Systemic lupus erythematosus in a multiethnic US cohort: XLIII. The significance of thrombocytopenia as a prognostic factor

Factors predictive of severe thrombocytopenia and its impact on poor outcomes in Latin American patients with systemic lupus erythematosus: Data from a multiethnic Latin American cohort

OBJECTIVE

To examine the predictors of the occurrence of severe thrombocytopenia and its impact on damage accrual and mortality in SLE patients.

METHODS

Factors associated with time to severe thrombocytopenia (platelet count ≤20,000/mm3) occurring from the onset of SLE symptoms were assessed by Cox proportional hazards regressions. The association of severe thrombocytopenia with mortality was evaluated by logistic regression analyses while its impact on damage was by negative binomial regression.

RESULTS

Of 1,217 patients, 33 (2.7%) developed severe thrombocytopenia over a mean (SD) follow-up time of 5.9 (3.6) years. The median time from the onset of SLE symptoms to severe thrombocytopenia occurrence was 22 months (IQR 8.7-62.0). Mestizo (60.6%) was the predominant ethnic group, followed by Caucasian (27.3%), while African Latin American exhibited the lowest frequency (12.1%). By multivariable analysis, Mestizo ethnicity (HR 2.67, 95% CI 1.12-6.37, p = 0.027), and autoimmune hemolytic anemia (AIHA) at baseline (HR 3.99; 95% CI 1.05-15.19, p = 0.042) were associated with a shorter time to the occurrence of severe thrombocytopenia while middle/high socioeconomic status (HR 0.23; 95% CI 0.08-0.69, p = 0.008) was associated with a longer time. Severe thrombocytopenia contributed neither to damage nor to mortality.

CONCLUSIONS

Severe thrombocytopenia occurs during the early course of SLE. Mestizo ethnicity and AIHA at baseline emerged as independent predictors of a shorter time to severe thrombocytopenia occurrence while a middle/high socioeconomic status seems to be protective against its occurrence. Damage and mortality did not seem to be impacted by the occurrence of severe thrombocytopenia.

Early diagnosis and clinical application of systemic lupus erythematosus based on a nomogram model

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease involving multi-system and multi-organ dysfunction, and is easily misdiagnosed early in the disease course. We aimed to accurately predict early SLE nomogram to provide a reference basis for the early clinical diagnosis of SLE. Methods: We retrospectively analyzed 167 patients who were first diagnosed with SLE at Fengxian District Central Hospital, Shanghai, between March 2017 and October 2022. Three groups of 129 physically healthy subjects, 67 patients with rheumatoid arthritis, and 40 patients with rashes were selected as controls during the same period. Patients with SLE and control group were randomly divided into training (n = 217) and validation (n = 141) group. Univariate and multivariate analyses were used to identify independent risk factors for early SLE diagnosis. The independent risk factors for diagnosis were used to construct a nomogram to predict early SLE. Results: Based on the training group, three variables were identified as independently influencing early SLE: platelets (odds ratio OR = 0.993, P = 0.047), albumin (OR = 0.833, P = 0.007), and complement component 1q (OR = 0.956, P = 0.000). The precision of the nomogram was assessed using C-index values and calibration plot diagrams. The C-index values were 0.929 for training group and 0.898 for validation group. Both the training group and validation group calibration curves showed good predicted outcomes. Conclusion: The construction of a nomogram can accurately predict the risk of early SLE. The model showed good discriminatory power and calibration for use in the diagnosis of SLE, providing a visual tool and reference basis for the early diagnosis of SLE.

Thrombocytopenia and disease outcomes in a cohort of patients with systemic lupus erythematosus. A post hoc analysis of the COMOSLE-EGYPT study

BACKGROUND

Thrombocytopenia ranges from 20% to 40% in patients with systemic lupus erythematosus (SLE). It is usually associated with severe disease manifestations and worse disease outcomes.

AIM OF THE STUDY

To identify the frequency of thrombocytopenia in a cohort of Egyptian patients with SLE and to examine the relationship of thrombocytopenia with various disease manifestations and disease outcomes.

METHODS

Data on 902 SLE patients were collected, including demographics, clinical, laboratory, immunological findings, and medications. SLE Disease Activity Index (SLEDAI) at baseline, last visit, and Systemic Lupus International Collaborating Clinics/ACR Damage Index (SLICC) were calculated. A comparison was done between patients with thrombocytopenia (group I) and patients without (group II) regarding different disease parameters. Regression analysis was done to examine if thrombocytopenia is a predictor of worse disease outcomes.

RESULTS

Thrombocytopenia was found in 33% of our cohort. Longer disease duration was observed in group I compared to group II (p value = .01). As regards clinical manifestations, significantly higher frequencies of constitutional manifestations, anemia, arterial thrombosis, pulmonary hypertension, cardiac manifestations, neurological manifestations, gastrointestinal tract (GIT), and hepatic manifestations were detected in group I compared to group II. The disease damage index was detected to be significantly higher in group I as compared to group II (p value < .001). Mortality was higher in group I (p value < .001). Although it was found that antiphospholipid antibodies (APL) were associated with thrombocytopenia and their presence resulted in higher damage (p value: .001), the presence of thrombocytopenia even in patients with negative APL antibodies was associated with higher damage and mortality. Apart from thrombocytopenia, the male gender was also found to be an independent risk factor for mortality.

CONCLUSION

Thrombocytopenia was associated with more organ damage and higher mortality in SLE patients with or without APL antibodies. SLE patients with thrombocytopenia have a 3.4 times higher risk of mortality than patients without thrombocytopenia. Apart from thrombocytopenia, the male gender was also found to be an independent risk factor for mortality.

Severe thrombocytopenia is associated with high mortality in systemic lupus erythematosus-analysis from Indian SLE Inception cohort for Research (INSPIRE)

Thrombocytopenia in patients with systemic lupus erythematosus (SLE) is associated with higher morbidity and mortality. We report frequency, associations and short-term outcome of moderate-severe thrombocytopenia in a prospective inception cohort from India (INSPIRE). We evaluated consecutive SLE patients classified per SLICC2012 for the occurrence of thrombocytopenia and its associations. The outcomes assessed included bleeding manifestations, kinetics of thrombocytopenia recovery, mortality and recurrence of thrombocytopenia. Among a total of 2210 patients in the cohort, 230 (10.4%) had incident thrombocytopenia, of whom moderate (platelet count [PC] 20-50 × 109/L) and severe thrombocytopenia (PC < 20 × 109/L) were noted in 61 (26.5%) and 22 (9.5%), respectively. Bleeding manifestations were generally limited to the skin. Compared to controls, cases had a higher proportion of autoimmune haemolytic anaemia (p < 0.001), leukopenia (p < 0.001), lymphopenia (p < 0.001), low complement (p < 0.05), lupus anticoagulant (p < 0.001), higher median SLEDAI 2 K (p < 0.001) and lower proportion of anti-RNP antibody (p < 0.05). There was no significant difference in these variables between moderate and severe thrombocytopenia. There was a sharp rise in PC by 1 week that was sustained in the majority through the period of observation. There was three times higher mortality in the severe thrombocytopenia group as compared to moderate thrombocytopenia and controls. The thrombocytopenia relapse and lupus flare rates were similar across categories. We report a low occurrence of major bleeds and higher mortality in those with severe thrombocytopenia as compared to moderate thrombocytopenia and controls. Key Points • Severe thrombocytopenia occurs in 1% of patients with SLE; however, major bleeds are uncommon. • Thrombocytopenia has a strong association with other lineage cytopenias and lupus anticoagulants. • Response to initial glucocorticoids therapy is quick and is well sustained with additional immunosuppressants. • Severe thrombocytopenia increases mortality threefold in SLE.

Prevalence and Patterns of Renal Involvement Among Patients With Systemic Lupus Erythematous at a Tertiary Center

BACKGROUND

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder characterized by widespread inflammation and damage to multiple organ systems. One of the most common and severe manifestations of SLE is lupus nephritis (LN).

OBJECTIVES

To determine the prevalence of LN among subjects with SLE and to identify the demographic, clinical, and laboratory parameters of SLE in subjects diagnosed with LN.

