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Reis-Neto ETD, Monticielo OA, Daher M, Lopes F, Angrimani D, Klumb EM. Life expectancy and death pattern associated with systemic lupus erythematosus diagnosis in Brazil between 2000 and 2019. Lupus 2024; 33:536-542. [PMID: 38414428 DOI: 10.1177/09612033241236383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
OBJECTIVES to evaluate the main factors associated with mortality and determine the life expectancy of SLE patients between 2000 and 2019 years in Brazil. METHODS death data related to SLE available in the Brazilian Unified Health System (SUS) (DATASUS) were evaluated in all Brazilian states. Three groups of death causes potentially associated from SLE were evaluated: cardiovascular and kidney diseases and infections. RESULTS The main causes of death associated with SLE were infection and kidney disease. Most SLE patients died between 19 and 50 years of age. Deaths associated with kidney disease were proportionally higher than in the general population with progressive decrease during the period. Instead, there have been an increase in the proportion of deaths due to infections both in SLE and in the general population. CONCLUSIONS SLE patients presented higher mortality compared to the general population matched for sex and age and the main causes associated with death were infection and kidney disease. Public health policies that promote early diagnosis, treatment and prevention of damage are necessary to reduce morbidity and mortality in SLE patients.
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Affiliation(s)
- Edgard Torres Dos Reis-Neto
- Division of Rheumatology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM / Unifesp), São Paulo, Brazil
| | - Odirlei Andre Monticielo
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | | | | | | | - Evandro Mendes Klumb
- Department of Rheumatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
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Jin Z, Chen Z, Pan W, Liu L, Wu M, Hu H, Ding X, Wei H, Zou Y, Qian X, Wang M, Wu J, Tao J, Tan J, Da Z, Zhang M, Li J, Feng X, Sun L. Comparison of Contributors to Mortality Differences in SLE Patients with Different Initial Disease Activity: A Larger Multicenter Cohort Study. J Clin Med 2023; 12:jcm12031061. [PMID: 36769709 PMCID: PMC9918091 DOI: 10.3390/jcm12031061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 01/21/2023] [Accepted: 01/22/2023] [Indexed: 02/03/2023] Open
Abstract
To explore the etiology of risk factors and quantify the mortality differences in systemic lupus erythematosus (SLE) patients with different initial disease activity. The Jiangsu Lupus database was established by collecting medical records from first-hospitalized SLE patients during 1999-2009 from 26 centers in Jiangsu province, China, and their survival status every five years. The initial SLEDAI scores [high (>12) vs. low-moderate (≤12)] differences in mortality attributable to risk factors were quantified using population attributable fraction (PAF), relative attributable risk (RAR) and adjusted relative risk (ARR). Among 2446 SLE patients, 83 and 176 deaths were observed in the low-moderate and high activity groups, with mortality rates of 7.7 and 14.0 per 1000 person years, respectively. Anemia was the leading contributor to mortality, with PAFs of 40.4 and 37.5 in the low-moderate and high activity groups, respectively, and explained 23.2% of the mortality differences with an ARR of 1.66 between the two groups. Cardiopulmonary involvement caused the highest PAFs in the low-moderate (20.5%) and high activity (13.6%) groups, explaining 18.3% of the mortality differences. The combination of anemia and cardiopulmonary involvement had the highest RAR, causing 39.8% of the mortality differences (ARR = 1.52) between the two groups. In addition, hypoalbuminemia and a decrease in the creatinine clearance rate accounted for 20-30% of deaths and explained 10-20% of the mortality differences between the two groups, while antimalarial drug nonuse accounted for about 35% of deaths and explained 3.6% of the mortality differences. Anemia, cardiopulmonary involvement and hypoalbuminemia may cause substantial mortality differences across disease activity states, suggesting additional strategies beyond disease activity assessment to monitor SLE outcomes.
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Affiliation(s)
- Ziyi Jin
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Zheng Chen
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Wenyou Pan
- Department of Rheumatology, Huai’an First People’s Hospital, Huai’an 223001, China
| | - Lin Liu
- Department of Rheumatology, Xuzhou Central Hospital, Xuzhou 221008, China
| | - Min Wu
- Department of Rheumatology, The Third Affiliated Hospital of Soochow University, Changzhou 213003, China
| | - Huaixia Hu
- Department of Rheumatology, Lianyungang Second People’s Hospital, Lianyungang 222000, China
| | - Xiang Ding
- Department of Rheumatology, Lianyungang First People’s Hospital, Lianyungang 222002, China
| | - Hua Wei
- Department of Rheumatology, Northern Jiangsu People’s Hospital, Yangzhou 225007, China
| | - Yaohong Zou
- Department of Rheumatology, Wuxi People’s Hospital, Wuxi 214028, China
| | - Xian Qian
- Department of Rheumatology, Jiangsu Province Hospital of TCM, Nanjing 210004, China
| | - Meimei Wang
- Department of Rheumatology, Southeast University Zhongda Hospital, Nanjing 210009, China
| | - Jian Wu
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, Suzhou 215005, China
| | - Juan Tao
- Department of Rheumatology, Wuxi TCM Hospital, Wuxi 214177, China
| | - Jun Tan
- Department of Rheumatology, Zhenjiang First People’s Hospital, Zhenjiang 212050, China
| | - Zhanyun Da
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Miaojia Zhang
- Department of Rheumatology, Jiangsu Province Hospital, Nanjing 210029, China
| | - Jing Li
- Department of Rheumatology, Affiliated Hospital of Jiangsu University, Zhenjiang 212050, China
| | - Xuebing Feng
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
- Correspondence: (X.F.); (L.S.); Tel.: +86-25-6818-2422(L.S.); Fax: +86-25-6818-2428(L.S.)
| | - Lingyun Sun
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
- Correspondence: (X.F.); (L.S.); Tel.: +86-25-6818-2422(L.S.); Fax: +86-25-6818-2428(L.S.)
