and others protective. Thus, protective molecules and their cognate antibodies may constitute a regulatory network involved in autoimmunity. Dysregulation of this system might contribute to the development of autoimmune diseases in predisposed individuals.

SLE diagnosis and treatment: when early is early

Around 1980 antinuclear antibody testing became widely used in routine laboratory practice leading to a tapering in the lag time between SLE onset and diagnosis. Since then nothing relevant has been introduced which could help us in making the diagnosis of SLE earlier than now. Notably, there is increasing evidence that early diagnosis and treatment could increase SLE remission rate and improve patient prognosis. Although it has been shown that autoantibodies appear before clinical manifestations in SLE patients, currently we cannot predict which autoantibody positive subjects will eventually develop the disease. Thus, great effort should be made in order to identify new biomarkers able to improve our diagnostic potential. B lymphocyte stimulator (BLyS), anti-ribosomal P protein and anti-C1q antibodies are among the most promising. In recent years, some therapeutic options have emerged as appropriate interventions for early SLE treatment, including antimalarials, vitamin D, statins and vaccination with self-derived peptides. All these immune modulators seem to be particularly useful when introduced in an early stage of the disease.

Cardiac involvement in systemic rheumatic diseases: An update

The high rates of cardiovascular (CV) mortality and morbidity observed in patients with systemic autoimmune diseases (SADs) cannot be fully explained by traditional atherosclerosis risk factors as standard therapy (i.e. corticosteroids and methotrexate), cytokines and disease activity may all contribute to accelerated atherosclerosis. There is considerable evidence showing that chronic inflammation and immune dysregulation play a pathogenetic role in the development of atherosclerosis in patients with SADs. Chronic inflammation, accelerated atherosclerosis and functional abnormalities of the endothelium suggest that subclinical CV involvement begins soon after the onset of the disease and progresses with disease duration. All cardiac structures may be affected during the course of SADs (valves, the conduction system, the myocardium, endocardium and pericardium, and coronary arteries), and the cardiac complications have a variety of clinical manifestations. As these are all associated with an unfavourable prognosis, it is essential to detect subclinical cardiac involvement in asymptomatic SAD patients, and begin adequate management and treatment early.

Pediatric lupus--are there differences in presentation, genetics, response to therapy, and damage accrual compared with adult lupus?

Some complement deficiencies predispose to systemic lupus erythematosus (SLE) early in life. Currently, there are no known unique physiologic or genetic pathways that can explain the variability in disease phenotypes. Children present with more acute illness and have more frequent renal, hematologic, and central nervous system involvement compared to adults with SLE. Almost all children require corticosteroids during the course of their disease; many are treated with immunosuppressive drugs. Mortality rates remain higher with pediatric SLE. Children and adolescents accrue more damage, especially in the renal, ocular and musculoskeletal organ systems. Conversely, cardiovascular mortality is more prevalent in adults with SLE.

Bisphosphonates in patients with autoimmune rheumatic diseases: Can they be used in women of childbearing age?

Autoimmune rheumatic diseases (ARD) are prevalent in women during their childbearing age. For their treatment, high doses of corticosteroid (CS) for long-term periods are often required, increasing the risk of bone loss. According to recent guidelines, bisphosphonates (BP) should be used as first line treatment to prevent CS induced osteoporosis. However, due to their long-term release from bone and their ability to cross the placenta, it has been suggested to avoid BP in women during their fertile years. BP seem to decrease foetus bone length in pregnant animals, but not in humans, at least, when they are administered at therapeutic dosage. BP are embryo toxic in animals when used at high dosage. In a systematic literature review, we found 58 women treated with BP close before or during pregnancy, showing no related congenital malformations. However, the Unit of Clinical and Epidemiological Genetics in University of Padova collected ten cases of women treated with BP during pregnancy, reporting 20% of congenital malformations. Thus, we suggest to avoid BP during pregnancy and caution with their use in fertile women. When they have to be given before pregnancy, specific affinities of the BP have to be considered to plan the washout period beforehand.

