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Thomas KN, Aggarwal A. Childhood rheumatic diseases: bites not only the joint, but also the heart. Clin Rheumatol 2023; 42:2703-2715. [PMID: 37160484 PMCID: PMC10169151 DOI: 10.1007/s10067-023-06621-9] [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] [Received: 12/27/2022] [Revised: 04/30/2023] [Accepted: 05/01/2023] [Indexed: 05/11/2023]
Abstract
Cardiovascular involvement in juvenile rheumatic diseases is the primary manifestation in paediatric vasculitis and a major organ manifestation in paediatric connective tissue diseases. Though coronary vasculitis is the prototypical manifestation of Kawasaki disease, it can also be seen in patients with polyarteritis nodosa. Pericarditis is the most common manifestation seen in juvenile rheumatic diseases like systemic onset JIA, and lupus. Cardiac tamponade, valvular insufficiency, aortic root dilatation and arrhythmias are seen rarely. Cardiac involvement is often recognized late in children. The development of cardiac disease in juvenile systemic sclerosis is associated with a poor outcome. In long term, childhood onset of rheumatic diseases predisposes to diastolic dysfunction and premature atherosclerosis during adulthood. Key Points • Pericarditis is the most common cardiac manifestation in SLE and can lead to tamponade. • Conduction defects are common in juvenile mixed connective tissue disease and systemic sclerosis. • Pulmonary hypertension is a significant contributor to mortality in juvenile systemic sclerosis. • In Kawasaki disease, early treatment can reduce risk of coronary artery aneurysms.
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Affiliation(s)
- Koshy Nithin Thomas
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.
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Abstract
Cardiovascular disease risk is evident during childhood for patients with juvenile systemic lupus erythematosus, juvenile dermatomyositis, and juvenile idiopathic arthritis. The American Heart Association defines cardiovascular health as a positive health construct reflecting the sum of protective factors against cardiovascular disease. Disease-related factors such as chronic inflammation and endothelial dysfunction increase cardiovascular disease risk directly and through bidirectional relationships with poor cardiovascular health factors. Pharmacologic and nonpharmacologic interventions to improve cardiovascular health and long-term cardiovascular outcomes in children with rheumatic disease are needed.
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Mendoza-Pinto C, Rojas-Villarraga A, Molano-González N, García-Carrasco M, Munguía-Realpozo P, Etchegaray-Morales I, Morales-Sánchez H, Berra-Romani R, Cervera R. Endothelial dysfunction and arterial stiffness in patients with systemic lupus erythematosus: A systematic review and meta-analysis. Atherosclerosis 2020; 297:55-63. [PMID: 32078830 DOI: 10.1016/j.atherosclerosis.2020.01.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 01/23/2020] [Accepted: 01/30/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS Non-invasive surrogates of cardiovascular (CV) disease such as endothelial dysfunction (ED) and peripheral arterial stiffness (AS) have been evaluated in systemic lupus erythematosus (SLE) patients. The aim of this study was to systematically review and meta-analyze reports of cardiovascular disease (CVD) in SLE patients, as measured by ED and AS. METHODS Studies analyzing the relationship of SLE with ED (flow-mediated dilatation [FMD], nitroglycerin-mediated dilatation [NMD] and peripheral arterial tonometry [PAT]) and AS (augmentation index [AIx], pulse wave velocity [PWV]) were systematically searched for in PubMed, Cochrane library, EMBASE, VHL, SciELO and Web of Science databases. Inclusion criteria included peer-review and English language. Mean differences (MD) and 95% confidence intervals (CIs) were estimated using the random effect model. The study was registered with PROSPERO, number CRD42019121068. RESULTS The meta-analysis included 49 studies. FMD data from 18 studies including 943 SLE subjects (mean age = 38.71 [95%CI 36.21, 41.21] years) and 644 unaffected controls (mean age = 38.63 [95%CI 36.11, 41.15] years) were included. When compared with unaffected controls, FMD in SLE subjects was decreased by 4.3% (95%CI: -6.13%, -2.47%): p < 0.001). However, NMD did not significantly differ between SLE patients and controls (MD = - 2.68%; 95% CI -6.00, 0.62; p = 0.11). A significantly increased AS between SLE patients and controls according to overall PWV (MD = 1.12 m/s; 95% CI 0.72-1.52; p < 0.001) was observed, but not for the brachial-ankle PWV. AIx was also increased in SLE patients compared with healthy controls (MD = 4.55%; 95% CI 1.48-7.63; p = 0.003). CONCLUSIONS Overall, SLE patients showed impaired FMD, an independent predictor of CV events. There was a higher degree of AS in SLE patients compared with controls. ED and AS in SLE should be considered when planning preventive strategies and therapies.