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Lisboa RV, de Oliveira FR, Quaresma TO, de Almeida RM, Ribeiro Oliveira RD, Junior PL. The Behaviour of Serum Survivin in Patients With Lupus Nephritis. Biomark Insights 2022; 17:11772719221131470. [PMID: 36311208 PMCID: PMC9597205 DOI: 10.1177/11772719221131470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 09/21/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Systemic lupus erythematosus (SLE) is a chronic, multi phenotypic, autoimmune
inflammatory disease and renal involvement significantly worsens its
prognosis. Apoptosis dysregulation plays a key pathogenic role. Survivin, a
protein from the apoptosis inhibitors family, has been considered a
promising strategy in cancer therapy and evaluated as one of the regulatory
pathways in the scenario of immune-mediated disorders. Objective: This study aims to explore survivin behaviour in SLE patients with lupus
nephritis (LN), assessing its potential as a therapeutic and prognostic
biomarker. Methods: 297 SLE patients were classified based on the American College of
Rheumatology (ACR) 1997 criteria, from 2000 to 2015. In a cross-sectional
study, the serum level of survivin was measured by an ELISA test and
compared between 200 SLE individuals and healthy controls. In a longitudinal
cohort, 97 patients with active LN had the concentration of survinin
measured, before and after treatment with cyclophosphamide pulse
therapy. Results: The serum concentration of survivin was significantly lower in the SLE group
than in healthy controls, regardless of concomitant NL or disease activity.
The longitudinal evaluation revealed a significant reduction in survivin
serum level after treatment. However, survivin rates were not able to
discriminate groups that achieved remission from those that maintained
nephritis activity. Conclusion: Our study suggests that survivin levels in SLE patients are lower than in the
general population. Even so, its use as a biomarker in SLE seems limited,
not reflecting disease activity or response to LN treatment, as in other
contexts.
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Affiliation(s)
- Renata Valente Lisboa
- Ribeirão Preto Medical School, Ribeirão
Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil,Center of Research in Inflammatory
Diseases (CRID), Ribeirão Preto Medical School, University of São Paulo, Ribeirão
Preto, São Paulo, Brazil,Renata Valente Lisboa, Division of
Rheumatology, Ribeirão Preto Medical School, University of São Paulo, Av.
Bandeirantes, 3900, Ribeirão Preto, São Paulo 14049-900, Brazil.
| | - Fabiola Reis de Oliveira
- Ribeirão Preto Medical School, Ribeirão
Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil,Center of Research in Inflammatory
Diseases (CRID), Ribeirão Preto Medical School, University of São Paulo, Ribeirão
Preto, São Paulo, Brazil
| | - Thaise Oliveira Quaresma
- Ribeirão Preto Medical School, Ribeirão
Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil,Center of Research in Inflammatory
Diseases (CRID), Ribeirão Preto Medical School, University of São Paulo, Ribeirão
Preto, São Paulo, Brazil
| | | | - Rene Donizeti Ribeiro Oliveira
- Ribeirão Preto Medical School, Ribeirão
Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil,Center of Research in Inflammatory
Diseases (CRID), Ribeirão Preto Medical School, University of São Paulo, Ribeirão
Preto, São Paulo, Brazil
| | - Paulo Louzada Junior
- Ribeirão Preto Medical School, Ribeirão
Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil,Center of Research in Inflammatory
Diseases (CRID), Ribeirão Preto Medical School, University of São Paulo, Ribeirão
Preto, São Paulo, Brazil
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Morales-Tisnés T, Quintero-Ortiz L, Quintero-Muñoz E, Sierra-Matamoros F, Arias-Aponte J, Rojas-Villarraga A. Prevalence of hospital readmissions and related factors in patients with autoimmune diseases. J Transl Autoimmun 2021; 4:100121. [PMID: 34585131 PMCID: PMC8450261 DOI: 10.1016/j.jtauto.2021.100121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/06/2021] [Indexed: 11/19/2022] Open
Abstract
Objective Autoimmune diseases generate an impact on the morbidity and mortality of patients and are a burden for the health system through hospital admissions and readmissions. The prevalence of readmission of patients with these diseases has not yet been described as a group, but rather as sub-phenotype. The objective of this study is to determine the prevalence of hospital readmissions in a Colombian population with autoimmunity and the factors related to readmission. Methods All patients with autoimmune diseases who were evaluated by the rheumatology service and hospitalized between August 2018 and December 2019 at the Fundación Hospital Infantil Universitario De San José de Bogotá were described. A bivariate analysis was done, and three multivariate logistic regression models were built with the dependent variable being readmission. Results Of the total 199 admissions, 131 patients were evaluated and 32% were readmitted. The most frequent sub-phenotype in both groups (readmission and no readmission) was SLE (51% and 59%). The most frequent cause of hospitalization and readmission was disease activity (68.7% and 64.3%). History of hypertension was associated with readmission (adjusted OR: 2.98-95% CI: 1.15-7.72). In a second model adjusted for confounding variables, no factor was associated. In a third model analyzing the history of kidney disease and previous use of immunosuppressants (adjusted for confounding variables), the previous use of immunosuppressants was related to readmission (OR: 2.78-95% CI 1.12-6.89). Conclusion Up to a third of patients with autoimmunity were readmitted and arterial hypertension was an associated factor. This suggested a greater systemic compromise and accumulated damage in patients who have these two conditions that may favor readmission. A history of immunosuppressant use may play a role in readmission, possibly by increasing the risk of developing infections.