METHODS

This is a descriptive study conducted at a tertiary hospital. Medical records were reviewed from outpatients who visited between January 2015 and October 2019 and who has fulfilled the classification criteria for diagnosis of SLE and had LN.

RESULTS

Among 365 patients with SLE, 36% had LN. The most prevalent World Health Organization class of LN was IV, which significantly correlated with both abnormal creatinine levels and nephrotic range proteinuria. Elevated serum creatinine correlated with the presence of hypertension and thrombocytopenia. Cutaneous manifestations were noted to be present in 100% of LN patients, followed by arthritis and/or arthralgia (82.9%), anemia (94.6%), and lymphopenia (87.6%).

CONCLUSION

This study aids in the recognition of the demographic, clinical, laboratory features, and the histological patterns of LN patients in Saudi Arabia, that probably has a role in the development and disease progression. A significant correlation was found between abnormal kidney function and hypertension, thrombocytopenia and nephrotic range proteinuria. The presence of World Health Organization class IV LN correlated with both impaired kidney function and nephrotic range proteinuria.

Refractory antiphospholipid antibody syndrome-induced thrombocytopaenia successfully treated with belimumab

Antiphospholipid antibody syndrome (APS) is an autoimmune disease with clinical symptoms such as recurrent arterial/venous thrombosis, pregnancy morbidities and thrombocytopaenia. Antiphospholipid antibodies are suggested to be involved in the pathological condition of APS. Therefore, belimumab (BLM), which reduces autoantibody production from B cells, is expected to be effective in the treatment of APS.We report a case of a 63-years-old woman with APS with refractory thrombocytopaenia. Her thrombocytopaenia did not respond to antithrombotic therapy and immunosuppressive treatment including corticosteroids and rituximab but improved with BLM. This is the first report of an APS-induced thrombocytopaenia treated successfully with BLM. BLM should be an effective treatment for APS-related thrombocytopaenia.

A modified regimen of low-dose rituximab therapy for patients with refractory immune thrombocytopenia associated with systemic lupus erythematosus

Background:

Severe and refractory immune thrombocytopenia (ITP) affects the life expectancy of patients with systemic lupus erythematosus (SLE) and poses a challenge in their clinical management. This intervention study employed a small sample size to evaluate the efficacy and safety of a modified low-dose rituximab (RTX) regimen in patients with SLE-associated refractory ITP.

Methods:

Eight patients with severe SLE-associated refractory ITP were enrolled in this intervention study. They received an infusion of intravenous RTX (200 mg) on days 1 and 15. The dose of corticosteroids (prescribed previously) was gradually tapered, and immunosuppressants were withdrawn. Patients were followed up at 1, 3, 6, and 12 months; platelet counts, other laboratory indicators, and side effects were recorded. We used intention-to-treat analysis to calculate the response rate.

Results:

Seven participants (87.5%) completed the study. At 1 month, two patients (25.0%) achieved partial response (PR); the PR rate increased to 87.5% at 3 months. At 6 months, three patients (37.5%) achieved complete response (CR). However, the CR rate dropped to 25.0% at 12 months. The overall responses (ORs) were 25.0% (2/8), 87.5% (7/8), 75.0%(6/8), and 75.0%(6/8) at 1, 3, 6, and 12 months, respectively. Two patients developed a mild infusion reaction and one discontinued the study due to herpes zoster virus infection and an allergic reaction 2 weeks after the first dose of RTX.

Conclusion:

Modified low-dose RTX therapy (two infusions of 200 mg every 2 weeks) could be a promising new option for patients with SLE-associated refractory ITP with a satisfactory response rate.

Pediatric lupus nephritis - An evil cousin of its adult counterpart: A single-center based experience from a tertiary care hospital of Eastern India

Context

Systemic lupus erythematosus is an autoimmune multisystem disease with a high predilection for renal involvement. Lupus nephritis develops in 20% to 75% within the first two years. Presentation varies from subnephrotic proteinuria to end-stage renal disease.

Aims

To study clinical features, biochemical, and serological parameters and correlate with histological activity and chronicity score [modified National Institute of Health (NIH) score].

Settings and Design

Retrospective, cross-sectional, single-center based study in a tertiary care hospital of Eastern India.

Subjects and Methods

We incuded 36 children with lupus nephritis diagnosed from February 2018 to March 2019. Laboratory data included were complete blood count (CBC), blood glucose, urine analysis, serum urea, creatinine, blood urea nitrogen (BUN), albumin, cholesterol, HBsAg, antihepatitis C virus (HCV) antibody, antistreptolysin O (ASO) titer, antinuclear antibody (ANA), myeloperoxidase antineutrophil cytoplasmic antibody (MPO ANCA), proteinase 3 antineutrophil cytoplasmic antibody (PR3 ANCA), double-stranded DNA (dsDNA), C3, and C4. Clinical parameters were age, sex, blood pressure (BP), skin lesions, arthralgia, edema, obesity. Renal biopsies examined with light microscopy, hematoxylin and eosin (H and E), periodic acid-Schiff (PAS), silver methanamine, Masson's trichrome (MT) stains. Immunofluorescence microscopy done with IgG, IgM, IgA, C3c, C1q, kappa, lambda antibodies.

Statistical Analysis Used

Kruskal-Wallis and χ² tests.

Results

Mean age was 15.12 ± 3.49 and 12.5 ± 1.73 years for lupus nephritis (LN) with activity and LN without activity, respectively. Mean dsDNA was higher and mean C3 was lower (52.35 ± 22.21 mg/dl) in active LN. Mean 24-hour urinary protein was higher in LN without activity. Serum creatinine was raised in active LN. LN class III and IV showed higher activity than chronicity.

Conclusions

Pediatric LN is proliferative and more active as compared with adult counterparts. Activity scores are much higher than chronicity scores.

FcγRIIA expression accelerates nephritis and increases platelet activation in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune inflammatory disease characterized by deposits of immune complexes (ICs) in organs and tissues. The expression of FcγRIIA by human platelets, which is their unique receptor for immunoglobulin G antibodies, positions them to ideally respond to circulating ICs. Whereas chronic platelet activation and thrombosis are well-recognized features of human SLE, the exact mechanisms underlying platelet activation in SLE remain unknown. Here, we evaluated the involvement of FcγRIIA in the course of SLE and platelet activation. In patients with SLE, levels of ICs are associated with platelet activation. Because FcγRIIA is absent in mice, and murine platelets do not respond to ICs in any existing mouse model of SLE, we introduced the FcγRIIA (FCGR2A) transgene into the NZB/NZWF1 mouse model of SLE. In mice, FcγRIIA expression by bone marrow cells severely aggravated lupus nephritis and accelerated death. Lupus onset initiated major changes to the platelet transcriptome, both in FcγRIIA-expressing and nonexpressing mice, but enrichment for type I interferon response gene changes was specifically observed in the FcγRIIA mice. Moreover, circulating platelets were degranulated and were found to interact with neutrophils in FcγRIIA-expressing lupus mice. FcγRIIA expression in lupus mice also led to thrombosis in lungs and kidneys. The model recapitulates hallmarks of human SLE and can be used to identify contributions of different cellular lineages in the manifestations of SLE. The study further reveals a role for FcγRIIA in nephritis and in platelet activation in SLE.

Treatment of severe thrombocytopenia associated with systemic lupus erythematosus in pregnancy with eltrombopag: A case report and literature review

WHAT IS KNOWN AND OBJECTIVE

Severe thrombocytopenia associated with systemic lupus erythematosus (SLE) in pregnancy is infrequent. Its occurrence can lead to serious adverse pregnancy consequences and perinatal complications. The thrombopoietin (TPO) analogue eltrombopag has been successfully used in the treatment of autoimmune thrombocytopenia, but its safety and efficacy in severe thrombocytopenia during pregnancy remain unclear.

CASE SUMMARY

We report a 33-year-old woman with SLE at 29 + 3 weeks gestational age who developed severe thrombocytopenia with complaints of epistaxis, gum bleeding and haematuresis. Most conventional treatments including glucocorticoids, intravenous immunoglobulin (IVIG) and cyclosporine did not elevate her platelets, but eltrombopag worked well and her platelet count gradually recovered, allowing her to deliver a healthy baby at 36 + 3 weeks gestational age.

