Systemic lupus erythematosus: follow-up study of 148 patients. I: Classification, clinical and laboratory findings, course and outcome

Is there a cure for systemic lupus erythematosus?

The morbidity and mortality of systemic lupus erythematosus (SLE) is a subject of intense relevance in the literature, yet descriptions of prolonged and sustained remissions or even cure are barely reported. In recent decades the life expectancy in SLE patients has improved, but the quality of life seems to be poor compared with other chronic diseases and with the general population. The immunopathogenesis of SLE is complex and not fully understood, so patients have been treated with nonspecific immunosuppressive therapies. But in recent years, because of advances in basic science, targeted therapies have been developed. Despite the progress made in treating SLE, currently a cure in SLE seems to be a myth. SLE it seems, remains incurable. A specific treatment has not emerged to directly abrogate a disease-specific autoimmune response. Relapsing manifestations and complications of treatment still remain important markers of morbidity.

The relationship between initial clinical manifestation and long-term prognosis of patients with systemic lupus erythematosus

The relationship between clinical manifestations and prognosis was examined and evaluated among systemic lupus erythematosus (SLE) patients. A total of 542 patients with SLE were selected and divided into nine groups according to their main clinical manifestation at the time of initial diagnosis. The relationship between these clinical manifestations and long-term prognosis was evaluated in respect to the survival, remission, relapse rates, the development of a new clinical manifestation, and/or damage index. Patients with neuropsychiatric SLE (NPSLE), accompanied with acute confusional state/seizure disorder, cerebral vascular disease, or pneumonitis had poor survival rates with cause of death related to their major organ involvement. Patients with nephropathy or leukopenia had lower remission rates, and an increase in relapse rates was frequently recognized in patients with pneumonitis. Body damage (damage index) was higher in patients with lupus psychosis, pneumonitis, and/or arthritis. The translation of the main manifestations after diagnosis was confirmed in 64 patients (11.8%), and often observed in patients with autoimmune hemolytic anemia and arthritis. The majority of these manifestations were nephropathy, NPSLE, thrombocytopenia, and pneumonitis, and the prognosis of patients with nephropathy and thrombocytopenia as a new main manifestation had a poor outcome. The results of long-term prognosis in SLE greatly differed with respect to the initial clinical manifestation at the time of diagnosis.

Infection-related morbidity and mortality in patients with connective tissue diseases: a systematic review

Patients suffering from connective tissue diseases (CTDs) constitute an important subgroup of immunosuppressed patients at risk for developing serious infections. Prophylactic antibiotic administration may decrease infection-related morbidity and mortality burden in patients with CTD, though one needs first to evaluate the overall effect of infection on morbidity and mortality in such patients and the presence of adequate prognostic/risk factors for infection development. Studies focusing on infection-related morbidity and mortality in patients with CTD were reviewed. Data on disease type, therapeutic regimens used, including corticosteroid dose and method of administration as well as other immunosuppressive agents, and outcome were extracted to evaluate the existence of specific treatment patterns predisposing to infection as well as infectious disease-related morbidity and mortality in patients with CTD. Thirty-nine studies focusing on infection incidence and/or outcome in patients with CTD were identified and analyzed; the majority of the reviewed studies (20) included patients with systemic lupus erythematosus (SLE). The mortality attributed to infection was 5.2%, while the overall mortality was 20%. There were no adequate data on the specific effect patterns of corticosteroid and immunosuppressant treatment on infection risk. Pneumocystis jiroveci (carinii) pneumonia, evaluated independently, exhibited significant mortality in patients with Wegener's granulomatosis, polymyositis/dermatomyositis, and SLE. In conclusion, infectious diseases are a major cause of mortality in patients with CTD. However, treatment-related factors predisposing to serious infections have not been adequately outlined. In addition, there are no data regarding the effect of prophylactic practices involving antibiotic administration in morbidity and mortality.

Surviving the butterfly and the wolf: mortality trends in systemic lupus erythematosus

OBJECTIVE

To address changes in survival of patients with systemic lupus erythematosus (SLE) and to compare mortality statistics with associated disease specific as well as comorbid conditions.