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Affiliation(s)
- Claudia Mendoza-Pinto
- Systemic Autoimmune Diseases Research Unit, High Specialized Medical Unit, UMAE CMNMAC - CIBIOR, Mexican Social Security Institute, Puebla, Mexico; Department of Immunology and Rheumatology, Medicine School, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | | | - Nicolás Molano-González
- Clinical Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Mario García-Carrasco
- Systemic Autoimmune Diseases Research Unit, High Specialized Medical Unit, UMAE CMNMAC - CIBIOR, Mexican Social Security Institute, Puebla, Mexico; Department of Immunology and Rheumatology, Medicine School, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico.
| | - Pamela Munguía-Realpozo
- Systemic Autoimmune Diseases Research Unit, High Specialized Medical Unit, UMAE CMNMAC - CIBIOR, Mexican Social Security Institute, Puebla, Mexico; Department of Immunology and Rheumatology, Medicine School, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Ivet Etchegaray-Morales
- Department of Rheumatology, Medicine School, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Héctor Morales-Sánchez
- Department of Rheumatology, Medicine School, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Roberto Berra-Romani
- Department of Biomedicine, School of Medicine, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Catalonia, Spain
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Cai Z, Xiang W, Peng X, Ding Y, Liao W, He X. MicroRNA-145 Involves in the Pathogenesis of Renal Vascular Lesions and May Become a Potential Therapeutic Target in Patients with Juvenile Lupus Nephritis. Kidney Blood Press Res 2019; 44:643-655. [PMID: 31430759 DOI: 10.1159/000500923] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/12/2019] [Indexed: 11/19/2022] Open
Abstract
AIMS The current study was conducted with the central objective of investigating the expression of microRNA-145 (miR-145) in renal vascular lesions (RVLs) in juvenile lupus nephritis (JLN) and its possible mechanism. METHODS The clinical data of 49 JLN patients confirmed by renal biopsy were collected and followed by grouping according to the RVLs score after hematoxylin-eosin staining: mild, moderate, and severe groups. In situ hybridization was used to detect the expression of miR-145 in renal vessels which was then being compared among different RVLs groups. Up-LV-miR-145 and LV-miR-NC lentiviral vectors were constructed and transfected into human vascular smooth muscle cells (HVSMCs), respectively. After HVSMCs were treated with 10.0 µg/L platelet-derived growth factor (PDGF)-BB for 24 h, the proliferation, migration, and apoptosis of endothelial cells were detected by MTT, Transwell assay, and flow cytometry, respectively. Western blot was used to detect expression of alpha-smooth muscle actin (α-SM-actin) and osteopontin (OPN). RESULTS The expression of miR-145 in renal vascular cells was statistically significant. The higher the inner membrane ratio, the lesser the miR-145 expression. After treatment with PDGF-BB, expression of miR-145 in HVSMCs decreased, proliferation and migration ability enhanced, apoptosis decreased, α-SM-actin decreased, and OPN increased. The proliferation and migration ability of HVSMCs in the LV-miR-145 group suppressed, apoptosis enhanced, α-SM-actin increased, and OPN decreased. CONCLUSIONS Our study revealed that miR-145 expression decreased with the increase of vascular damage. miR-145 can inhibit proliferation, migration, and differentiation phenotypic transformation of HVSMCs induced by PDGF-BB. miR-145 may be involved in the pathogenesis of RVLs and may be a new target for treatment of RVLs in lupus nephritis.