WHAT IS NEW AND CONCLUSION

This suggests that eltrombopag in combination with glucocorticoids has a good safety and efficacy profile in pregnant patients with SLE complicated by severe thrombocytopenia.

Hematological Manifestations among Patients with Rheumatic Diseases

BACKGROUND

Rheumatic diseases have many hematological manifestations. Blood dyscrasias and other hematological abnormalities are sometimes the first sign of rheumatic disease. In addition, novel antirheumatic biological agents may cause cytopenias.

SUMMARY

The aim of this review was to discuss cytopenias caused by systemic lupus erythematosus and antirheumatic drugs, Felty's syndrome in rheumatoid arthritis, and autoimmune hemolytic anemia, thrombosis, and thrombotic microangiopathies related to rheumatological conditions such as catastrophic antiphospholipid syndrome and scleroderma renal crisis. Key Message: The differential diagnosis of various hematological disorders should include rheumatic autoimmune diseases among other causes of blood cell and hemostasis abnormalities. It is crucial that hematologists be aware of these presentations so that they are diagnosed and treated in a timely manner.

Understanding Risk Factors for Poor Outcomes in a Multiethnic Longitudinal Cohort: The LUMINA (Lupus in Minorities: Nature vs. Nurture) Experience (LUMINA LXXXII)

The Lupus in Minorities: Nature Vs Nurture (LUMINA) cohort has placed Hispanics on the lupus map in the United States. Texan Hispanic and African American patients experience, overall, worse outcomes than the Caucasian and Puerto Rican Hispanic patients. The genetic component of ethnicity is important early in the disease course whereas socioeconomic factors become more important subsequently. The role of hydroxychloroquine in preventing damage accrual and reducing mortality in lupus patients is a major contribution of LUMINA.

Prevalence and influential factors of thrombocytopaenia in systemic lupus erythematosus patients: a retrospective analysis of 3140 cases in a Chinese population

Introduction

The present study aimed to investigate the prevalence and influential factors of thrombocytopaenia in systemic lupus erythematosus (SLE) patients among the Chinese population in order to provide evidence for improving the treatment and nursing of SLE patients.

Methods

A retrospective analysis of 3140 SLE patients admitted to two large tertiary hospitals was conducted in Anhui, China, from 2011 to 2018. In addition, the influential factors related to SLE with thrombocytopaenia were analysed through univariate and multivariate analysis.

Results

A total of 804 SLE patients had thrombocytopaenia (25.6%). The top 5 clinical manifestations of SLE inpatients were proteinuria (51.0%), lupus nephritis (45.9%), new rash (38.4%), haematuria (36.7%) and pyuria (32.2%). The incidence of neurological manifestations, oral mucosal ulceration, pleurisy, pericarditis, hyperglycaemia, leucocytopaenia, urinary casts, haematuria, pyuria and high disease activity in the thrombocytopaenia group were higher than those in the non-thrombocytopaenia group ( p < 0.05). Multivariate analysis showed age (odds ratio (OR) = 1.009, p = 0.005), neurological manifestations (OR = 1.373, p = 0.048), pericarditis (OR = 1.394, p = 0.048), hyperglycaemia (OR = 1.717, p < 0.001), leucocytopaenia (OR = 2.551, p < 0.001), haematuria (OR = 1.582, p < 0.001), serum C3 level <0.85 g/L (OR = 1.525, p = 0.001), serum C4 concentration <0.10 g/L (OR = 1.287, p = 0.020), serum CRP concentration <8 ng/L (OR = 1.314, p = 0.005), prothrombin time >15.30 seconds (OR = 1.479, p = 0.032), activated partial thromboplatin time >45 seconds (OR = 1.924, p < 0.001) and thrombin time >21 seconds (OR = 1.629, p = 0.015) were associated with thrombocytopaenia.

Conclusion

Thrombocytopaenia has a high prevalence in SLE patients and is related to some baseline, clinical and laboratory characteristics, affecting multiple organs and systems.

Treatment of primary and secondary immune thrombocytopenia

PURPOSE OF REVIEW

Medical therapies for the treatment of immune thrombocytopenia (ITP) complicating SLE are increasingly being investigated as alternatives to splenectomy and IVIG. The purpose of this review is to highlight the therapies that are utilized in the treatment of primary ITP and ITP secondary to lupus.

RECENT FINDINGS

Corticosteroids are still the standard initial treatment of ITP, with the addition of IVIG when a rapid response is needed. There are few studies dedicated to assessing the efficacy of disease-modifying antirheumatic (DMARD), biologic, and nonimmunosuppressive agents as treatment for lupus thrombocytopenia/lupus ITP. Rituximab and thrombopoeitin mimetics have been the most extensively studied therapies for primary ITP in recent years. Results of trials show adequate initial responses; however, the duration of therapy and sustainability of responses are variable. Splenectomy is less often utilized.

SUMMARY

Although corticosteroids, intravenous immunoglobulin and splenectomy have proven to be effective measures to treat immune thrombocytopenia, newer studies have demonstrated positive outcomes of immunosuppressives and thrombopoeitin mimetics. In most cases, the reported duration of therapy was not prolonged. More studies are needed to fully assess the effect of medical therapy in lupus ITP and to determine how long to continue maintenance therapy.

Chinese SLE Treatment and Research group (CSTAR) registry: Clinical significance of thrombocytopenia in Chinese patients with systemic lupus erythematosus

Objectives

To investigate the prevalence, clinical characteristics, and prognosis of thrombocytopenia (TP) in Chinese patients with systemic lupus erythematosus (SLE).

Methods

The study was conducted based on the Chinese SLE Treatment and Research group (CSTAR) registry. Thrombocytopenia was defined as the platelet count<100,000/mm³ at enrollment. Severe thrombocytopenia was defined as the platelet count<50,000/mm³. The prevalence of SLE-related TP, the associations of thrombocytopenia with demographic data, organ involvements, laboratory findings, disease activity, damage, and mortality were investigated.

Results

Of 2104 patients with SLE, 342 patients (16.3%) were diagnosed with thrombocytopenia. The prevalence of neuropsychiatric SLE, vasculitis, myositis, nephritis, mucocutaneous lesions, pleuritis, fever, leukocytopenia and hypocomplementemia were significantly higher in patients with thrombocytopenia (p<0.05). SLE disease activity index (SLEDAI) was significantly higher in patients with thrombocytopenia (p<0.05). Multivariate analysis showed that leukocytopenia (OR = 2.644), lupus nephritis (OR = 1.539), hypocomplementemia (OR = 1.497) and elevated SLEDAI (OR = 1.318) were independently associated with thrombocytopenia (p<0.05). Long disease duration (OR = 1.006) was an independent risk factor of severe thrombocytopenia, while anti-rRNP (OR = 0.208) was an independent protective factor of severe thrombocytopenia (p<0.05). Long disease duration was an independent risk factor of mortality in patients with thrombocytopenia (RR = 1.006). The 6-year survival of patients with thrombocytopenia was significantly lower than patients without thrombocytopenia (88.2% vs. 95.5%).

Conclusions

Thrombocytopenia was a common manifestation of SLE and was associated with leukocytopenia, nephritis and severe disease activity. Severe thrombocytopenia tended to occur in long-term and relatively inactive SLE. Patients with SLE-related thrombocytopenia has a decreased long-term survival rate. Long disease duration was an independent risk factor of mortality in patients with thrombocytopenia.

Misunderstandings Between Platelets and Neutrophils Build in Chronic Inflammation

Regulated hemostasis, inflammation and innate immunity entail extensive interactions between platelets and neutrophils. Under physiological conditions, vascular inflammation offers a template for the establishment of effective intravascular immunity, with platelets providing neutrophils with an array of signals that increase their activation threshold, thus limiting collateral damage to tissues and promoting termination of the inflammatory response. By contrast, persistent systemic inflammation as observed in immune-mediated diseases, such as systemic vasculitides, systemic sclerosis, systemic lupus erythematosus or rheumatoid arthritis is characterized by platelet and neutrophil reciprocal activation, which ultimately culminates in the generation of thrombo-inflammatory lesions, fostering vascular injury and organ damage. Here, we discuss recent evidence regarding the multifaceted aspects of platelet-neutrophil interactions from bone marrow precursors to shed microparticles. Moreover, we analyse shared and disease-specific events due to an aberrant deployment of these interactions in human diseases. To restore communications between the pillars of the immune-hemostatic continuum constitutes a fascinating challenge for the near future.