METHODS

Review of the international literature on survival of patients with SLE.

RESULTS

During the first half of the 20th century, SLE was considered a rapidly progressive and almost invariably fatal disease. Since the 1950s, the estimated 5-year survival of SLE patients in developed countries rose from <50% to >95% and similar increases were seen in 10-year survival. Mortality rates of SLE patients, however, remain approximately 3 times that of an age- and sex-matched population in most studies, indicating that death still occurs prematurely in a substantial portion of patients, albeit later in the disease course. This improved prognosis does not appear to have been shared equally by all racial/ethnic groups. This appears to be attributable more to socioeconomic and sociocultural factors than to true differences in disease manifestations. Along with the increased survival of SLE patients, there has been a change in the causes of death. Most notably, there has been a dramatic increase in the proportionate mortality from vascular disease, particularly accelerated atherosclerosis. Both disease and therapeutic modalities, in particular corticosteroids, appear to contribute to the high prevalence of coronary artery disease (CAD).

CONCLUSIONS

Much progress has been made in improving the survival of SLE, but there is need for further improvement. Aggressive treatment of risk factors for CAD is advisable, but it remains to be assessed to what extent such interventions can further reduce mortality.

Mortality and causes of death in systemic lupus erythematosus

Cohort studies of survival in systemic lupus erythematosus (SLE) often have been limited by methodologic problems. In studies of inception cohorts of patients followed since 1980, survival at 5 years has exceeded 90%. These estimates are generally higher than survival estimates from earlier studies, suggesting that short-term survival in SLE has improved. There is less evidence to support major improvements over time in survival after 10 years or more of SLE. Infections, atherosclerotic disease, and active systemic lupus erythematosus or organ damage caused by SLE are the main causes of death in patients with SLE, but the proportion of early deaths caused by active SLE has decreased over time.

The disproportionate impact of chronic arthralgia and arthritis among women

The heterogeneous group of diseases that causes chronic arthralgia and arthritis is the most common cause of activity limitation and disability among middle age and older women. For reasons that remain poorly understood this group of diseases affects women substantially more frequently than men. In particular, the prevalence rates of the most common causes of arthralgia and arthritis, osteoarthritis and rheumatoid arthritis, and the prevalence rates of less common diseases that cause arthralgia, including systemic lupus erythematosus, systemic sclerosis, and fibromyalgia, are between two and 10 times higher in women. Prevalence rates for most of these conditions increase with age, and may vary among populations. For example, in the United States, systemic lupus erythematosus is approximately three times as common among African-American women as among white women. All of these disorders typically have an insidious onset and variable course that can make diagnosis difficult. Yet, most patients with these diseases benefit from early diagnosis and early nonoperative treatments including patient education, patient participation in disease treatment, activity modification, assistive devices, and medications. Furthermore, early aggressive medical therapy may prevent development of permanent joint and visceral damage in patients with inflammatory diseases including rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis. Failure to make the diagnosis of an underlying disease in patients with arthralgia may lead to inappropriate treatment or delay in treatment that can result in irreversible impairment. Because many women with these conditions seek medical care from orthopaedists, orthopaedic residency education and continuing medical education should place emphasis on early diagnosis and nonoperative treatment of patients with arthralgia and arthritis, and, when appropriate, early referral to rheumatologists.

High disease activity at baseline does not prevent a remission in patients with systemic lupus erythematosus

OBJECTIVE

To evaluate the utility of systemic lupus erythematosus (SLE) initial clinical manifestations and the SLE Disease Activity Index (SLEDAI) for identifying patients who will have a remission.

METHODS

We studied 100 SLE patients (85 females, 15 males) and identified all patients who had remission (defined as at least one continuous year during which lack of disease activity permitted withdrawal of all treatment to suppress general lupus activity of a particular clinical manifestation). Changes in laboratory parameters without clinical activity, thus not requiring treatment, did not invalidate remission. We did not include any patient who had never required treatment. We evaluated the SLEDAI values and the main SLE manifestations at the time of diagnosis of SLE, and also every 3 months during the first year of disease.