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Affiliation(s)
- Zhaomin Cai
- Department of Clinical Laboratory, People's Hospital of Baoan District of Shenzhen, Shenzhen, China
| | - Wei Xiang
- Department of Pediatrics, Hainan Provincial Maternal Hospital, Hainan Province, Haikou, China
| | - Xiaojie Peng
- Department of Nephrology, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Yan Ding
- Department of Dermatology, Hainan Provincial Dermatology Disease Hospital, Haikou, China
| | - Wang Liao
- Department of Cardiology, Hainan General Hospital, Haikou, China
| | - Xiaojie He
- Laboratory of Pediatric Nephrology, Institute of Pediatrics, Central South University, Changsha, China,
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Abdel-Monem SM, Ganeb SS, Fawzy RM, Bendary AM, Elhawary ZN. Carotid artery atherosclerosis and ECG changes in patients with systemic lupus erythematosus: relation to disease activity and severity. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2019. [DOI: 10.4103/err.err_56_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Atkinson MA, Joo S, Sule S. Hepcidin and arterial stiffness in children with systemic lupus erythematosus and lupus nephritis: A cross-sectional study. PLoS One 2019; 14:e0214248. [PMID: 30925172 PMCID: PMC6440617 DOI: 10.1371/journal.pone.0214248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/08/2019] [Indexed: 11/28/2022] Open
Abstract
Background Cardiovascular disease is common in patients with systemic lupus erythematosis (SLE) and lupus nephritis (LN). Up to 80% of children with SLE develop kidney disease, which is also associated with increased risk for cardiovascular disease and death compared to those without renal involvement. Hepcidin is an iron-regulatory protein which may contribute to atherosclerosis and is elevated in autoimmune disease. Pulse wave velocity (PWV) is a validated indicator of arterial stiffness, an early marker of cardiovascular risk, and is increased in children with SLE versus healthy controls. Our objective was to quantify hepcidin and PWV in children with SLE and investigate if those with biopsy-proven LN have higher hepcidin levels and higher PWV compared to those without kidney disease. Methods Cross-sectional analysis with hepcidin was measured via ELISA assay in 16 children aged 10–21 years with SLE recruited from a single center. Subjects were classified as having LN if histologic evidence of the disease was documented on a clinical renal biopsy. Serum hepcidin was quantified using a validated competitive enzyme-linked immunoassay. Carotid-femoral PWV was measured using applanation tonometry. Wilcoxon rank sum testing was used to compare median levels of hepcidin, PWV, and other continuous variables by nephritis status. Results The cohort (n = 16) was 93.8% female and 68.8% African-American with mean (SD) 16 (3.6) years. 37.5% (n = 6) had LN. Overall median (IQR) hepcidin was 34.4 (18.9, 91.9) ng/ml, and PWV 4.4 (4, 4.6) meters/second. Although significance was limited by small sample size, both hepcidin and PWV were higher in the subjects with LN. Median (IQR) hepcidin in subjects with LN was 71.5 (26.4, 116.4) ng/ml compared to 27.9 (18.7, 59.7) ng/ml in those with SLE(p = 0.19). Similarly, median (IQR) PWV in those with LN was 4.4 (4.4, 4.9) meters/second compared to 3 (3.75, 4.55) meters/second in those with without kidney involvement (p = 0.10). Conclusion PWV and serum hepcidin were higher in subjects with LN compared to those with SLE alone, suggesting that elevated hepcidin levels may be associated with morbid CV changes in children with LN. This association, along with identification of additional predictors of arterial stiffness in patients with LN, warrants further investigation.
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Affiliation(s)
- Meredith A. Atkinson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
| | - Sarah Joo
- Kaiser San Francisco, San Francisco, California, United States of America
| | - Sangeeta Sule
- Division of Rheumatology, Children’s National Medical Center, Washington, District of Columbia, United States of America
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Abstract
Childhood-onset systemic lupus erythematosus (SLE) is a subset of SLE with an onset before 18 years of age. Patients with early onset SLE tend to have a greater genetic component to their disease cause, more multisystemic involvement, and a more severe disease course, which includes greater risks for developing nephritis and end-stage kidney disease. Five- and 10-year mortality is lower than in adult-onset SLE. Although patient and renal survival have improved with advances in induction and maintenance immunosuppression, accumulation of irreversible damage is common. Cardiovascular and infectious complications are frequent, as are relapses during adolescence and the transition to adulthood.