The non-haemostatic role of platelets in systemic lupus erythematosus

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

Patient perceptions and preferences of biologic therapies in SLE

Objective

To evaluate patient perceptions of biologic therapies from a large, population-based cohort of patients with SLE with significant numbers of blacks and whites and across the full spectrum of socioeconomic strata and disease severity.

Methods

This was a cross-sectional study of validated patients with SLE enrolled in the Georgians Organized Against Lupus Cohort between September 2014 and August 2015. The survey instrument was developed ad hoc by the authors and contained an introduction on biologics.

Results

A total of 676 participants were on average 48.4 years old with 15.9 years of disease; 93.2% were female and 80.6% were black; 34.2% had private health insurance and 9.8% had no insurance; and 26.8% and 27.5% had Medicare or Medicaid, respectively. Of all respondents, 30.8% had heard of biologics, with a significant difference between blacks and whites (25.2% vs 53.4%, respectively). There were no significant differences, however, between blacks and whites with respect to ever having been on biologics (7.6% and 11.5%, respectively) or where they got their information about biologics. Out of 202 individuals who had heard of biologics, 102 (51.3%) were familiar with potential benefits or side effects, and most (n=129, 66.5%) had a neutral perception to risks associated with biologic use. There was no perception of biologics working differently between races/ethnicities. More (n=76, 62.8%) blacks preferred intravenous over subcutaneous modalities compared with whites (n=12, 37.5%) but were not as willing to pay as much out of pocket for it. Individuals with Medicare were significantly more likely to have been on biologics.

Conclusions

There are important similarities and differences between blacks and whites with lupus with respect to their perceptions of biologic therapies and their impact. There are opportunities to increase patient exposure to information about biologics and improve their understanding in order for them to make the best informed decision possible.

Thrombocytopenia as a Prognostic Marker for Systemic Lupus Erythematosus: A Systematic Review and Meta-analysis

BACKGROUND

Systemic lupus erythematosus (SLE) patients often exhibit hematological abnormalities, but the role of thrombocytopenia on the prognosis of SLE shows inconsistent results. The purpose of this meta-analysis was to confirm the impact of thrombocytopenia on mortality and end organ damage in patients with SLE.

MATERIALS AND METHODS

Three electronic databases, PubMed, Embase and Cochrane library were systematically searched to identify the eligible studies from inception to November 2017 in order to evaluate the impact of thrombocytopenia on the prognosis of patients with SLE. The summary odds ratios (ORs) and 95% confidence intervals (CIs) were used to measure the impact of thrombocytopenia on mortality and end organ damage based on the random-effects model.

RESULTS

A total of 8 studies that reported data on 2,158 patients with SLE were included. The summary OR indicated that SLE subjects with thrombocytopenia were significantly associated with an increased risk of mortality (OR: 4.57; 95% CI: 2.28-9.17; P < 0.001) and end-organ damage (OR: 3.31; 95% CI: 1.11-9.86; P = 0.031). Furthermore, the sensitivity analysis indicated stable mortality, while the result for end organ damage was variable. In addition, the patients with thrombocytopenia with disease duration <60 months presented a greater risk for mortality than those with disease duration ≥60.0 months (P = 0.002).

CONCLUSIONS

Patients with SLE and thrombocytopenia were found to be associated with an increased risk of mortality and end organ damage.

Mortality in autoimmune rheumatic diseases with anti-Ro/SSA antibody in Korea: Single center-based retrospective study

AIM

The clinical importance of the anti-Ro antibody has not been completely understood. This study investigated identification of the association between mortality and clinical features in patients with autoimmune rheumatic diseases and detectable anti-Ro antibody titers.

METHODS

We retrospectively analyzed a total of 336 patients with autoimmune rheumatic diseases and positive anti-Ro antibody titers from January 2012 to January 2015. Clinical manifestations and other autoantibodies detected during the follow-up period were identified. Cumulative survival rates were assessed by Kaplan-Meier analysis. Differences between survival curves for each risk factor were analyzed by log-rank test. The relative risk of mortality was assessed using standardized mortality ratios (SMRs).

RESULTS

There was no difference in the mortality rates of patients with autoimmune rheumatic diseases with or without detectable anti-Ro antibody (SMR: 1.373, 95% CI: 0.539-2.791). Six patients (4 with systemic lupus erythematosus [SLE] and two with Sjögren's syndrome [SS]) died during the follow-up period. In the whole study population, the mortality rate of patients with lymphopenia was higher than those without lymphopenia (P = 0.023). In a sub-group of patients with both SLE and SS, Kaplan-Meier analysis showed that lymphopenia and interstitial lung disease were associated with increased mortality (P = 0.024 and P = 0.023, respectively).

CONCLUSION

This study demonstrated that presence of the anti-Ro antibody was not associated with increased mortality in patients with autoimmune rheumatic disease. Conversely, we found that lymphopenia was independently associated with mortality in patients with autoimmune rheumatic disease.

How can we define low disease activity in systemic lupus erythematosus?

BACKGROUND

In recent years, low disease activity emerged as a state that is associated with improved long-term outcomes in systemic lupus erythematosus (SLE). Our aim was to review the current concepts for low disease activity in SLE in order to serve as the basis of a future consensus for standardization.

METHODS

The PubMed database was searched for relevant articles from inception up to July 2018. Medical Subject Headings (MeSH terms) included "lupus" AND "low disease activity" OR "minimal disease activity".

RESULTS

Three different definitions of low disease activity in lupus have been proposed. Minimal disease activity (MDA) is defined as a clinical SLE Disease Activity Index 2000 (SLEDAI-2K)≤1 on antimalarials, immunosuppressives in standard doses and prednisone ≤5 mg/day. Low disease activity (LDA) allows for a clinical SLEDAI-2K≤2 maintained on antimalarials only. Lupus Low Disease Activity State (LLDAS) accepts a SLEDAI-2K≤4 with no activity from major organ systems, a Physician's Global Assessment of ≤1 with no new activity, prednisone dose ≤7.5 mg/day and standard doses of antimalarials, immunosuppressives and biologics. Active serology (anti-dsDNA and complement C3/C4) is not included in the MDA and LDA but counts towards disease activity in the LLDAS definition. All definitions were associated with less damage-accrual and mortality in the long-term that were comparable to those of clinical remission.

CONCLUSIONS

There is solid evidence that low disease activity is associated with improved outcomes in SLE and could serve as a therapeutic target in daily practice and clinical trials. Future research should focus on advancing a consensus for the best possible definition.

Retrospective analysis of the risk of hemorrhage associated with moderate and severe thrombocytopenia of 173 patients with systemic lupus erythematosus

The aim of the study was to observe the risk of hemorrhage from moderate and severe thrombocytopenia in systemic lupus erythematosus (SLE).A retrospective analysis was undertaken of cases admitted to Qilu Hospital, China. Blood platelet counts (BPCs) of ≤20 × 10/L represent severe thrombocytopenia, and a BPC of 21 to 50 × 10/L indicates moderate thrombocytopenia. A comparison was made from the perspective of severity with a view to determine the influence of thrombocytopenia on the risk of hemorrhage and the results.Moderate and severe thrombocytopenia occurred in 173 cases, accounting for 15.2% of the total hospitalized patients with SLE with a male to female ratio of 1:23.7. The average age of those patients was 34.8 ± 14.6 years. In the group of severe thrombocytopenia, patients without visceral involvement had a mean age of onset of 31.4 ± 14.2 years with a median of 28.0 years compared with 37.8 ± 14.8 years with a median of 38.5 years for patients with visceral involvement; this difference was statistically significant (P = .034). Seventy-one (76.3%) of 93 patients with severe thrombocytopenia and 20 (25.0%) of 80 patients with moderate thrombocytopenia developed hemorrhagic conditions of various grades, the difference between both were markedly statistically significant. Twenty-three patients with SLE died. Nine deaths were due to a hemorrhage caused by thrombocytopenia, while more were caused by infection.Severe thrombocytopenia is a significant adverse prognostic factor of SLE. SLE with the main manifestation of thrombocytopenia tends to make younger visceral organ owners suffer.