RESULTS

Twenty-four of the 100 SLE patients achieved remission that occurred a mean of 64 months after the diagnosis. They remained in remission for a mean of 55 months. There were no statistical differences in SLEDAI values and the initial manifestations (including renal and cerebral) between patients who reached remission and those who did not. The patients who have a higher SLEDAI score take longer to achieve remission.

CONCLUSION

SLE patients with severe initial clinical manifestations and higher SLEDAI values may achieve clinical remission.

A multicentre study of 513 Danish patients with systemic lupus erythematosus. I. Disease manifestations and analyses of clinical subsets

A Danish multicentre study was undertaken of the manifestations, infections, thrombotic events, survival and predictive factors of survival in 513 Danish patients with systemic lupus erythematosus (SLE) according to the 1982 classification criteria of the American College of Rheumatology. The mean duration of follow-up was 8.2 years from diagnosis and 12.8 years from first symptom. This paper describes the most common clinical and laboratory manifestations and their relationship to sex and age at the time of onset and diagnosis. Cluster analysis revealed three clinically defined clusters at the time of disease onset. Cluster 1 (57% of patients) consisted of relatively elderly patients without nephropathy or malar rash, but with a high prevalence of discoid lesions. Cluster 2 (18%) consisted of patients with nephropathy, a third of whom also developed serositis and lymphopenia. The patients of the third cluster (25%) all had malar rash and half were photosensitive. Follow-up showed that the patients of cluster 2 developed azotaemia, large proteinuria, arterial hypertension and myositis significantly more often than did the rest of the patients, but the mortality was not increased. The risk of developing renal end-stage disease was highest in men with early-onset disease.

Remission of systematic lupus erythematosus

The occurrence and characteristics of remissions in patients with systematic lupus erythematosus (SLE) have not been determined. We therefore studied this in a cohort of 667 patients and found that 156 patients had achieved at least 1 period of 1 year or more of treatment-free clinical remission. This represents an incidence density of 0.028 new cases/person/year. Remission occurred within the first 2 years of disease in 62 patients. The mean duration of first remission was 4.6 years (range, 1-21 yr), and 81 patients were still in the initial remission up until cutoff time. Half of the remaining 75 patients who flared after achieving remission have not entered again in remission. Twenty-six of the 38 patients who did remained in remission, and the remaining 12 had subsequent flares and remissions. Treatment-free remission accounted for a mean of 5.8 years, corresponding to half the time of follow-up. Remission was not limited to patients with mild disease: at least 41 patients achieved remission despite renal involvement, 19 had had neuropsychiatric lupus, 15 had had thrombocytopenia, and 8 had had hemolytic anemia. We also found that the longer the time lapse between the initial manifestation and the diagnosis of SLE, the less likely it was for a patient to enter into remission. There was a continuous increase in likelihood of achieving a first remission from the beginning of disease up to 30 years of disease duration, when it reached 70%. Patients who achieved remission had increased survival, independently of the effect of other disease manifestations that cause increased mortality. We conclude that a significant proportion of patients with SLE, including those with severe organ involvement, may become symptom-free and in need of no more medication, perhaps indefinitely. Our findings support the notion that, in general, SLE is a more benign disease than previously considered.

Causes of death in systemic lupus erythematosus. Long-term followup of an inception cohort

OBJECTIVE

To describe the causes of death in a cohort of patients with systemic lupus erythematosus (SLE), and to determine if the major causes of death differ according to patient age, sex, race, socioeconomic status, and the duration of SLE.

METHODS

We examined survival in a cohort of 408 patients with SLE. During a median of 11 years of followup, 144 patients died. The cause of death was determined for 134 patients (93%).

RESULTS

SLE was the most common cause of death, occurring in 49 patients (34%), followed by infection (n = 32; 22%), cardiovascular disease (n = 23; 16%), cerebrovascular disease (n = 8; 6%), and cancer (n = 8; 6%). Deaths due to SLE and due to infections were more common among younger patients, and deaths due to cancer were more common among older patients. Although the risk of death due to SLE was greatest during the first 3 years after diagnosis, deaths due to SLE occurred throughout the course of disease.