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Salomão RG, de Carvalho LM, Izumi C, Czernisz ÉS, Rosa JC, Antonini SRR, Bueno AC, Almada MORDV, Coelho-Landell CDA, Jordão AA, Ferriani VPL, Monteiro JP. Homocysteine, folate, hs-C-reactive protein, tumor necrosis factor alpha and inflammatory proteins: are these biomarkers related to nutritional status and cardiovascular risk in childhood-onset systemic lupus erythematosus? Pediatr Rheumatol Online J 2018; 16:4. [PMID: 29316941 PMCID: PMC5761099 DOI: 10.1186/s12969-017-0220-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/21/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Childhood-onset systemic lupus erythematosus (c-SLE) is a chronic autoimmune disease which increases cardiovascular risk factors (CRF) such as elevated homocysteine, TNF-α, and hs-C reactive protein. METHODS We evaluated BMI, waist circumference (WC), 24-h recalls, SLEDAI-2 K, SLICC/ACR-DI, serum levels of homocysteine, folate, TNF-α, hs-C reactive protein, lipid profile, proteomic data, and duration of corticosteroid therapy in 19 c-SLE and 38 healthy volunteers. Physiological and anthropometric variables of c-SLE and healthy controls were compared by ANCOVA. k-cluster was used to separate c-SLE into two different groups with the best and the worst metabolic profile according to previous analysis showing some metabolites that were statistically different from controls, such as homocysteine, TNF-α, hs-CRP and folate levels. These two clusters were again compared with the control group regarding nutritional parameters, lipid profile and also proteomic data. RESULTS Individuals with c-SLE presented higher BMI, WC, homocysteine, triglycerides, TNF-α, hs-CRP and lower folate levels when compared to controls. We found 10 proteins whose relative abundances were statistically different between control group and lupus clusters with the best (LCBMP) and the worst metabolic profile (LCWMP). A significant positive correlation was found between TNF-α and triglycerides and between hs-CRP and duration of corticosteroid therapy. CONCLUSION Cardiovascular disease (CVD) risk parameters were worse in c-SLE. A less protective CVD proteomic profile was found in LCWMP.
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Affiliation(s)
- Roberta Garcia Salomão
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirão Preto, São Paulo, Brasil.
| | - Luciana Martins de Carvalho
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirão Preto, São Paulo, Brasil
| | - Clarice Izumi
- Protein Chemistry Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brasil
| | - Érika Silva Czernisz
- Protein Chemistry Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brasil
| | - José César Rosa
- Protein Chemistry Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brasil
| | - Sonir Roberto Rauber Antonini
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirão Preto, São Paulo, Brasil
| | - Ana Carolina Bueno
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirão Preto, São Paulo, Brasil
| | - Maria Olímpia Ribeiro do Vale Almada
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirão Preto, São Paulo, Brasil
| | - Carolina de Almeida Coelho-Landell
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirão Preto, São Paulo, Brasil
| | - Alceu Afonso Jordão
- Department of Medical Clinical, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brasil
| | - Virgínia Paes Leme Ferriani
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirão Preto, São Paulo, Brasil
| | - Jacqueline Pontes Monteiro
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirão Preto, São Paulo, Brasil
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Avar Aydin PO, Shan J, Brunner HI, Mitsnefes MM. Blood pressure control over time in childhood-onset systemic lupus erythematous. Lupus 2018; 27:657-664. [PMID: 29301473 DOI: 10.1177/0961203317751061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Hypertension (HTN) is prevalent in patients with systemic lupus erythematosus (SLE) and causes early cardiovascular aging and progression of renal and cardiac disease. The aim of this longitudinal retrospective study was to evaluate the prevalence of HTN, the follow-up blood pressure trends, and risk factors for HTN in a population-based cohort with childhood-onset SLE (cSLE). Methods Demographic and clinical data of consecutive visits from the baseline to the last visit were extracted from electronic medical records of patients with cSLE. Results A total of 110 patients with cSLE were identified with a median follow-up duration of 29.5 months; 19% had lupus nephritis (LN) at diagnosis. Further, 29% and 23% had HTN and preHTN at the baseline visit. Compared to those without HTN, patients with HTN had higher disease activity, obesity, more frequent LN, and lower eGFR. In multivariate analysis, the presence of LN, obesity, and high extra-renal disease activity were independent predictors of HTN at baseline. Conclusions While HTN is a known feature of LN, HTN is common and persistent in cSLE without LN, with about one-third of patients having uncontrolled elevated blood pressure almost three years after the onset of lupus. In addition to LN, obesity and high overall disease activity were independent predictors of HTN.