Investigation of pathological and clinical features of lupus nephritis in 73 autopsied cases with systemic lupus erythematosus

The aims of this study were to analyze the clinical and pathological features of lupus nephritis (LN) and examine the association between these features and pathological condition, treatment, and prognosis. Of the 177 systemic lupus erythematosus patients who died while receiving inpatient care at Juntendo University Hospital between 1960 and 2001, we investigated the clinical features, treatment, and pathological features of 73 of these who underwent pathological autopsy and had a clear medical history. We divided these cases into two groups, i.e., those up to 1979 (Group A) and those during and after 1980 (Group B) in order to investigate changes in tendencies by age. We also divided the cases into three groups by time interval between diagnosis and death to investigate long-term prognosis. Uremia was the direct cause of death in 38.9% of cases in Group A and only 10.8% of cases in Group B. Pathological features showed a tendency to change to a sclerotic lesion as the duration of the disorder became longer. Uremia attributable to LN was the direct cause of death in relatively fewer cases, although it is still found in the majority of LN cases and remains a problem requiring stringent management. The treatment of sclerotic lesions may be an issue that needs further attention.

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.

White blood cell count abnormalities and infections in one-year follow-up of 124 patients with SLE

The purpose of our study was to evaluate the frequency of leukocyte count abnormalities in a large cohort of SLE patients and its association with infection. To make this evaluation, we studied consecutive patients with SLE diagnosis and prospectively followed them in the Coimbra Lupus Cohort. Data about white blood cell count abnormalities and infection during one-year follow-up were obtained. The presence of leukopenia, lymphopenia, and neutropenia was registered for one-year period. Infections were classified as severe or mild. We found that of the 124 patients who were included (91.1% female, mean age 41.2, mean disease duration 11.1), mild infections occurred in 43.5%, and severe in 3.2% of the patients. Twelve percent, 41.1%, and 4.8% of the patients had persistent leukopenia, lymphopenia, and neutropenia, respectively. Fourteen percent received a pneumococcal vaccination. Patients with neutropenia had a significantly higher number of infections (P = 0.033). Thus, our study showed that neutropenia was associated with an increased risk of infection during this one-year follow-up. Infections were frequent, but most of them were mild.

Autologous hematopoietic stem cell transplantation for autoimmune diseases: an observational study on 12 years' experience from the European Group for Blood and Marrow Transplantation Working Party on Autoimmune Diseases

BACKGROUND

Autologous hematopoietic stem cell transplantation has been used since 1996 for the treatment of severe autoimmune diseases refractory to approved therapies. We evaluated the long-term outcomes of these transplants and aimed to identify potential prognostic factors.

DESIGN AND METHODS

In this observational study we analyzed all first autologous hematopoietic stem cell transplants for autoimmune diseases reported to the European Group for Blood and Marrow Transplantation (EBMT) registry between 1996-2007. The primary end-points for analysis were overall survival, progression-free survival and transplant-related mortality at 100 days.

RESULTS

Nine hundred patients with autoimmune diseases (64% female; median age, 35 years) who underwent a first autologous hematopoietic stem cell transplant were included. The main diseases were multiple sclerosis (n=345), systemic sclerosis (n=175), systemic lupus erythematosus (n=85), rheumatoid arthritis (n=89), juvenile arthritis (n=65), and hematologic immune cytopenia (n=37). Among all patients, the 5-year survival was 85% and the progression-free survival 43%, although the rates varied widely according to the type of autoimmune disease. By multivariate analysis, the 100-day transplant-related mortality was associated with the transplant centers' experience (P=0.003) and type of autoimmune disease (P=0.03). No significant influence of transplant technique was identified. Age less than 35 years (P=0.004), transplantation after 2000 (P=0.0015) and diagnosis (P=0.0007) were associated with progression-free survival.

CONCLUSIONS

This largest cohort studied worldwide shows that autologous hematopoietic stem cell transplantation can induce sustained remissions for more than 5 years in patients with severe autoimmune diseases refractory to conventional therapy. The type of autoimmune disease, rather than transplant technique, was the most relevant determinant of outcome. Results improved with time and were associated with the transplant centers' experience. These data support ongoing and planned phase III trials to evaluate the place of autologous hematopoietic stem cell transplantation in the treatment strategy for severe autoimmune diseases.