Clinical and Serologic Features in Patients With Incomplete Lupus Classification Versus Systemic Lupus Erythematosus Patients and Controls

OBJECTIVE

Incomplete lupus erythematosus (ILE) involves clinical and/or serologic manifestations consistent with but insufficient for systemic lupus erythematosus (SLE) classification. Because the nature of ILE is poorly understood and no treatment recommendations exist, we examined the clinical manifestations, medication history, and immunologic features in a diverse collection of ILE and SLE patients.

METHODS

Medical records of subjects enrolled in the Lupus Family Registry and Repository were reviewed for medication history and American College of Rheumatology (ACR) classification criteria to identify ILE patients (3 ACR criteria; n = 440) and SLE patients (≥4 ACR criteria; n = 3,397). Participants completed the Connective Tissue Disease Screening Questionnaire. Anticardiolipin and plasma B lymphocyte stimulator (BLyS) were measured by enzyme-linked immunosorbent assay, antinuclear antibodies (ANAs) by indirect immunofluorescence, and 13 autoantibodies by bead-based assays.

RESULTS

On average, ILE patients were older than SLE patients (46.2 years versus 42.0 years; P < 0.0001), and fewer ILE patients were African American (23.9% versus 32.2%; P < 0.001). ILE patients exhibited fewer autoantibody specificities than SLE patients (1.3 versus 2.6; P < 0.0001) and were less likely to have ANA titers ≥1:1,080 (10.5% versus 19.5%; P < 0.0001). BLyS levels were intermediate in ILE patients (controls < ILE; P = 0.016; ILE < SLE; P = 0.008). Pericarditis, renal, or neurologic manifestations occurred in 12.5% of ILE patients and were associated with non-European American race/ethnicity (P = 0.012). Hydroxychloroquine use increased over time, but was less frequent in ILE than SLE patients (65.2% versus 83.1%; P < 0.0001).

CONCLUSION

Although usually characterized by milder symptoms, ILE manifestations may require immunomodulatory treatments. Longitudinal studies are necessary to understand how ILE affects organ damage and future SLE risk, and to delineate molecular pathways unique to ILE.

Distinct clinical correlates of immune thrombocytopenic purpura at diagnosis of childhood-onset and adult SLE

OBJECTIVES

To compare clinical and laboratorial features between childhood-onset systemic lupus erythematosus (cSLE) and adult SLE (aSLE) at concomitant diagnosis of immune thrombocytopenic purpura (ITP).

METHODS

This study evaluated 56 cSLE and 73 aSLE patients regularly followed at Pediatric and Rheumatology Divisions of the same University hospital with ITP (platelets count <100,000/mm³ in the absence of other causes) at lupus onset.

RESULTS

Median current age was 11.6 and 27.3 years in cSLE and aSLE, respectively. cSLE had a higher frequency of ITP compared to aSLE (17% vs. 4%, p < .0001) and the former group had more hemorrhagic manifestations (36% vs. 16%, p = .0143). Constitutional symptoms and reticuloendothelial manifestations (p < .05), as well as pericarditis (25% vs. 10%, p = .029) and central nervous system (CNS) involvement (30% vs. 14%, p = .029) were more common in cSLE. Conversely, in aSLE, ITP was solely associated with cutaneous and articular involvements (p < .05). Concerning treatment, intravenous methylprednisolone, intravenous immunoglobulin, blood transfusion and platelets transfusion were more frequently used in the cSLE population (p < .05).

CONCLUSION

ITP at cSLE has distinct features compared to aSLE with a more severe presentation characterized by concomitant constitutional/reticuloendothelial manifestations, CNS involvement and hemorrhagic manifestation. These findings reinforce the need for a more aggressive treatment in this age group.

Prognostic significance of platelet count in SLE patients

Hematological abnormalities, especially thrombocytopenia (TCP), are highly prevalent among patients with systemic lupus erythematosus (SLE) and at the same time it has been reported as a significant prognostic factor of SLE course. We further investigate the correlation between platelet count and the clinical manifestations and disease activity of SLE, in a cohort of Saudi Arabian female patients. A retrospective analysis was done for the medical records of 100 SLE female patients, selected from all patients diagnosed and treated for SLE at the Rheumatology outpatient clinics in Hera'a General Hospital, Holly Makkah, Saudi Arabia. The data collected from every patient's file included laboratory investigations (complete blood count, platelet parameters, ESR, anti-double-stranded DNA antibody, ANA), clinical manifestations, as well as SLE disease activity index (SLEDAI-2k) scores throughout a period of six sequential follow-up visits. Patients were divided into three groups according to the SLEDAI-2k: mild, moderate, and high-activity group. We found that, out of 100 patients, TCP was the most prevalent hematological abnormality evident in 15%, more than leucopenia (14%) and anemia (2%). TCP was acute in onset and associated with arthritis, neurologic manifestations, and nephritis. Platelet count showed a significant negative correlation with disease activity, in all of the three groups of patients. We concluded that platelet count has a negative correlation with disease activity in SLE patients, whatever the associated manifestations, and it should be considered as a prognostic factor, identifying patients with aggressive disease course.

Bone Marrow Megakaryocytes May Predict Therapeutic Response of Severe Thrombocytopenia in Patients with Systemic Lupus Erythematosus

Objective.

To analyze the predictive value of megakaryocyte counts in bone marrow (BM-MK) for determining the therapeutic response of severe thrombocytopenia (TP) in patients with systemic lupus erythematosus (SLE).

Methods.

Thirty-five patients with SLE with severe TP (platelet count ≤ 50 × 109/l) from the Peking Union Medical College Hospital admitted between 2007 and 2014 with appreciable bone marrow aspiration results were analyzed retrospectively. The associations between therapeutic response and clinical manifestations, laboratory findings including BM-MK counts, were evaluated.

Results.

Seventeen (49%) and 8 (23%) patients achieved a complete response (CR) and a partial response (PR), respectively, and 10 had no response (NR). The BM-MK counts in each group were 102 ± 25 (0–322), 136 ± 48 (2–419), and 28 ± 12 (0–105) per slide, respectively. Significant differences were observed in the counts of BM-MK between patients who achieved a clinical response (CR + PR) and those who did not (NR; p = 0.007). Patients in the NR group exhibited fewer BM-MK compared with those in the CR and PR groups (p = 0.017 and p = 0.006, respectively). A receiver-operation characteristic analysis identified that a cutoff value of BM-MK counts at 20 performed pretty well in discriminating patients with differential responses to immunotherapy, with sensitivity and specificity and area under the curve of 88%, 70%, and 0.798, respectively.

Conclusion.

BM-MK count may serve as a good predicting factor for immunotherapeutic response in patients with SLE with severe TP. Patients with BM-MK counts < 20 per slide tend to exhibit poor clinical response.

Development and validation of a simple lupus severity index using ACR criteria for classification of SLE

Objective

To develop a simple systemic lupus erythematosus (SLE) severity index that requires knowledge of only American College of Rheumatology (ACR) criteria and subcriteria.

Methods

This study used demographic, mortality and medical records data of 1915 patients with lupus from the Lupus Family Registry and Repository. The data were randomly split (2:1 ratio) into independent training and validation sets. A logistic regression with ridge penalty was used to model the probability of being prescribed major immunosuppressive drugs—a surrogate indicator of lupus severity. ACR criteria and subcriteria were used as predictor variables in this model, and the resulting regression coefficient estimates obtained from the training data were used as item weightings to construct the severity index.

Results

The resulting index was tested on the independent validation dataset and was found to have high predictive accuracy for immunosuppressive use and early mortality. The index was also found to be strongly correlated with a previously existing severity score for lupus. In addition, demographic factors known to influence lupus severity (eg, age of onset, gender and ethnicity) all showed robust associations with our severity index that were consistent with observed clinical trends.