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Affiliation(s)
- P O Avar Aydin
- 1 Division of Rheumatology, 2518 Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - J Shan
- 2 34732 Peking Union Medical College Hospital , Peking, China
| | - H I Brunner
- 1 Division of Rheumatology, 2518 Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - M M Mitsnefes
- 3 Division of Nephrology and Hypertension, 2518 Cincinnati Children's Hospital , Cincinnati, OH, USA
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Hogan J, Godron A, Baudouin V, Kwon T, Harambat J, Deschênes G, Niel O. Combination therapy of rituximab and mycophenolate mofetil in childhood lupus nephritis. Pediatr Nephrol 2018; 33:111-116. [PMID: 28780657 DOI: 10.1007/s00467-017-3767-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 07/08/2017] [Accepted: 07/10/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND In clinical trials, the addition of rituximab (RTX) to the combination therapeutic regimen of mycophenolate mofetil (MMF) and corticosteroids failed to improve outcome in lupus nephritis (LN). However, recent data suggest that RTX may have steroid-sparing beneficial effects with an efficacy similar to that of conventional regimens. We report our experience with RTX in the treatment of children with LN. METHODS Patients treated with RTX for first occurrence of LN class III to V were enrolled in the study. Treatment consisted of methylprednisolone pulse (500 mg/m2) followed by RTX (1000 mg/1.73 m2) at days 1 and 15, and MMF (1200 mg/m2/day). Prednisolone tapering and withdrawal was left to the physician's discretion. Complete remission (CR) was defined as a urine protein-to-creatinine ratio (U Pr/Cr) of <5 mg/mg and normal serum creatinine, and partial remission (PR) as a U Pr/Cr of <30 mg/mg and a <15% rise in serum creatinine over baseline. RESULTS Twelve patients were included in the study, with median follow-up of 23.7 [interquartile range (IQR) 12.8-33.5] months. Median age of the patients was 13.6 [12.3-15.1] years, median proteinuria was 32 [19-67] mg/mg and median estimated glomerular filtration rate was 76.1 [59.3-97.7] mL/min/1.73 m2. Median CD20 depletion duration was 10 [6.8-11.0] months. Prednisolone was rapidly tapered, with median dose of 0.3 [0.15-0.41], 0.10 [0.09-0.16] and 0.0 [0.0-0.04] mg/kg/day at 3, 6 and 12 months respectively. At 3 months, three and seven patients achieved CR and PR, respectively; at 6 and 12 months all patients achieved remission (9 CR, 3 PR) and none relapsed during follow-up. Five infectious complications were observed, including three varicella-zoster virus (VZV) infections. CONCLUSIONS In our pediatric patients with LN, therapy with RTX + MMF combined with a rapid decrease in steroid appears to have been an efficacious treatment for severe LN but was associated with high rate of VZV infection. The potential of RTX to allow complete steroid avoidance warrants further investigation in children.
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Affiliation(s)
- Julien Hogan
- Pediatric Nephrology Department, Robert Debré Hospital, Assistance publique-Hôpitaux de Paris (APHP), Paris, France.