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Key Words
- AHT, Arterial Hypertension.
- AIDs, Autoimmune Diseases.
- APS, Antiphospholipid Syndrome.
- Autoimmune disease
- Autoimmune tautology
- DMARDs, Disease-modifying antirheumatic drugs.
- Hospital readmission
- ICD – 10, International Classification of Diseases 10th edition.
- ICU, Intensive Care Unit.
- Polyautoimmunity
- RA, Rheumatoid Arthritis.
- SLE, Systemic Lupus Erythematosus.
- SS, Systemic Sclerosis
- SjS, Sjögren Syndrome.
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Affiliation(s)
- Tatiana Morales-Tisnés
- School of Medicine, Fundación Universitaria de Ciencias de la Salud-FUCS, Bogotá, 111221, Colombia
- Corresponding author. School of Medicine, Fundación Universitaria de Ciencias de la Salud, Carrera 59 a 134 - 15, Postal Code: 111111, Bogotá, Colombia. Tel: +51 3118834750.
| | - Lina Quintero-Ortiz
- School of Medicine, Fundación Universitaria de Ciencias de la Salud-FUCS, Bogotá, 111221, Colombia
| | - Elías Quintero-Muñoz
- School of Medicine, Fundación Universitaria de Ciencias de la Salud-FUCS, Bogotá, 111221, Colombia
| | - Fabio Sierra-Matamoros
- School of Medicine, Fundación Universitaria de Ciencias de la Salud-FUCS, Bogotá, 111221, Colombia
- Epidemiology Department, Fundación Universitaria de Ciencias de la Salud-FUCS, Bogotá, 111221, Colombia
| | - Julián Arias-Aponte
- School of Medicine, Fundación Universitaria de Ciencias de la Salud-FUCS, Bogotá, 111221, Colombia
| | - Adriana Rojas-Villarraga
- School of Medicine, Fundación Universitaria de Ciencias de la Salud-FUCS, Bogotá, 111221, Colombia
- Research Division, Fundación Universitaria de Ciencias de la Salud-FUCS, Bogotá, 111221, Colombia
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5
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Klumb EM, Scheinberg M, de Souza VA, Xavier RM, Azevedo VF, McElwee E, Restrepo MR, Monticielo OA. The landscape of systemic lupus erythematosus in Brazil: An expert panel review and recommendations. Lupus 2021; 30:1684-1695. [PMID: 34255586 PMCID: PMC8489682 DOI: 10.1177/09612033211030008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/09/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE The objective of this review is to address the barriers limiting access to diagnosis and treatment of systemic lupus erythematosus (SLE) and lupus nephritis (LN) in Brazil, specifically for patients in the public healthcare system, arguably those with the least access to innovation. DESIGN A selected panel of Brazilian experts in SLE/LN were provided with a series of relevant questions to address in a multi-day conference. During the conference, responses were discussed and edited by the entire group through numerous drafts and rounds of discussion until a consensus was achieved. RESULTS The authors propose specific and realistic recommendations for implementing access to innovative diagnostic tools and treatment alternatives for SLE/LN in Brazil. Moreover, in creating these recommendations, the authors strived to address barriers and impediments for technology adoption. The multidisciplinary care required for SLE/LN necessitates the collective participation of all involved stakeholders. CONCLUSION A great need exists to expand the adoption of innovative diagnostic tools and treatments for SLE/LN not only in Brazil but also in most countries, as access issues remain an urgent demand. The recommendations presented in this article can serve as a strategy for new technology adoption in other countries in a similar situation.