Conclusions

This new index can be easily computed using ACR criteria, which may be among the most readily available data elements from patient medical records. This tool may be useful in lupus research, especially large dataset analyses to stratify patients by disease severity, an important prognostic indicator in SLE.

Thrombocytopenia in Systemic Lupus Erythematosus: Clinical Manifestations, Treatment, and Prognosis in 230 Patients

The aim of the study was to examine the clinical characteristics and prognosis according to severity of thrombocytopenia and response to treatment for thrombocytopenia in patients with systemic lupus erythematosus (SLE).We retrospectively evaluated 230 SLE patients with thrombocytopenia, and reviewed their clinical data and laboratory findings. Thrombocytopenia was defined as platelet counts under 100,000/mm, and patients were divided into 3 thrombocytopenia groups according to severity: mild (platelet counts >50,000/mm), moderate (>20,000/mm, ≤50,000/mm), and severe (≤20,000/mm). Clinical characteristics, treatments, and prognoses were compared among the groups. Furthermore, complete remission of thrombocytopenia was defined as platelet counts >100,000/mm after treatment.There was no significant difference in clinical or laboratory findings among the groups according to severity of thrombocytopenia. However, hemorrhagic complications were more frequent in severe thrombocytopenia (P < 0.001) and mortality was also higher (P = 0.001). Complete remission was achieved in 85.2% of patients. The clinical characteristics and modality of treatment did not differ between the patients with and without complete remission. Mortality in patients with complete remission (1.5%) was significantly lower than in those without complete remission (29.4%, P < 0.001). Survival was significantly higher in patients with complete remission from thrombocytopenia (odds ratio = 0.049, 95% confidence interval: 0.013-0.191, P < 0.001).The severity of thrombocytopenia in SLE patients can be a useful independent prognostic factor to predict survival. Moreover, complete remission of thrombocytopenia after treatment is an important prognostic factor. The severity of thrombocytopenia and response to treatment should be closely monitored to predict prognosis in SLE patients.

Features associated with hematologic abnormalities and their impact in patients with systemic lupus erythematosus: Data from a multiethnic Latin American cohort

OBJECTIVE

To examine hematological manifestations' correlates and their impact on damage accrual and mortality in SLE patients from the multiethnic, Latin American, GLADEL cohort.

METHODS

In patients with recent SLE diagnosis (≤2 years), the association between follow-up hematological manifestations (per ACR criteria) and socio-demographic and clinical variables was examined by univariable and multivariable logistic regressions; their impact on damage accrual and mortality was examined by Poisson and Cox proportional-hazards regression analyses, respectively.

RESULTS

Of 1437 patients, 948 (66.0%) developed ≥1 hematological manifestation [5.5% hemolytic anemia (AHA), 16.3% thrombocytopenia, and 56.4% lymphopenia] over 4.3 (3.3) follow-up years. Younger age, Mestizo ethnicity, hematologic disorder (at/or before SLE diagnosis), and first damage recorded were associated with hematological manifestations while antimalarials were negatively associated. AHA (at/or before SLE diagnosis), anti-Sm, and anti-RNP antibodies were associated with subsequent AHA occurrence while musculoskeletal involvement was negatively associated. Thrombocytopenia (at/or before SLE diagnosis), AHA, anti-phospholipid antibodies (aPLs), anti-SSA/Ro, anti-SSB/La antibodies, and first damage recorded were associated with later thrombocytopenia occurrence. Lymphopenia (at/or before SLE diagnosis), younger age at diagnosis, Mestizo ethnicity, having medical insurance, and first damage recorded were associated with subsequent lymphopenia occurrence while antimalarials and azathioprine treatment were negatively associated. AHA was associated with damage accrual and mortality after adjusting for variables known to affect these outcomes.

CONCLUSIONS

Mestizo ethnicity and early hematological manifestations are risk factors for their subsequent occurrence while antimalarials have a protective effect. The associations between AHA and aPLs and thrombocytopenia were corroborated. AHA contributes independently to damage accrual and diminished survival.

Platelet Activation and Thrombus Formation over IgG Immune Complexes Requires Integrin αIIbβ3 and Lyn Kinase

IgG immune complexes contribute to the etiology and pathogenesis of numerous autoimmune disorders, including heparin-induced thrombocytopenia, systemic lupus erythematosus, rheumatoid- and collagen-induced arthritis, and chronic glomerulonephritis. Patients suffering from immune complex-related disorders are known to be susceptible to platelet-mediated thrombotic events. Though the role of the Fc receptor, FcγRIIa, in initiating platelet activation is well understood, the role of the major platelet adhesion receptor, integrin αIIbβ3, in amplifying platelet activation and mediating adhesion and aggregation downstream of encountering IgG immune complexes is poorly understood. The goal of this investigation was to gain a better understanding of the relative roles of these two receptor systems in immune complex-mediated thrombotic complications. Human platelets, and mouse platelets genetically engineered to differentially express FcγRIIa and αIIbβ3, were allowed to interact with IgG-coated surfaces under both static and flow conditions, and their ability to spread and form thrombi evaluated in the presence and absence of clinically-used fibrinogen receptor antagonists. Although binding of IgG immune complexes to FcγRIIa was sufficient for platelet adhesion and initial signal transduction events, platelet spreading and thrombus formation over IgG-coated surfaces showed an absolute requirement for αIIbβ3 and its ligands. Tyrosine kinases Lyn and Syk were found to play key roles in IgG-induced platelet activation events. Taken together, our data suggest a complex functional interplay between FcγRIIa, Lyn, and αIIbβ3 in immune complex-induced platelet activation. Future studies may be warranted to determine whether patients suffering from immune complex disorders might benefit from treatment with anti-αIIbβ3-directed therapeutics.

Chronic active disease pattern predicts early damage in juvenile systemic lupus erythematosus

OBJECTIVE

The objective of this article is to assess disease activity patterns and their relationship to damage, death and growth failure in a cohort of juvenile lupus.

METHODS

Chronic active, relapsing-remitting and long quiescent activity patterns were retrospectively classified according to longitudinal scores of both the Modified SLEDAI-2K and ECLAM. The Pediatric SLICC/ACR Damage Index (Ped-SDI) was scored at the last visit in patients followed more than six months. Survival analysis was performed considering death, damage and growth failure, and stratified according to disease activity patterns. Cox model analysis identified predictors for damage and growth failure among onset clinical variables.

RESULTS

Thirty-seven patients with 11 years mean age at diagnosis and 3.2 years mean follow-up were studied. According to the Modified SLEDAI-2K, activity pattern was 67.5% relapsing-remitting, 29.8% chronic active and 2.7% long quiescent and by ECLAM, 45.9%, 48.7% and 5.4%, respectively. The five-year survival was 90%. Damage accrued in 62.5% and growth failure in 31.3%. Chronic active cases progressed to damage earlier than relapsing-remitting (log-rank test, p < 0.05). Damage was associated with disease duration (p < 0.0001), thrombocytopenia (p < 0.05) and alopecia (p < 0.004). Growth failure was associated with disease duration (p < 0.007) and renal failure (p < 0.007).

CONCLUSION

Damage was observed in nearly two-thirds of patients, and occurred earlier in the chronic active pattern. Disease duration, thrombocytopenia and alopecia at onset predicted damage.

Clinical features and outcome of pregnancy with SLE-associated thrombocytopenia

OBJECTIVE

To analyze the course of maternal diseases and compare pregnancy outcomes in patients with systemic lupus erythematosus (SLE)-associated thrombocytopenia to patients without.

METHODS

Medical charts of 77 pregnancies in 73 SLE patients were systematically reviewed. Patients were divided into two groups according to the presence or absence of thrombocytopenia. Patients who are new onset SLE during pregnancy were also been studied.