Pulmonary involvement of systemic lupus erythematosus: analysis of 90 necropsies

Pleuropulmonary manifestations of systemic lupus erythematosus (SLE) have been reported to be of variable prevalence, depending on the diagnostic methods used. The objective of this study was to determine the anatomopathological prevalence and the nature of lung involvement associated with SLE and to define if there were differences in the grade and type of pulmonary involvement in patients who had died at different time periods, before or after 1996. Complete autopsy studies of 90 patients with SLE diagnosis carried out between 1958 and 2006 and their clinical records were studied. All patients fulfilled the American College of Rheumathology (ACR) diagnostic criteria for SLE. Two groups of patients were analyzed: patients who had died before 1996 and those deceased in 1996–2006. Some pleuropulmonary involvement was detected in 97.8% of the autopsies. The most frequent findings were pleuritis (77.8%), bacterial infections (57.8%), primary and secondary alveolar haemorrhages (25.6%), followed by distal airway alterations (21.1%), opportunistic infections (14.4%) and pulmonary thromboembolism (7.8%), both acute and chronic. No cases of acute or chronic lupus pneumonitis were found. Opportunistic lung infections were invasive aspergillosis, disseminated strongyloidiasis, mucormicosis and Pneumocystis carinii. Only three of 23 patients with alveolar haemorrhage showed capillaritis. The four patients with primary pulmonary hypertension (PHT) had plexiform lesions. Deceased patients’ age at death (46.09 ± 11.01 vs 30.3 ± 11.5 years, P < 0.0001) as well as survival time from diagnosis date (11.8 ± 11.2 vs 4.4 ± 4.9 years, P < 0.0001) in the second time period evaluated were significantly higher. However, there were no statistically significant differences in the prevalence of any of the pulmonary manifestations. Sepsis was considered the major cause of death without significant differences in both groups. Our results show that pulmonary manifestations directly caused by systemic lupus erythematosus are very uncommon and that their prevalence has not changed in the past 10 years. Pulmonary infection is still the most frequent affection, and it is an important cause of death in patients with lupus.

[Damage in cuban patients with systemic lupus erythematosus. Relation with disease features]

OBJECTIVE

To determine damage presence and predictors factors for its appearance in a cohort of cuban patients with systemic lupus erythematosus (SLE).

PATIENTS AND METHODS

A retrospective cohort study included 80 patients presenting with SLE seen in Rheumatology Service of "Hermanos Ameijeiras" Clinical Surgical Hospital in Havana City, Cuba. Damage was assessed using The Systemic Lupus International Collaborating Clinics/American College of Rheumatology (ACR) Damage Index (SLIC/ACR), a tool approved for damage measurement. Damage presence was related to initial disease features to diagnose this condition, to sociodemographic elements, to treatments used, and to the disease course time. Statistical analysis had two variants: the univariate and multivariate type using Chi2 and statistical significance was established in p<0, 05.

RESULTS

We found that 39 patients (48,8%) had some degree of damage. More involved domains were the musculoskeletal (18,8%), neuropsychiatric, and skin, 16,3%, pulmonary and ocular, present in 15% of cases. In the multivariate analysis, damage was associated with the use of higher than 30 mg/day Prednisone doses for more of 4 weeks (OR=54,68, CI 95%=3,56-97,45, p=0.001), presence of leukopenia (RO=18,73, CI 95%=2,74-62,23m p=0,004), and time course of disease (OR=1,02, CI 95%=1,00 2-1,09, p=0.006).

CONCLUSIONS

Damage was practically present in half of the study patients, the most involved domain was the musculoskeletal, and use of higher than 30mg prednisone doses were the factor most associated with the presence of damage.