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Affiliation(s)
- Evandro Mendes Klumb
- Rheumatology Department, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
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6
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Bultink IEM, de Vries F, van Vollenhoven RF, Lalmohamed A. Mortality, causes of death and influence of medication use in patients with systemic lupus erythematosus vs matched controls. Rheumatology (Oxford) 2021; 60:207-216. [PMID: 32653901 PMCID: PMC8312724 DOI: 10.1093/rheumatology/keaa267] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/31/2020] [Indexed: 01/26/2023] Open
Abstract
Objectives We wanted to estimate the magnitude of the risk from all-cause, cause-specific and
sex-specific mortality in patients with SLE and relative risks compared with matched
controls and to evaluate the influence of exposure to medication on risk of mortality in
SLE. Methods We conducted a population-based cohort study using the Clinical Practice Research
Datalink, Hospital Episode Statistics and national death certificates (from 1987 to
2012). Each SLE patient (n = 4343) was matched with up to six controls
(n = 21 780) by age and sex. Cox proportional hazards models were
used to estimate overall and cause-specific mortality rate ratios. Results Patients with SLE had a 1.8-fold increased mortality rate for all-cause mortality
compared with age- and sex-matched subjects [adjusted hazard ratio (HR) = 1.80, 95% CI:
1.57, 2.08]. The HR was highest in patients aged 18–39 years (adjusted HR = 4.87, 95%
CI: 1.93, 12.3). Mortality rates were not significantly different between male and
female patients. Cumulative glucocorticoid use raised the mortality rate, whereas the HR
was reduced by 45% with cumulative low-dose HCQ use. Patients with SLE had
increased cause-specific mortality rates for cardiovascular disease, infections,
non-infectious respiratory disease and for death attributable to accidents or suicide,
whereas the mortality rate for cancer was reduced in comparison to controls. Conclusion British patients with SLE had a 1.8-fold increased mortality rate compared with the
general population. Glucocorticoid use and being diagnosed at a younger age were
associated with an increased risk of mortality. HCQ use significantly reduced the
mortality rate, but this association was found only in the lowest cumulative dosage
exposure group.
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Affiliation(s)
- Irene E M Bultink
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, VU University Medical Center, Amsterdam
| | - Frank de Vries
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht.,Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht
| | - Ronald F van Vollenhoven
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, VU University Medical Center, Amsterdam
| | - Arief Lalmohamed
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
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Murimi-Worstell IB, Lin DH, Nab H, Kan HJ, Onasanya O, Tierce JC, Wang X, Desta B, Alexander GC, Hammond ER. Association between organ damage and mortality in systemic lupus erythematosus: a systematic review and meta-analysis. BMJ Open 2020; 10:e031850. [PMID: 32444429 PMCID: PMC7247371 DOI: 10.1136/bmjopen-2019-031850] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE At least half of patients with systemic lupus erythematosus (SLE) develop organ damage as a consequence of autoimmune disease or long-term therapeutic steroid use. This study synthesised evidence on the association between organ damage and mortality in patients with SLE. DESIGN Systematic review and meta-analysis. METHODS Electronic searches were performed in PubMed, Embase, Cochrane Library and Latin American and Caribbean Health Sciences Literature for observational (cohort, case-control and cross-sectional) studies published between January 2000 and February 2017. Included studies reported HRs or ORs on the association between organ damage (measured by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) score) and mortality. Study quality was assessed using the modified Newcastle-Ottawa assessment. Pooled HRs were obtained using the DerSimonian and Laird random-effects model. Heterogeneity was assessed using the Cochrane Q (Q) and I2 statistics. RESULTS The search yielded 10 420 articles, from which 21 longitudinal studies were selected. Most studies (85%) were of high quality. For 10 studies evaluating organ damage (SDI) as a continuous variable and reporting HR as a measure of association, a 1-unit increase in SDI was associated with increased mortality; pooled HR was 1.34 (95% CI: 1.24 to 1.44, p<0.001; Q p=0.027, I2=52.1%). Exclusion of one potential outlying study reduced heterogeneity with minimal impact on pooled HR (1.33 (95% CI: 1.25 to 1.42), p<0.001, Q p=0.087, I2=42.0%). The 11 remaining studies, although they could not be aggregated because of their varying patient populations and analyses, consistently demonstrated that greater SDI was associated with increased mortality. CONCLUSIONS Organ damage in SLE is consistently associated with increased mortality across studies from various countries. Modifying the disease course with effective therapies and steroid-sparing regimens may reduce organ damage, improve outcomes and decrease mortality for patients with SLE.
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Affiliation(s)
- Irene B Murimi-Worstell
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dora H Lin
- Carle Illinois College of Medicine, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Henk Nab
- Inflammation & Autoimmunity, AstraZeneca, Cambridge, UK
| | - Hong J Kan
- Center for Population Health IT, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Oluwadamilola Onasanya
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jonothan C Tierce
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Xia Wang
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland, USA
| | - Barnabas Desta
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Edward R Hammond
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland, USA
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8
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Ingvarsson RF, Landgren AJ, Bengtsson AA, Jönsen A. Good survival rates in systemic lupus erythematosus in southern Sweden, while the mortality rate remains increased compared with the population. Lupus 2019; 28:1488-1494. [PMID: 31551031 DOI: 10.1177/0961203319877947] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To ascertain the mortality rate and causes of death in patients with systemic lupus erythematosus (SLE) within a defined region in southern Sweden during the time period 1981-2014 and determine whether these have changed over time. METHODS In 1981, a prospective observation study of patients with SLE was initiated in southern Sweden. All incident SLE patients within a defined geographic area were identified using previously validated methods including diagnosis and immunology registers. Patients with a confirmed SLE diagnosis were then followed prospectively at the Department of Rheumatology in Lund. Clinical data was collected at regular visits. Patients were recruited from 1981 to 2006 and followed until 2014. The patient cohort was split into two groups based on the year of diagnosis to determine secular trends. Causes of death were retrieved from medical records and from the cause of death registry at The National Board of Health and Welfare in Sweden. RESULTS In all, 175 patients were diagnosed with SLE during the study period. A total of 60 deaths occurred during a total of 3053 years of follow-up. In the first half of the study inclusion period 46 patients died, compared with 14 in the latter. The majority of patients (51.7%) died of cardiovascular disease. Infections caused 15% of the deaths and malignancy was the cause of death in 13.3% of patients. SLE was the main cause of death for 6.7% of the patients and a contributing factor for half of the patients. Standardized mortality ratio was increased in patients by a factor of 2.5 compared with the general population. Deaths occurred at an even rate throughout the whole observation period. No significant difference in standardized mortality ratio was observed between genders but was increased in older female patients. Furthermore, secular mortality trends were not identified. CONCLUSIONS In this long-term epidemiologic follow-up study of incident SLE, we report a substantially raised mortality rate amongst SLE patients compared with the general population. The mortality rates have not changed significantly during the observation period that spanned three decades. The main cause of death was cardiovascular disease and this finding was consistent over time.