RESULT

Thrombocytopenia was found in 18 (23.3%) of the pregnancies. SLE patients with thrombocytopenia during pregnancy had higher percentage of disease flaring (11/18 versus 14/59, p = 0.003) and SLE-Pregnancy Disease Activity Index (7.89 ± 6.192 versus 2.41 ± 3.3.89, p = 0.001) compared to patients without. Also, patients with thrombocytopenia had a higher percentage of pulmonary, cardiac and multiple organ system involvement. There was a statistically significant difference in preeclampsia and early onset hypertensive disorder induced before 34 weeks as well as the rate of live birth less than 34 weeks (33.3% versus 6.8%, p = 0.003 & 38.9% versus 13.6%, p = 0.018 & 16.7% versus 1.7%, p = 0.038). Patients with thrombocytopenia suffered from higher rate of pregnancy loss (22.2% versus 3.4%, p = 0.024) and neonatal death (33.3% versus 1.7%, p = 0.000). In our study there were 17 patients with new-onset of SLE during pregnancy. The hematological system manifestation occurred in all of them and there was a significant increase in the incidence of thrombocytopenia (n = 12, 70.6%).

CONCLUSION

Thrombocytopenia in SLE during pregnancy indicates higher disease activity, severe organ damage, early onset preeclampsia and higher pregnancy loss.

An integrated extrapolation of long-term outcomes in systemic lupus erythematosus: analysis and simulation of the Hopkins lupus cohort

OBJECTIVE

The aim of this study was to develop an SLE disease model that simulates long-term outcomes of SLE to estimate the long-term effectiveness and cost-effectiveness of SLE treatments.

METHODS

Longitudinal data from 1354 patients from the Hopkins Lupus Cohort were included in the analysis. Statistical models were created to estimate disease activity [Safety of Estrogen in Lupus Erythematosus National Assessment (SELENA) SLEDAI scale] and prednisone dose over time using linear regression. Survival models for organ damage and mortality were created. The models were combined in a predictive simulation of SLE organ damage and mortality. Predictions were assessed against the Hopkins Lupus Cohort data.

RESULTS

The analyses found that change in the annual average SLEDAI score was associated with the previous annual average SLEDAI score, renal involvement, age, male gender, African American ethnicity, anaemia, haematological involvement, increased DNA binding and low complement. The annual average prednisone dose increased for every unit increase in annual average SLEDAI. Organ damage and mortality modelling demonstrated that adjusted mean SLEDAI and binary SLEDAI organ involvement indicators predicted mortality, cardiovascular, renal, neuropsychiatric, pulmonary, gastrointestinal, ocular and skin damage. The cumulative average prednisone dose was associated with risk of cardiovascular, ocular, musculoskeletal, neuropsychiatric and gastrointestinal damage, gonadal failure and diabetes mellitus. The simulation reproduced mean SLEDAI and organ damage scores from the Hopkins Lupus Cohort.

CONCLUSION

Longitudinal modelling of an SLE cohort confirmed relationships between risk factors and long-term outcomes in SLE. The models serve to estimate the probability of SLE outcomes over time and can be used to estimate the effectiveness and cost-effectiveness of new treatments.

Clinical characteristics and risk factors of intracranial hemorrhage in systemic lupus erythematosus

We enrolled and reviewed 26 medical records of systemic lupus erythematosus (SLE) with intracranial hemorrhage (cases) and 104 randomly matched records of SLE without intracranial hemorrhage (controls) out of 6653 admitted patients at Peking Union Medical College Hospital from 1994 to 2012, to analyze the clinical characteristics and risk factors of intracranial hemorrhage in SLE. The incidence of SLE with intracranial hemorrhage was only 0.39% within the last 18 years at Peking Union Medical College Hospital. However, the in-hospital fatality rate was quite high (23.1%). Headache was the most common symptom (53.5%) in SLE patients with intracranial hemorrhage. The anatomical localization of the hemorrhages in the brain was predominantly located in the cerebrum. Intracranial hemorrhage could happen in either stable or active SLE patients. SLE patients with intracranial hemorrhage presented other neuropsychiatric syndromes defined by the American College of Rheumatology (ACR) in 1999, thrombocytopenia and antiphospholipid syndrome more frequently than controls. Thrombocytopenia was the independent risk factor for intracranial hemorrhage coexisting with SLE (OR=3.687, 95% CI 1.510-9.001, p=0.004).

Acute presentation of thrombocytopaenia in systemic lupus erythematosus is associated with a high mortality in South Africa

The objective of this study was to determine the pattern of presentation, response to treatment, and outcome in patients with systemic lupus erythematosus (SLE) and thrombocytopaenia (TCP). A retrospective review of the records of patients with SLE and TCP and a matched control group of SLE patients without TCP, seen in the rheumatology department in Durban, South Africa, was performed. The demographic data, clinical findings, laboratory findings, treatment and outcome were recorded. There were 54 patients and an equal number of controls. They comprised 30 Indians and 24 African Blacks, median age of 33 years and female to male ratio 5.8:1. A group of eight patients who initially presented with idiopathic thrombocytopaenic purpura (ITP) and subsequently developed SLE were analysed separately. An acute presentation was noted in 31 patients (57%). Patients with an acute presentation had an increased prevalence of renal disease (77% vs 43.5%; p=0.01) and an increased number of deaths (38.7% vs 4.4%; p=0.004). The majority of patients responded to corticosteroids (68.5%) and splenectomy. There was an increased prevalence of renal disease (p=0.03) and deaths (p=0.004) among patients with TCP. The majority of deaths had an acute presentation ((12/13; 92.3%) (p=0.004)), and were due to infection and active lupus. TCP with an acute presentation is associated with a high mortality and predicts survival in SLE.

Clinical implications and prognostic significance of thrombocytopenia in Tunisian patients with systemic lupus erythematosus

Objective: The objective of this study was to determine the role of thrombocytopenia in terms of disease manifestations, disease activity and prognostic impact in a cohort of Tunisian systemic lupus erythematosus (SLE) patients. Methods: The charts of 182 SLE patients diagnosed between 1996 and 2009 were retrospectively reviewed. The clinical manifestations, immunological profiles, disease activity, SLE relapses and survival rate at the time of follow-up were recorded. Results: Thrombocytopenia (<100,000/mm3) and severe thrombocytopenia (<20,000/mm3) was observed in 19.2% and 4.4%, respectively. Hemorrhagic manifestations were observed in 11 patients (31.4%). Thrombocytopenia was significantly associated with splenomegaly, renal disorders, neurologic manifestations, arterial thrombosis, leucopenia, low C3 level at SLE diagnosis, SLE relapses and infectious complications. Using multivariate logistic regression, thrombocytopenia was independently associated with splenomegaly (odds ratio [OR] = 9.36, p = 0.001), neurologic manifestations (OR = 4.6, p = 0.006) and renal disease (OR = 4.15, p = 0.02). By multivariable Cox proportional hazard regression analyses, thrombocytopenia was associated with the occurrence of mortality after adjusting for variables known to influence it (hazard ratio [HR] = 1.79, p = 0.045). The cause of death was unrelated to hemorrhagic complications in all patients. Conclusion: Our results, concerning North-African SLE patients, confirm the findings of previous studies which suggest that thrombocytopenia correlates with more severe disease and has a negative impact on the survival of lupus patients.

Analysis of 12,517 inhabitants of a Sardinian geographic isolate reveals that predispositions to thrombocytopenia and thrombocytosis are inherited traits

BACKGROUND

Thrombocytopenia is a common finding in several diseases but almost nothing is known about the prevalence of thrombocytopenia in the general population. We examined the prevalence of thrombocytopenia and determinants of platelet count in a healthy population with a wide age range.

DESIGN AND METHODS

We performed a cross-sectional study on 12,517 inhabitants of ten villages (80% of residents) in a secluded area of Sardinia (Ogliastra). Participants underwent a complete blood count evaluation and a structured questionnaire, used to collect epidemiological data.

RESULTS

We observed a platelet count lower than 150 × 10⁹/L in 3.2% (2.8%-3.6%) of females and 4.8% (4.3%-5.4%) of males, with a value of 3.9% (3.6%-4.3%) in the entire population. Thrombocytopenia was mild (platelet count: 100 × 10⁹/L-150 × 10⁹/L), asymptomatic and not associated with other cytopenias or overt disorders in most cases. Its standardized prevalence was quite different in different villages, with values ranging from 1.5% to 6.8%, and was negatively correlated with the prevalence of a mild form of thrombocytosis, which ranged from 0.9% to 4.5%. Analysis of platelet counts across classes of age revealed that platelet number decreased progressively with aging. As a consequence, thrombocytopenia was nearly absent in young people and its prevalence increased regularly during lifetime. The opposite occurred for thrombocytosis.