| | - Astrid Godron
- Pediatric Nephrology Unit, Pellegrin-Enfants Hospital-Bordeaux University, Bordeaux, France
| | - Véronique Baudouin
- Pediatric Nephrology Department, Robert Debré Hospital, Assistance publique-Hôpitaux de Paris (APHP), Paris, France
| | - Theresa Kwon
- Pediatric Nephrology Department, Robert Debré Hospital, Assistance publique-Hôpitaux de Paris (APHP), Paris, France
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Pellegrin-Enfants Hospital-Bordeaux University, Bordeaux, France
| | - Georges Deschênes
- Pediatric Nephrology Department, Robert Debré Hospital, Assistance publique-Hôpitaux de Paris (APHP), Paris, France
| | - Olivier Niel
- Pediatric Nephrology Department, Robert Debré Hospital, Assistance publique-Hôpitaux de Paris (APHP), Paris, France
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Wang P, Mao YM, Zhao CN, Liu LN, Li XM, Li XP, Pan HF. Increased Pulse Wave Velocity in Systemic Lupus Erythematosus: A Meta-Analysis. Angiology 2017. [PMID: 28635303 DOI: 10.1177/0003319717715964] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Systemic lupus erythematosus (SLE) is associated with increased cardiovascular risk. This study aims to derive a more precise estimation on pulse wave velocity (PWV) level in patients with SLE and related factors. A literature search was performed using PubMed, EMBASE, and The Cochrane Library databases, studies published up to February 28, 2017, in English. Pooled standardized mean difference (SMD) with 95% confidence interval (CI) was calculated by fixed-effect or random-effect model analysis. Heterogeneity test was performed by the Q statistic and quantified using I2; publication bias was evaluated using a funnel plot and Egger's linear regression test. Of 156 studies found, 27 met eligibility criteria, and 14 studies were finally included in the meta-analysis. Meta-analysis revealed that the SLE group had significantly higher PWV levels than the control group; SMD = 0.56 and 95% CI (0.30-0.82). Subgroup analyses showed that body mass index (BMI), sample size, and disease duration were associated with PWV in patients with SLE. Overall, our study suggests that patients with SLE have a higher PWV level, and it is associated with BMI, sample size, and disease duration.
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Affiliation(s)
- Peng Wang
- 1 Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China.,2 The Key Laboratory of Major Autoimmune Diseases, Anhui Province, Hefei, Anhui, China
| | - Yan-Mei Mao
- 1 Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China.,2 The Key Laboratory of Major Autoimmune Diseases, Anhui Province, Hefei, Anhui, China
| | - Chan-Na Zhao
- 1 Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China.,2 The Key Laboratory of Major Autoimmune Diseases, Anhui Province, Hefei, Anhui, China
| | - Li-Na Liu
- 1 Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China.,2 The Key Laboratory of Major Autoimmune Diseases, Anhui Province, Hefei, Anhui, China
| | - Xiao-Mei Li
- 3 Department of Rheumatology, Anhui Provincial Hospital, Hefei, Anhui, China
| | - Xiang-Pei Li
- 3 Department of Rheumatology, Anhui Provincial Hospital, Hefei, Anhui, China
| | - Hai-Feng Pan
- 1 Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China.,2 The Key Laboratory of Major Autoimmune Diseases, Anhui Province, Hefei, Anhui, China
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Pattrakornkul N, Pruangprasert P, Chanthong P, Chawanasuntorapoj R, Pattaragarn A. Subclinical atherosclerosis in young Thai adults with juvenile-onset systemic lupus erythematosus. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.1002.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in adult patients with systemic lupus erythematosus (SLE). Increased risk of CVD and atherosclerosis has been demonstrated in children with SLE. However, evidence of atherosclerosis in adults with juvenile-onset SLE is limited and their additional CVD risk factors unclear.
Objectives
To investigate the presence of subclinical atherosclerosis in young Thai adults with juvenile-onset SLE, and evaluate atherosclerotic risk factors.
Methods
We recruited a cohort of patients aged 18-40 years who had been diagnosed SLE before the age of 18 years for this observational study. Patients with chronic kidney disease stage IV or V, alcoholism, chronic liver disease, or life threatening illness were excluded. Common carotid intima-media thickness (CCIMT) was measured. Clinical and laboratory parameters, treatment, and SLE-related factors, which could be risk factors for atherosclerosis and classic risk factors were obtained.
Results
We enrolled 29 patients (24 female). Their mean age was 25.1 years and mean disease duration 11.3 years. The age of participants, persistent proteinuria and use of cyclosporin correlated with increased CCIMT by multivariable analysis (P = 0.02, 0.02, and 0.03, respectively). These patients had significantly abnormal CCIMT when compared with a healthy population (mean 690 (SD 150) μm versus mean 447 (SD 76) μm, respectively; P < 0.001).