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Affiliation(s)
- R F Ingvarsson
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Lund, Sweden.,Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - A J Landgren
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - A A Bengtsson
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Lund, Sweden
| | - A Jönsen
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Lund, Sweden
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Keeling SO, Vandermeer B, Medina J, Chatterley T, Nevskaya T, Pope J, Alaburubalnabi Z, Bissonauth A, Touma Z. Measuring Disease Activity and Damage with Validated Metrics: A Systematic Review on Mortality and Damage in Systemic Lupus Erythematosus. J Rheumatol 2018; 45:1448-1461. [DOI: 10.3899/jrheum.171310] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2018] [Indexed: 12/31/2022]
Abstract
Objective.To identify the effect of disease activity and damage, measured by validated indices, on mortality and damage accrual, in order to inform upcoming Canadian systemic lupus erythematosus (SLE) recommendations.Methods.Following GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to fill in evidence-to-decision tables to create recommendations for “minimal investigations needed to monitor SLE patients at baseline and subsequent visits,” a systematic literature review was performed. The effect of disease activity and damage, measured by validated metrics, on mortality and damage was systematically reviewed, with metaanalyses performed when available.Results.A title/abstract screen of 5599 articles identified 816 articles for full paper review, with 102 meeting inclusion criteria and 53 with extractable data. Thirty-three articles describing outcomes related to disease activity and 20 articles related to damage were identified. Mortality was associated with higher SLE Disease Activity Index-2000 scores in 6 studies (HR 1.14, 95% CI 1.06–1.22) and higher Systemic Lupus International Collaborating Clinics/ACR Damage Index scores in 6 studies (HR 1.53, 95% CI 1.28–1.83). Higher SLE Activity Measure scores were associated with increased risk of damage in 3 studies (OR 1.06, 95% CI 1.04–1.08). British Isles Lupus Assessment Group was associated with mortality in 1 study with HR of 1.15.Conclusion.Active SLE disease and damage are associated with and predict greater mortality and damage. The use of validated disease activity and damage metrics is important in the assessment of disease activity and damage and will inform upcoming Canadian recommendations for the assessment of SLE.
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Mortalidade por lúpus eritematoso sistêmico no Brasil: avaliação das causas de acordo com o banco de dados de saúde do governo. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Ácidos graxos ômega‐3, estado inflamatório e marcadores bioquímicos de pacientes com lúpus eritematoso sistêmico: estudo piloto. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2016.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Costi LR, Iwamoto HM, Neves DCDO, Caldas CAM. Mortality from systemic erythematosus lupus in Brazil: evaluation of causes according to the government health database. REVISTA BRASILEIRA DE REUMATOLOGIA 2017; 57:574-582. [PMID: 29032927 DOI: 10.1016/j.rbre.2017.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 05/10/2017] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To characterize the causes of mortality in patients with systemic lupus erythematosus (SLE) in Brazil between 2002 and 2011. METHODS An exploratory ecological study of a time series using data from the Mortality Information System of DATASUS, the Department of the Unified Health System (Brazil's National Health System). RESULTS Brazil's SLE mortality rate was 4.76 deaths/105 inhabitants. The mortality rate was higher in the Midwest, North and Southeast regions than in the country as a whole. There were 6.3% fewer and 4.2% more deaths than expected in the Northeast and Southeast regions, respectively. The mean age at death was 40.7±18 years, and 45.61% of deaths occurred between the ages of 20 and 39. Incidence was highest in women (90.7%) and whites (49.2%). Disorders of the musculoskeletal system and connective tissue were mentioned as an underlying cause of death in 77.5% of cases, and diseases of the circulatory system and infectious and parasitic diseases were also noted in fewer cases. SLE was mentioned as an underlying cause of death in 77% of cases, with no difference between the Brazilian regions (p=0.2058). The main SLE-related causes of death were, sequentially, diseases of the respiratory and circulatory systems and infectious and parasitic diseases. CONCLUSIONS This study identified a need for greater control of risk factors for cardiovascular diseases and a better understanding of the pathogenesis of atherosclerosis in SLE. Infectious causes are still frequent, and management should be improved, especially in the early stages of the disease.