[Immunoablation followed by autologous stem cell transplantation in lupus: a clinical update]

Systemic lupus erythematosus (SLE) is a classic systemic autoimmune disease. Standard treatment consists of chronic therapy with antimalarials, glucocorticoids and immunosuppressive/cytotoxic drugs, which is associated with considerable side effects. In contrast, immunoablation of autoreactive immunologic memory followed by autologous stem cell transplantation (ASCT) has been the only regimen capable of inducing long-term remission of up to 10 years after cessation of immunosuppressive therapy, even in severely affected patients. Introduced in 1996, the procedure has since been performed in 147 patients with severe SLE refractory to standard treatment in clinical studies worldwide. Most of these patients achieved clinical long-term remission. However, SLE relapses and secondary autoimmune disorders have been reported. Transplant-related mortality occurred in 6% of the 147 cases, with a wide center effect (2-13%). Here we summarise the results published in the literature on immunoablation followed by ASCT in SLE and discuss future perspectives for optimising this therapeutic approach. It may be possible to improve the outcome and reduce the risks of treatment by identifying patients with a poor prognosis at an early stage, before irreversible organ damage has taken place.

Increased arterial stiffness correlated with disease activity in systemic lupus erythematosus

To evaluate the relationships between arterial stiffness, disease activity and end-organ damage in systemic lupus erythematosus (SLE), non-invasive vascular assessments were made on 32 female SLE patients and 32 female normal controls. The patients had significantly increased brachial-ankle pulse wave velocity (PWV) (13.06 +/- 1.79 vs. 11.50 +/- 1.00 m/s; P < 0.001), heart-ankle PWV (8.98 +/- 1.16 vs. 7.88 +/- 0.73 m/s; P < 0.001), carotid augmentation index (AI) (21.6 +/- 17.2% vs. 5.4 +/- 14.0%; P = 0.001) and carotid intima-medial thickness (IMT) (0.753 +/- 0.132 vs. 0.644 +/- 0.092 mm; P = 0.002) when compared with controls. The disease activity and organ damage were evaluated by SLE disease activity index (SLEDAI) and systemic lupus international collaborating clinics (SLICC) damage index. Patients with active disease (SLEDAI > or = 3) had significantly higher carotid AI (34.4 +/- 9.7% vs. 17.8 +/- 17.3%, P < 0.05) than stable ones (SLEDAI < 3) and those with organ damage (SLICC > or = 1) had significantly higher heart-ankle PWV (9.69 +/- 1.13 vs. 8.61 +/- 1.02 m/s, P < 0.05) than those with SLICC = 0. After making adjustments for age, body mass index (BMI) and blood pressure, carotid AI was found to show correlation with SLEDAI and haPWV with SLICC. A carotid AI value of 33.3% identified SLEDAI > or = 3 with a sensitivity of 83% and a specificity of 80%, whereas a heart-ankle PWV value of 9.0 m/s identified SLICC > or = 1 with a sensitivity of 91% and a specificity of 67%. In conclusion, SLE was an independent risk factor of sub-clinical atherosclerosis and arterial stiffness may identify the presence of active disease.

Cardiovascular co-morbidity in rheumatic diseases

Patients with rheumatic disorders have an increased risk of cardiovascular disease (CVD). This excess co-morbidity is not fully explained by traditional risk factors. Disease severity is a major risk factor for CVD in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Shared disease mechanisms in atherosclerosis and rheumatic disorders include immune dysregulation and inflammatory pathways, which are potential targets for therapy. Lessons from RA and SLE may have implications for future research on the pathogenesis of atherosclerotic vascular disease in general. Recent data indicate that suppression of inflammation reduces the risk of CVD morbidity and mortality in patients with severe RA. The modest, but clinically relevant, efficacy of atorvastatin treatment in RA adds to the evidence for important anti-inflammatory properties for statins. There is increased recognition of the need for structured preventive strategies to reduce the risk of CVD in patients with rheumatic disease. Such strategies should be based on insights into the role of inflammation in CVD, as well as optimal management of life style related risk factors. In this review, the research agenda for understanding and preventing CVD co-morbidity in patients with rheumatic disorders is discussed.

Subclinical atherosclerosis in rheumatoid arthritis and systemic lupus erythematosus

Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are associated with increased mortality, largely as a consequence of cardiovascular disease. Increased cardiovascular morbidity and mortality in patients with RA and SLE cannot be entirely explained by traditional risk factors, suggesting that the systemic inflammation that characterizes these diseases may accelerate atherosclerosis. We used carotid ultrasonography to investigate the prevalence and correlates to preclinical atherosclerosis in patients with RA and SLE. Because atherosclerosis is a systemic disease, assessment of carotid plaque by ultrasonography provides a robust, direct measure of systemic atherosclerosis. We observed a substantially increased prevalence of carotid plaque in RA and SLE patients compared with age- and sex-matched controls, which remained after adjustment for traditional risk factors. The presence of carotid atherosclerosis was associated with disease duration in both RA and SLE and damage in SLE. These data support the hypothesis that inflammation associated with RA and SLE contributes to accelerated atherosclerosis and argue that RA and SLE disease activity should be more aggressively managed.