Conclusions
Subclinical atherosclerosis, identified by abnormal CCIMT, appears in young adults with juvenile-onset SLE. The CCIMT abnormality progresses with increasing age, and persistent proteinuria and use of cyclosporin appears to increase the risk for atherosclerosis.
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Affiliation(s)
- Nalinee Pattrakornkul
- Department of Pediatrics , Faculty of Medicine Siriraj hospital , Mahidol University , Bangkok 10700 , Thailand
| | - Patamakom Pruangprasert
- Department of Pediatrics , Faculty of Medicine Siriraj hospital , Mahidol University , Bangkok 10700 , Thailand
| | - Prakul Chanthong
- Department of Pediatrics , Faculty of Medicine Siriraj hospital , Mahidol University , Bangkok 10700 , Thailand
| | - Ratana Chawanasuntorapoj
- Department of Medicine , Faculty of Medicine Siriraj hospital , Mahidol University , Bangkok 10700 , Thailand
| | - Anirut Pattaragarn
- Department of Pediatrics , Faculty of Medicine Siriraj hospital , Mahidol University , Bangkok 10700 , Thailand
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Ahmed EAS, Ganeb SS, El-shambaky AY, Galal OT, Tohamy MY. Study of early atherosclerosis in juvenile-onset systemic lupus erythematosus patients. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2017. [DOI: 10.4103/1110-161x.200835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Su-Angka N, Khositseth A, Vilaiyuk S, Tangnararatchakit K, Prangwatanagul W. Carotid intima-media thickness and arterial stiffness in pediatric systemic lupus erythematosus. Lupus 2017; 26:989-995. [PMID: 28420050 DOI: 10.1177/0961203317692434] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The carotid intima-media thickness (CIMT) and carotid arterial stiffness index (CASI) act as the surrogate markers of atherosclerosis. We aim to assess CIMT and CASI in pediatric systemic lupus erythematosus (SLE). Methods Patients ≤ 20 years old fulfilling diagnostic criteria for SLE were enrolled. Patients with active smoking, coronary heart disease, cerebrovascular disease, arterial thrombosis, family history of hypercholesterolemia, chronic liver disease, or other chronic severe diseases were excluded. The patients were categorized into four groups: active SLE, age- and sex-matched control (control A), inactive SLE, and age- and sex-matched control (control I), according to the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). All subjects underwent ultrasound of carotid arteries to evaluate CIMT and CASI. Results One hundred and two SLE patients (26 active and 76 inactive) and one hundred and three healthy controls (26 control A and 77 control I) were enrolled. The median CIMT in all groups were not significantly different (0.43, 0.41-0.44; 0.43, 0.41-0.44; 0.42, 0.41-0.43; and 0.42, 0.41-0.43 mm, respectively).The CASI in active SLE (13.5, 11.4-17.3) was significantly higher than in control A (8.2, 7.2-9.2) ( p < 0.0001), whereas CASI in inactive SLE (12.7, 10.9-15.7) was significantly higher than in control I (8.9, 7.6-9.8). However, the CASI in active and inactive SLE was not significantly different. Conclusions The higher CASI in active and inactive pediatric SLE, implying functional change of carotid arteries, may be early evidence of increased atherosclerosis in pediatric SLE. This functional dysfunction has been found both in inactive and active SLE.
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Affiliation(s)
- N Su-Angka
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
| | - A Khositseth
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
| | - S Vilaiyuk
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
| | - K Tangnararatchakit
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
| | - W Prangwatanagul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
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15
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Why are kids with lupus at an increased risk of cardiovascular disease? Pediatr Nephrol 2016; 31:861-83. [PMID: 26399239 DOI: 10.1007/s00467-015-3202-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 08/14/2015] [Accepted: 08/25/2015] [Indexed: 01/12/2023]
Abstract
Juvenile-onset systemic lupus erythematosus (SLE) is an aggressive multisystem autoimmune disease. Despite improvements in outcomes for adult patients, children with SLE continue to have a lower life expectancy than adults with SLE, with more aggressive disease, a higher incidence of lupus nephritis and there is an emerging awareness of their increased risk of cardiovascular disease (CVD). In this review, we discuss the evidence for an increased risk of CVD in SLE, its pathogenesis, and the clinical approach to its management.