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Survival analysis of patients with systemic lupus erythematosus in a tertiary hospital in southern Brazil. Clin Rheumatol 2017; 36:2005-2010. [DOI: 10.1007/s10067-017-3735-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 06/03/2017] [Accepted: 06/11/2017] [Indexed: 01/17/2023]
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Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a disease distributed worldwide, which occurs in both genders, and across racial/ethnic and age groups; however, higher rates are observed in adults, in women and in non-Caucasians. Genetic, environmental, sociodemographic and methodological issues are responsible not only for these differences but for the variable course and outcome of the disease. Non-Caucasians have a more severe disease with a higher risk for early mortality and damage accrual. Males also have a more severe disease; however, a negative impact of male gender on lupus outcomes has not been firmly established. Childhood-onset is associated with a more severe disease; moreover, it is also associated with higher damage and diminished survival; finally, late-onset lupus is mild but it is associated with higher damage accrual and a diminished survival. Areas covered: In this review, we discuss the incidence and prevalence of SLE, the impact of age, gender and race/ethnicity in SLE and in the survival of those affected. Expert commentary: Age, gender and race/ethnicity impact disease expression in SLE patients; despite improvements in survival, mortality in SLE remains almost three times higher than in the general population.
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Affiliation(s)
- Guillermo J Pons-Estel
- a Department of Autoimmune Diseases , Institut Clinic de Medicina I Dermatologia, Hospital Clinic , Barcelona , Catalonia , Spain.,b Division of Rheumatology and Autoimmune Diseases , Sanatorio Parque, Grupo Oroño , Rosario , Argentina
| | - Manuel F Ugarte-Gil
- c Servicio de Reumatología , Hospital Nacional Guillermo Almenara Irigoyen, EsSalud , Lima , Perú.,d School of Medicine , Universidad Científica del Sur , Lima , Perú
| | - Graciela S Alarcón
- e Division of Clinical Immunology and Rheumatology, School of Medicine , The University of Alabama at Birmingham , Birmingham , AL , USA.,f Department of Medicine, School of Medicine , Universidad Peruana Cayetano Heredia , Lima , Perú
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Abstract
Opportunistic infections can cause manifestations that resemble neuropsychiatric systemic lupus erythematosus and they can also trigger lupus flares. Therefore, central nervous system infections as differential diagnosis in neuropsychiatric systemic lupus erythematosus may be difficult, leading to delayed diagnosis and specific treatment. Central nervous system infection in systemic lupus erythematosus is not common but, if left misdiagnosed and not treated promptly, can be fatal. Complementary diagnosis tests are generally non-specific and disappointing. Caution with immunosuppressive drug treatment should be emphasized while an opportunistic infection cannot be ruled out. In this review, we discuss the various types of central nervous system infections reported in systemic lupus erythematosus patients, highlighting the importance of their early recognition in order to improve morbidity and mortality. Prevention with vaccination is a recommended approach.
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Affiliation(s)
- F M Ribeiro
- Rheumatology Department, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - F Signorelli
- Internal Medicine Department, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
- Internal Medicine Department, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Omega-3 fatty acids, inflammatory status and biochemical markers of patients with systemic lupus erythematosus: a pilot study. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 57:526-534. [PMID: 29173690 DOI: 10.1016/j.rbre.2016.09.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/30/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Studies have shown that omega-3 fatty acids reduce the concentrations of eicosanoids, cytokines, chemokines, C-reactive protein (CRP) and other inflammatory mediators. OBJECTIVE To investigate the effects of omega-3 fatty acids on circulating levels of inflammatory mediators and biochemical markers in women with systemic lupus erythematosus (SLE). METHODS Experimental clinical study (clinical trial: NCT02524795); 49 women with SLE (ACR1982/1997) were randomized: 22 to the omega-3 group (daily intake of 1080mg EPA+200mg DHA, for 12 weeks) and 27 to the control group. The inflammatory mediators and biochemical markers at T0 and T1 in omega-3 group were compared using Wilcoxon test. U-Mann-Whitney test was used to compare variations of measured variables [ΔV=pre-treatment (T0)-post-treatment (T1) concentrations] between groups. p<0.05 was considered significant. RESULTS The median (interquartile range - IQR) of age was 37 (29-48) years old, of disease duration was 7 (4-13) years, and of SLEDAI-2K was 1 (0-2). The median (IQR) of variation in CRP levels between the two groups showed a decrease in omega-3 group while there was an increase in control group (p=0.008). The serum concentrations of IL-6 and IL-10, leptin and adiponectin did not change after a 12 week treatment. CONCLUSIONS Supplementation with omega-3 had no impact on serum concentrations of IL-6, IL-10, leptin and adiponectin in women with SLE and low disease activity. There was a significant decrease of CRP levels as well as evidence that omega-3 may impact total and LDL-cholesterol.