CONCLUSION

In this study of patients with SLE who were followed up for an extended period of time beginning soon after diagnosis, SLE was the most common cause of death, and deaths due to SLE occurred throughout the course of illness.

Long-term survival in systemic lupus erythematosus. Patient characteristics associated with poorer outcomes

OBJECTIVE

To investigate the associations of age, sex, race, and socioeconomic status with long-term survival in patients with systemic lupus erythematosus (SLE).

METHODS

We examined survival in an inception cohort of 408 patients with SLE. The cohort included 177 black females, 162 white females, 49 white males, and 20 black males. The median duration of followup was 11 years (range 0.1-22 years).

RESULTS

One hundred forty-four patients died during the study. The 5-, 10-, and 15-year survival estimates for the entire cohort were 82%, 71%, and 63%, respectively. In univariate analyses, mortality rates increased with age and were higher among males, blacks, those without private medical insurance, and those living in census tracts with lower household incomes. In multivariate analyses, age, sex, and both socioeconomic indicators were associated with total mortality (mortality from any cause), while race was not. Lower socioeconomic status and increased age were also associated with higher rates of death from SLE.

CONCLUSION

Socioeconomic status, but not race, is associated with mortality in SLE. SLE-related mortality also tends to increase with age, which suggests that SLE may not be less severe when it occurs later in life.

Systemic lupus erythematosus in Greece. Clinical features, evolution and outcome: a descriptive analysis of 292 patients

The purpose of this study was the descriptive analysis of patients with systemic lupus erythematosus (SLE) with a particular focus on initial clinical features, evolution and outcome of disease, prevalence of clinical and serological manifestations and identification of clinicoserological associations indicative of renal and CNS involvement. The methodology applied was the following: retrospective analysis of the clinical charts of 292 unselected patients (246 female (84.2%) and 46 male (15.7%)) with SLE examined between 1982 and 1992. Multivariate analysis and hierarchical log linear models were used to examine for clinicoserological associations. Descriptive analysis was based on the prevalence of main clinicoserological features and disease outcome. The outcome was examined on the basis of the number of flares, the presence of chronic renal failure, the presence of central nervous system (CNS) involvement with subsequent disability and deaths. Flares were considered the severe alterations in disease status, requiring additional therapy to be controlled. The disease begins most frequently in the second and third decade of life with cutaneous and joint manifestations, while renal and CNS involvement developed later. The prevalence of serious renal, pulmonary and CNS involvement as well as the prevalence of RF, anti-Sm and anti-nRNP antibodies remain low. Multivariate analysis revealed the associations of renal involvement with leukopenia and serositis, of anti-Sm with leukopenia, of secondary Sjogren's syndrome with RF and of thromboembolic events with anticardiolipin antibodies. Patients with childhood onset SLE have a higher tendency for developing renal involvement than adult onset SLE patients. In addition, anti-Ro(SSA) antibodies were associated with anti-La(SSB) and RF, while anti-Sm antibodies were associated with anti-nRNP and RF. Flares occurred with a frequency of 0.07 per patient per year. Only 63.6% of flares were accompanied by positive anti-dsDNA reactivities. Reported deaths were 0.0047 per patient per year. Hierarchical log linear models indicated that the main variables of the disease were sufficient to describe our disease model and that the order of the interaction between the variables was insignificant. We conclude that the prevalence of various clinical features associated with SLE is similar, although the prevalence of CNS and pulmonary involvement as well as anti-Sm and anti-nRNP antibodies are less prominent in Greek SLE patients than that reported in the literature. The various clinicoserological associations detected do not appear to be of major significance as they are not powerful enough to subgroup the disease.

The actual survival rate in systemic lupus erythematosus: study of a 1976 cohort

The purpose of this study was to establish the actual survival rate of a cohort of 51 patients with systemic lupus erythematosus (SLE) all of whom were followed during 12 years from 1976 to 1988 and to evaluate the prognostic significance of the severe complications of the disease. Forty-eight were females. The mean age was 28.5 at onset, 36.2 at diagnosis and 42 at entry; 80% had four or more 1982 ARA criteria at diagnosis and 96% in 1988. Survival rates were: 96% at two years, 86.3% at five years and 74.5% at twelve years. The main cause of death was infection (62%); SLE was directly responsible in only one case. Manifestations considered as severe occurred in almost two-thirds of the cases without any concordance in the time sufficient to recognize different severe forms of the disease.