CONCLUSIONS

Given the high genetic differentiation among Ogliastra villages with "high" and "low" platelet counts and the substantial heritability of this quantitative trait (54%), we concluded that the propensity to present mild and transient thrombocytosis in youth and to acquire mild thrombocytopenia during aging are new genetic traits.

Livedoid vasculopathy and recurrent thrombosis in a patient with lupus: seronegative antiphospholipid syndrome?

Livedoid vasculopathy is a rare condition which predominantly affects young women. It is characterized by intense painful purpuric maculae in the legs, ankles and feet, due to thrombosis of the small and medium-sized dermal vessels, in the absence of vasculitis. Livedoid vasculopathy has been frequently associated with hypercoagulable states and antiphospholipid syndrome. We describe a 34-year-old White woman suffering from systemic lupus erythematosus, livedo reticularis, haemolytic anaemia, severe thrombocytopenia and recurrent venous thrombosis who was admitted to the hospital for extremely painful purpuric lesions in her lower limbs. The clinical and histological findings were diagnostic of livedoid vasculopathy. Once the initial sub-therapeutic international normalized ratio levels were corrected, livedoid vasculopathy did not recur. Tests for antiphospholipid antibodies were repeatedly negative. This case, the first reported of livedoid vasculopathy in a patient with seronegative antiphospholipid syndrome and systemic lupus erythematosus, draws attention to livedoid vasculopathy, a thrombotic dermopathy that may be under-diagnosed in patients with antiphospholipid syndrome.

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.

Prognostic impact of atypical presentation in pediatric systemic lupus erythematosus: results from a multicenter study

OBJECTIVES

The aim of the study is to assess the rate of atypical manifestations at onset in pediatric systemic lupus erythematosus (SLE) and to evaluate their effect on disease outcome.

STUDY DESIGN

This is a multicenter retrospective cohort study. A manifestation was considered atypical if it was not included in the American College Rheumatology classification criteria for SLE but was reported in literature as associated with SLE. Unfavorable outcome was considered presence of organ damage in the Systemic Lupus International Collaborative Clinics/American College of Rheumatology Damage Index at the last available evaluation.

RESULTS

One hundred patients were enrolled in the study; 24% presented atypical clinical features at onset. Univariate analysis showed a significant association of worse outcome variables with the presence of atypical manifestations at onset (P = .004), as well as renal involvement (P = .027). A multivariate logistic regression analysis showed that atypical manifestations at onset (P = .018), renal involvement at onset or during follow up (P = .024), and central nervous system disease involvement during follow up (P = .021) were independent predictors of poor prognosis.

CONCLUSIONS

Our data support a relatively high rate of atypical onset in pediatric SLE. Presence of atypical manifestations at presentation and early kidney disease correlate with poor outcome. Similarly, during follow-up, kidney and central nervous system diseases are associated with worse outcome.

Use of rituximab in the treatment of refractory systemic lupus erythematosus: Singapore experience

We performed a retrospective study of 10 patients with refractory systemic lupus erythematosus treated with rituximab to determine the efficacy, safety and impact on hospitalization days. Patients received rituximab according to a standardized protocol, all achieved B-cell depletion with clinical improvement in nine patients. At 12 months, BILAG scores improved significantly from a median of 13.5 (range 3-20) at baseline to 1 (range 0-27) (p < 0.05). There was significant reduction in urinary total protein excretion with stabilization of renal function in patients with nephritis. Two out of three patients with thrombocytopenia had normalization of platelet counts. The median duration of B-cell depletion was 6 months (range 6-18). Two patients required retreatment and responded well. There were no adverse outcomes following rituximab therapy. Patients with lupus nephritis spent a median of 17.1 days per year (range 1.9-49) in hospital on conventional treatment which was reduced to 0 days (range 0-14.8, p = 0.027) post-rituximab treatment. The cost of hospitalization was 5989 Singapore dollars per patient-year while on conventional treatment and 5792 Singapore dollars per patient-year post-rituximab. This study adds to the growing literature of rituximab efficacy with potential cost saving in lupus nephritis.

SLE disease patterns in a Danish population-based lupus cohort: an 8-year prospective study

In 1995 all systemic lupus erythematosus (SLE) patients in the county of Funen were retrieved from four separate and independent sources as part of an 8-year prospective study to determine the pattern of disease activity and damage accumulation in a community based lupus cohort of predominantly Scandinavian ancestry. Incident cases were subsequently identified by surveillance of these sources. Established and new cases underwent annual, structured interviews, clinical examination and blood sampling. The Systemic Lupus Erythematosus Diseases Activity Index SLEDAI and Systemic Lupus International Collaborating Clinics SLICC scores were calculated. Flares were defined as modified — SLEDAI ≥ 4.

The annual flare rate in definite SLE (D-SLE) was 0.21 (95%CI 0.18—0.24) versus 0.03 (95%CI 0.01—0.07) in incomplete SLE (I-SLE). Forty-three per cent of the entire study population had no disease exacerbations. Infections requiring hospital admission and thrombocytopenia were significantly more frequent among patients with relapsing disease (p < 0.04—0.01). Patients with flares had slightly shorter disease duration and were younger at disease onset than patients with a quiescent course. The most recently diagnosed patients had the lowest annual rate of damage accrual.

According to flare rate, two major subsets of almost equal size were identified — one having a long quiescent course, the other exhibiting relapses alternating with remissions. An increased risk of flares was associated with short disease duration and younger age at disease onset, infections requiring hospital admission and thrombocytopenia. Temporal damage increment was the lowest in the most recently diagnosed patients. Lupus (2010) 19, 239—246.

The impact of systemic lupus erythematosus on employment

OBJECTIVE

Our primary objective was to examine work status (e.g., job loss, changes in amount worked) and predictors of job loss in patients with systemic lupus erythematosus (SLE).

METHODS

Recently diagnosed SLE patients were enrolled in the Carolina Lupus Study between 1997 and 1999; an age-, sex-, and state-matched control group selected through driver's license registries for the 60-county study area was also enrolled. In 2001, a followup study of both groups was conducted (median 4 yrs since diagnosis). Work history data were obtained in an in-person interview at enrollment and a telephone interview at followup.

RESULTS

Fifty-one patients (26%) and 26 controls (9%) (p < 0.0001) who were working the year before diagnosis (or for controls, a corresponding reference year) were no longer working at followup; 92% of patients compared with 40% of controls who were no longer working indicated that they had stopped working because of their health (p < 0.0001). College graduates were less likely to quit their jobs due to health compared to non-college graduates (adjusted OR = 0.27, 95% CI 0.09, 0.84). SLE patients with arthritis were 3 times more likely to have left their jobs due to health reasons compared to those who didn't have arthritis (adjusted OR = 3.3, 95% CI 1.2, 8.8); an association was also seen with pleuritis (adjusted OR 2.3, 95% CI 1.1, 4.6).

CONCLUSION

The burden expressed as work cessation due to health, especially among lesser educated patients and those with arthritis or pleuritis, is significant even early in the disease process.

Amerindian ancestry in Argentina is associated with increased risk for systemic lupus erythematosus

Previous studies have demonstrated that in admixed populations, West African ancestry is associated with an increased prevalence of systemic lupus erythematosus (SLE). In the current study, the effect of Amerindian ancestry in SLE was examined in an admixed population in Argentina. The Argentine population is predominantly European with approximately 20% Amerindian admixture, and a very small (<2%) contribution from West Africa. The results indicate that Amerindian admixture in this population is associated with a substantial increase in SLE susceptibility risk (Odds Ratio=7.94, P=0.00006). This difference was not due to known demographic factors, including site of collection, age and gender. In addition, there were trends towards significance for Amerindian ancestry influencing renal disease, age of onset and anti-SSA antibodies. These studies suggest that populations with Amerindian admixture, like those with West African admixture, should be considered in future studies to identify additional allelic variants that predispose to SLE.