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Tang Y, Zhang X, Ji L, Mi X, Liu F, Yang L, Qin W. Clinicopathological and outcome analysis of adult lupus nephritis patients in China. Int Urol Nephrol 2015; 47:513-20. [PMID: 25563231 DOI: 10.1007/s11255-014-0903-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/20/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND The objective of this study was to assess clinicopathological characteristics and outcomes of lupus nephritis adult patients in China. METHODS Clinicopathological features, treatment strategies, responses and outcome of 681 adult patients with biopsy-proved lupus nephritis were retrospectively analyzed. RESULTS Six hundred and eighty-one LN patients were included and followed up for 52.5 ± 14.1 months. Differences in age, disease duration, BP, proteinuria, serum albumin, creatinine, ANCA-positive ratio and SLEDAI scores were noticed between male and female patients, indicating severer disease in male patients. LN IV patients were much severer in systemic damage as well as immunological changes. During follow-up, 354 patients achieved CR, 107 patients achieved PR, 95 patients progressed to ESRD and 36 patients died. Prognosis and treatment response of patients with different histological types differ apparently. Renal outcome of patients with LN II and III was benign, while LN IV, V and VI was poor. Cyclophosphamide was effective in most patients. MMF and CNI could be used as salvage treatment. In multivariate analysis, BP, sCr, hypocomplementemia, severe proliferative lesion (LN IV or VI) and SLEDAI score were recognized as independent indicators of poor renal outcome. Infections, especially pulmonary fungus infection, thrombotic microangiopathy are the most common causes of death in LN patients. CONCLUSIONS Clinicopathological characteristics, treatment responses and long-term outcomes differ remarkably in LN patients with different gender and pathological subtypes. New indicators of poor renal outcome were identified. Infections and TTP were the most common causes of death in LN patients.
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Affiliation(s)
- Yi Tang
- Division of Nephrology, West China Hospital of Sichuan University, 37# Guoxue Rd, Chengdu, Sichuan, China
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Klumb EM, Silva CAA, Lanna CCD, Sato EI, Borba EF, Brenol JCT, Albuquerque EMDND, Monticielo OA, Costallat LTL, Latorre LC, Sauma MDFLDC, Bonfá ESDDO, Ribeiro FM. Consenso da Sociedade Brasileira de Reumatologia para o diagnóstico, manejo e tratamento da nefrite lúpica. REVISTA BRASILEIRA DE REUMATOLOGIA 2015; 55:1-21. [DOI: 10.1016/j.rbr.2014.09.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 09/14/2014] [Indexed: 12/29/2022] Open
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Elfving P, Puolakka K, Kautiainen H, Virta LJ, Pohjolainen T, Kaipiainen-Seppänen O. Mortality and causes of death among incident cases of systemic lupus erythematosus in Finland 2000-2008. Lupus 2014; 23:1430-4. [PMID: 25057036 DOI: 10.1177/0961203314543919] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objectives of the study were to investigate mortality and causes of death in patients with recent-onset systemic lupus erythematosus (SLE) in Finland. Data for patients with SLE for the study were collected (2000-2007) from the nationwide register on decisions of special reimbursements for drugs, maintained by the Social Insurance Institution (SII) in Finland. Data on deaths of the patients were obtained from the official death certificate statistics of Statistics Finland until the end of 2008. Of the 566 incident SLE patients, median follow-up time was 5.4 (IQR 3.3, 7.1) years, and 30 patients (23 females, seven males) died in the years 2000 through 2008. Mean age at death was 67.8 ± 17.2 years for females and 62.3 ± 15.2 years for males. The 5-year survival rates were 94.8% (95%CI 92.0-96.6%) and 88.2% (95%CI 76.5-94.3%), respectively. The age- and sex-adjusted standardized mortality ratio was 1.48 (95%CI 1.01-2.12). Primary causes of death were cardiovascular diseases, malignancy and SLE itself. In conclusion, survival of the patients with SLE was inferior to that of the general population. Cardiovascular diseases were responsible for 37% of deaths.
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Affiliation(s)
- P Elfving
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - K Puolakka
- Department of Medicine, South Karelia Central Hospital, Lappeenranta, Finland
| | - H Kautiainen
- Unit of Primary Health Care, Helsinki University Central Hospital, Helsinki, Finland Department of General Practice, University of Helsinki, Helsinki, Finland Unit of Primary Health Care, Kuopio University Hospital, Kuopio, Finland
| | - L J Virta
- Research Department, Social Insurance Institution, Turku, Finland
| | - T Pohjolainen
- Rehabilitation Unit, Orton Hospital, Helsinki, Finland
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Fatemi A, Matinfar M, Sayedbonakdar Z, Maracy M, Karimzadeh H, Saber M, Smiley A. Outcome of adult onset systemic lupus erythematosus in Iran. Lupus 2014; 23:1211-6. [PMID: 24833666 DOI: 10.1177/0961203314534304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM The aim of this study was to determine systemic lupus erythematosus (SLE) survival in adult patients and its predictors in Iran. METHODS The adult patients diagnosed with SLE and admitted to our referral general hospital from 1992 to 2011 were studied. Demographic, clinical and laboratory data at the time of diagnosis were obtained retrospectively and analyzed. Survival rates were calculated by the Kaplan-Meier method. Predictors of mortality were assessed by Cox regression analysis. RESULTS In total, 417 were enrolled in the study; 23 were lost to follow-up. Mean (SD) age of SLE onset was 30 (9.7) years. During the study period 35 patients (8.9%) died. The most common causes of death were active SLE (43%), infections (28.6%) and circulatory diseases (20%). Overall survival rates after 5, 10, 15 and 20 years were 93%, 90%, 90% and 80%, respectively. Poor survival predictors in univariate analysis were pericarditis, seizure and hematuria. With multivariate Cox regression analysis, no pericarditis (p = 0.007, HR = 0.22, 95%CI: 0.075-0.657) and no seizure (p = 0.019, HR = 0.35, 95%CI: 0.149-0.846) at the time of SLE diagnosis were found as protective factors in patients' survival. CONCLUSION Our study revealed that the survival rate of SLE is comparable with the acceptable worldwide trend. Presenting with pericarditis and seizure at the time of SLE diagnosis prominently decreased the survival rate. Prospective and multicenter studies are needed to better identify the behavior of SLE in Iran.