Lupus: improving long-term prognosis

Over recent decades short- and medium-term survival has greatly improved in patients affected with systemic lupus erythematosus, but long-term prognosis still remains poor mainly due to complications of the disease and/or its treatment. To improve long-term prognosis in systemic lupus erythematosus, we should try to adopt, early in the disease course, strategies that can contribute to reducing long-term complications, including screening for and prophylaxis against infections, control of risk factors for atherosclerosis, and cancer surveillance. However, in patients with systemic lupus erythematosus all these preventive strategies are often not sufficient. Indeed, two important systemic lupus erythematosus-related factors play a relevant role in all these complications: severe disease manifestations, such as glomerulonephritis and central nervous system involvement, and corticosteroid and cyclophosphamide use. Therefore, to prevent long-term complications, we should try to control disease activity and severity using the lowest effective dosage of these drugs. Moreover, strategies directed at preventing clinical manifestations in asymptomatic antinuclear antibody-positive individuals or in antiphospholipid antibody-positive systemic lupus erythematosus patients, as well as at preventing severe manifestations in patients with mild systemic lupus erythematosus at the time of the diagnosis should be considered.

Infections as triggers and complications of systemic lupus erythematosus

A growing body of experimental and clinical evidence supports the pivotal role of infections in the induction or exacerbation of systemic lupus erythematosus (SLE). Infections can be responsible for aberrant immune response leading to a loss of tolerance towards native proteins. Molecular mimicry, especially between Sm or Ro autoantigens and EBV Nuclear Antigen-1 response, as well as the over-expression of type 1 INF genes are among the major contributors to SLE development. On the other hand infections are very common in SLE patients, where they are responsible for 30-50% of morbidity and mortality. Several factors, either genetic, including complement deficiencies or mannose-binding lectin deficiency or acquired such as severe disease manifestations or immunosuppressant use, predispose SLE patients to infections. All types of infections, including bacterial, viral and opportunistic infections, have been reported and the most frequently involved sites of infections are the same as those observed in the general population, including respiratory, skin, and urinary tract infections. Some preventive measures could be adopted in order to reduce the rate of infections in SLE patients: i.e. screening for Mycobacterium tuberculosis and for some chronic viral infections before immunosuppressive treatment; adequate prophylaxes or drug adjustments when indicated, and pneumococcal and influenza vaccinations in patients with stable disease.

Mechanisms of disease: macrophage migration inhibitory factor in SLE, RA and atherosclerosis

The past decade has seen the emergence of two new paradigms in inflammatory disease: first, cardiovascular complications of atherosclerosis are markedly increased in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE); and second, inflammatory mechanisms are important in the pathogenesis of atherosclerosis. These concurrent developments have lead to the concept that inflammatory mediators operative in RA and SLE might be causal in the accelerated atherosclerosis observed, a concept supported by clinical studies showing that this acceleration is not fully explained by traditional vascular risk factors. Separate lines of evidence implicate the cytokine macrophage migration inhibitory factor (MIF) in RA, SLE, and atherosclerosis. Several reports have revealed definitive in vivo evidence of the activity of MIF in a model of SLE, demonstrated a novel role for MIF in monocyte/macrophage recruitment, and showed that MIF regulates a key mediator of inflammatory cell activation. Together with evidence that MIF circulates in increased concentrations in patients with RA and SLE, this information suggests that in addition to contributing to each disease, MIF might contribute directly to the acceleration of atherosclerosis in RA and SLE.