Lupus erythematosus in the 1980s: a survey of 570 patients

Five hundred seventy lupus erythematosus patients observed in a private practice between 1980 and 1989 were surveyed. Fifty-five percent were diagnosed after 1980. Five hundred three fulfilled criteria for systemic lupus erythematosus ( [SLE]; 464 idiopathic, 23 overlap, 16 drug-induced) and 67 had biopsy-documented cutaneous (discoid) lupus. In the idiopathic SLE group, symptoms began at a mean age of 31 years and patients were observed for a mean of 6 years. Findings in idiopathic SLE patients were (1) 27% have a family history of autoimmune disease; (2) nephritis patients without nephrotic syndrome rarely develop renal failure (4%); (3) nephrotic syndrome patients are relatively cyclophosphamide-resistant; (4) organ-threatening disease is present in 54%; and (5) 13% of women who become pregnant are recurrent aborters and 26% never conceive. In an analysis of cohort data, 5- and 10-year survivals were 97% +/- 2% and 93% +/- 3%, respectively. Additionally, men and patients with renal disease or thrombocytopenia had a poorer prognosis. Blacks had similar clinical findings and survival to whites. Approximately 50% of deaths were from active disease and 50% from complications of therapy. Prolonged survival has resulted from new diagnostic procedures and serologic tests, and improved antibiotics and antihypertensive agents, as well as more efficacious treatment modalities.

Outcome of systemic lupus erythematosus. A study of 66 patients over 7 years with special reference to the predictive value of anti-DNA antibody determinations

A cohort of 66 patients with SLE that were thoroughly studied, both clinically and serologically in 1980-81, when they had a mean disease duration of eight years, were evaluated seven years later in order to assess the long-range outcome of the disease. Five patients were lost from follow-up and 12 (20%) died during the follow-up. The estimated 10-year survival was 91%. A total of 30 patients (45%), showed no signs of nephritis at any stage, and in only eight an active nephritis was found during the follow-up. The previous antibody determinations, provided no predictive information regarding the behaviour of the renal manifestations. Arthralgia was the main clinical symptom during the follow-up. Hypertension developed in 23%. At the end of the follow-up the disease was regarded as active in 13% of the patients.

Unusual eye manifestations in systemic lupus erythematosus patients

One hundred and twelve records of patients with systemic lupus erythematosus were reviewed and four cases with unusual ocular manifestations are described. We found that anterior uveitis is not an uncommon manifestation of systemic lupus erythematosus and physicians must be aware of it during the patient's evaluation, since it can be treated without serious visual loss. Optic neuritis is uncommon in systemic lupus erythematosus and visual loss may be permanent despite therapy.

Systemic lupus erythematosus. Follow-up study of 148 patients. II: Predictive factors of importance for course and outcome

The predictive value of a number of clinical and laboratory variables for the mortality of 148 patients with systemic lupus erythematosus (SLE) with a mean observation period of 8 years and a 10-year-survival of 80 per cent was calculated by means of differentiated survival rate analyses and stepwise regression analyses. The predictive power of several variables increased if the calculations were based on deaths caused by SLE rather than on the total mortality rate. The survival rate decreased after 1973 because a diagnosis of SLE was made in some patients with terminal disease who would have remained without a diagnosis before that time. The causes of death and the treatment were identical before and after 1973. The presence of a high number of diagnostic ARA criteria within the first year of observation was a predictor of decreased survival. Severe but non-fatal infections (meningitis, septicemia, pneumonia) significantly reduced the survival rate. Patients with proteinuria and azotemia, within the first 2 years of observation, had a 10-year-survival of 70 per cent. The survival of patients with CNS manifestations was not significantly reduced. The butterfly rash and the presence of lymphopenia were predictors of decreased survival, whereas the presence of DNA antibodies had no predictive value for survival.