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Affiliation(s)
- A Fatemi
- Department of Rheumatology, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - M Matinfar
- Department of Internal Medicine, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Z Sayedbonakdar
- Department of Rheumatology, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - M Maracy
- Department of Biostatistics & Epidemiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - H Karimzadeh
- Department of Rheumatology, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - M Saber
- Department of Dermatology, Isfahan University of Medical Sciences, Isfahan, Iran
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Ugarte-Gil MF, Acevedo-Vásquez E, Alarcón GS, Pastor-Asurza CA, Alfaro-Lozano JL, Cucho-Venegas JM, Segami MI, Wojdyla D, Soriano ER, Drenkard C, Brenol JC, de Oliveira e Silva Montandon AC, Costallat LTL, Massardo L, Molina-Restrepo JF, Guibert-Toledano M, Silveira LH, Amigo MC, Barile-Fabris LA, Chacón-Díaz R, Esteva-Spinetti MH, Pons-Estel GJ, McGwin G, Pons-Estel BA. The number of flares patients experience impacts on damage accrual in systemic lupus erythematosus: data from a multiethnic Latin American cohort. Ann Rheum Dis 2014; 74:1019-23. [PMID: 24525909 DOI: 10.1136/annrheumdis-2013-204620] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 01/24/2014] [Indexed: 01/27/2023]
Abstract
PURPOSE To determine the association between the number of flares systemic lupus erythematosus (SLE) patients experience and damage accrual, independently of other known risk factors. METHODS SLE patients (34 centres, nine Latin American countries) with a recent diagnosis (≤2 years) and ≥3 evaluations were studied. Disease activity was ascertained with the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and damage with the SLICC/ACR Damage Index (SDI). Flare was defined as an increase ≥4 points in the SLEDAI between two study visits. An ambidirectional case- crossover design was used to determine the association between the number of flares and damage accrual. RESULTS 901 patients were eligible for the study; 500 of them (55.5%) experienced at least one flare, being the mean number of flares 0.9 (SD: 1.0). 574 intervals from 251 patients were included in the case-crossover design since they have case and control intervals, whereas, the remaining patients did not. Their mean age at diagnosis was 27.9 years (SD: 11.1), 213 (84.9%) were women. The mean baseline SDI and SLEDAI were 1.3 (1.3) and 13.6 (8.1), respectively. Other features were comparable to those of the entire sample. After adjusting for possible confounding variables, the number of flares, regardless of their severity, was associated with damage accrual (SDI) OR 2.05, 95% CI 1.43 to 2.94, p<0.001 (OR 2.62, 95% CI 1.31 to 5.24, p=0.006 for severe and OR 1.91, 95% CI 1.28 to 2.83, p=0.001 for mild-moderate). CONCLUSIONS The number of flares patients experience, regardless of their severity, increases the risk of damage accrual, independently of other known risk factors.
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Affiliation(s)
- Manuel F Ugarte-Gil
- Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú. Universidad Científica del Sur, Lima, Perú
| | - Eduardo Acevedo-Vásquez
- Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú. Universidad Nacional Mayor de San Marcos, Lima, Perú
| | - Graciela S Alarcón
- Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cesar A Pastor-Asurza
- Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú. Universidad Nacional Mayor de San Marcos, Lima, Perú
| | - José L Alfaro-Lozano
- Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú
| | - Jorge M Cucho-Venegas
- Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú
| | - Maria I Segami
- Universidad Nacional Mayor de San Marcos, Lima, Perú Servicio de Reumatología, Hospital Nacional Edgardo Rebagliati Martins, EsSalud, Lima, Perú
| | | | - Enrique R Soriano
- Servicio de Reumatología, Hospital Italiano and Fundación Dr. Pedro M. Catoggio para el Progreso de la Reumatología, Buenos Aires, Argentina
| | - Cristina Drenkard
- Division of Rheumatology, Emory University School of Medicine, Atlanta, USA
| | - João Carlos Brenol
- Hospital das Clinicas de Porto Alegre, Universidade Federal do, Rio Grande do Sul, Brazil
| | | | - Lilian T Lavras Costallat
- Divisao de Reumatologia, Faculdade de Ciencias Medicas, Universidade Estadual da Campinas, Campinas, Brazil
| | - Loreto Massardo
- Department of Clinical Immunology and Rheumatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | | | - Luis H Silveira
- Departamento de Reumatología, Instituto Nacional de Cardiología Ignacio Chávez, México D.F., México
| | | | - Leonor A Barile-Fabris
- Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico D.F., Mexico
| | - Rosa Chacón-Díaz
- Servicio de Reumatología, Centro Nacional de Enfermedades Reumáticas, Hospital Universitario de Caracas, Caracas, Venezuela
| | | | - Guillermo J Pons-Estel
- Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA Department of Autoimmune Diseases, Institut Clinic de Medicina I Dermatologia, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Gerald McGwin
- Department of Epidemiology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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