Mycophenolate Mofetil in Lupus Glomerulonephritis: Effectiveness and Tolerability

Mycophenolate mofetil (MMF) is an immunosuppressive agent initially used in the treatment of transplant recipients. MMF has been used in renal, heart, and liver transplantation, where it seems more effective than other immunosuppressive regimens in reducing the incidence of acute rejection episodes. MMF has a variety of immunosuppressive effects, including selective suppression of T and B lymphocyte proliferation, and has been more recently used in many autoimmune inflammatory conditions. Systemic lupus erythematosus (SLE) is an autoimmune disease that can potentially involve any organ or system of the human body. Glomerulonephritis (GLN) has been recognized as the most frequent severe manifestation of SLE, leading to poor long-term prognosis. In the treatment of lupus GLN, several therapeutic approaches, all including immunosuppressive drugs, such as cyclophosphamide, azathioprine, or cyclosporine A, have been used. The short- and long-term toxicity of these drugs limits their use in a substantial number of patients. Over the last few years, MMF has emerged as an alternative therapeutic regimen in lupus GLN, mainly for patients refractory to other therapies. These studies have shown that it is highly effective and generally well tolerated.

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.

Cardiovascular risk factors, fitness and physical activity in rheumatic diseases

PURPOSE OF REVIEW

There is increased recognition of an excess risk of cardiovascular disease in patients with rheumatic disorders. Physical inactivity is a frequent complication of arthritis, and also common in the general population. In this review, we highlight recent findings on risk factors for cardiovascular disease in patients with rheumatic diseases, and explore the role of physical activity for the prevention of cardiovascular disease.

RECENT FINDINGS

Inflammatory mechanisms are clearly involved in cardiovascular disease in patients with systemic lupus erythematosus and rheumatoid arthritis. In rheumatoid arthritis, disability is also a major predictor of cardiovascular disease. A sedentary lifestyle increases the risk of cardiovascular disease in the general population, and high physical activity prevents cardiovascular disease mortality and morbidity. Successful treatment of rheumatic disease with control of inflammation and improved functional capacity may also reduce the risk of cardiovascular disease.

SUMMARY

As part of the effort to prevent vascular comorbidity, regular exercise should be encouraged in patients with rheumatic diseases, and structured interventions to reduce adverse lifestyle factors scientifically evaluated.

Gender as risk factor for autoimmune diseases

Most autoimmune diseases occur significantly more frequently in women than men. This female preponderance for abnormal autoimmune function has largely gone unexplained. Many investigations have concentrated on the effects of female and male sex hormones on immune function, by suggesting that estrogens favor the antibody production-enhancing Th2 response and, by doing so, possibly, increase the risk towards abnormal autoimmune function. Others have suggested that women are genetically predisposed towards abnormal autoimmune function, possibly because the X chromosome may confer susceptibility towards tolerance breakdown. Recent developments have, however, opened new research avenues. The possible association between persistent fetal-maternal microchimerism and the development of autoimmune diseases has attracted special interest. Since, in analogy to allogeneic organ transplantation, fetal-maternal (and maternal-fetal) microchimerism may play an important role in the immunologic tolerance of the fetal semi-allograft, female preponderance for autoimmune diseases may be understood as a consequence of increased allogeneic cell traffic in females (in comparison to males), increased risk for long-term microchimerism and, therefore, as a consequence of the former two, the development of abnormal autoimmunity. Under an evolutionary view point the occurrence of autoimmune diseases, in general, can be seen as the price to be paid for successful reproduction. In view of increased exposure to cell traffic, women, of course, would be expected to pay a higher price, reflected in more autoimmunity.

Mycophenolate mofetil: What is its place in the treatment of autoimmune rheumatic diseases?

Mycophenolate mofetil (MMF) is a new immunosuppressant recently introduced in the treatment of autoimmune conditions. The greatest experience with the use of MMF has been achieved in the treatment of proliferative lupus glomerulonephritis. However, MMF has also been used to control SLE extra-renal manifestations as well as other autoimmune rheumatic diseases such as idiopathic inflammatory arthropathies, inflammatory myopathies, systemic sclerosis, and systemic vasculitis. MMF seems to be well tolerated and effective and could be considered a useful alternative to standard immunosuppressants for the treatment of autoimmune rheumatic disorders. However, further studies are needed in order to determine its real place in the treatment of these conditions. In this paper, the use of MMF in different autoimmune rheumatic diseases is reviewed and discussed.