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Barsalou J, Bradley TJ, Tyrrell PN, Slorach C, Ng LWK, Levy DM, Silverman ED. Impact of Disease Duration on Vascular Surrogates of Early Atherosclerosis in Childhood-Onset Systemic Lupus Erythematosus. Arthritis Rheumatol 2016; 68:237-46. [PMID: 26361097 DOI: 10.1002/art.39423] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/01/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine whether longer disease duration negatively impacts carotid intima-media thickness (CIMT), flow-mediated dilation (FMD), and pulse wave velocity (PWV) in a cohort of patients with childhood-onset systemic lupus erythematosus (SLE), and to compare CIMT, FMD, and PWV in patients with childhood-onset SLE with those in healthy children and explore determinants of vascular test results in childhood-onset SLE. METHODS Cross-sectional analysis was performed in a prospective longitudinal cohort of patients with childhood-onset SLE at the latest followup visit. Clinical and laboratory data were collected for patients with childhood-onset SLE. CIMT, FMD, and PWV were measured using standardized protocols in patients with childhood-onset SLE and healthy children. Correlations between disease duration and results of the 3 vascular tests were performed. Vascular data in patients with childhood-onset SLE were compared with those in healthy children. Multivariable linear regression was used to identify determinants of CIMT, FMD, and PWV in childhood-onset SLE. RESULTS Patients with childhood-onset SLE (n = 149) and healthy controls (n = 178) were enrolled. The median age of the patients was 17.2 years (interquartile range [IQR] 15.7-17.9 years), and their median disease duration was 3.2 years (IQR 1.8-4.9 years). The median age of the healthy children was 14.7 years (IQR 13.1-15.9 years). Longer disease duration correlated with worse FMD (r = -0.2, P = 0.031) in patients with childhood-onset SLE. Patients with childhood-onset SLE had smaller (better) CIMT, higher (better) FMD, and similar PWV compared with healthy controls. Linear regression analysis explained <24% of the variation in vascular test results in patients with childhood-onset SLE, suggesting that other variables should be explored as important determinants of CIMT, FMD, and PWV. CONCLUSION In this cohort of 149 patients with childhood-onset SLE, patients did not have worse CIMT, FMD, or PWV than did healthy controls. Longer disease duration was associated with worse FMD, suggesting progressive endothelial dysfunction over time.
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Affiliation(s)
- Julie Barsalou
- Centre Hospitalier Universitaire St. Justine, University of Montreal, Montreal, Quebec, Canada), Timothy J. Bradley, MBChB, FRACP, Cameron Slorach, RDCS, Lawrence W. K. Ng, BSc, Deborah M. Levy, MD, MS, FRCPC: The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Timothy J Bradley
- Centre Hospitalier Universitaire St. Justine, University of Montreal, Montreal, Quebec, Canada), Timothy J. Bradley, MBChB, FRACP, Cameron Slorach, RDCS, Lawrence W. K. Ng, BSc, Deborah M. Levy, MD, MS, FRCPC: The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Cameron Slorach
- Centre Hospitalier Universitaire St. Justine, University of Montreal, Montreal, Quebec, Canada), Timothy J. Bradley, MBChB, FRACP, Cameron Slorach, RDCS, Lawrence W. K. Ng, BSc, Deborah M. Levy, MD, MS, FRCPC: The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lawrence W K Ng
- Centre Hospitalier Universitaire St. Justine, University of Montreal, Montreal, Quebec, Canada), Timothy J. Bradley, MBChB, FRACP, Cameron Slorach, RDCS, Lawrence W. K. Ng, BSc, Deborah M. Levy, MD, MS, FRCPC: The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Deborah M Levy
- Centre Hospitalier Universitaire St. Justine, University of Montreal, Montreal, Quebec, Canada), Timothy J. Bradley, MBChB, FRACP, Cameron Slorach, RDCS, Lawrence W. K. Ng, BSc, Deborah M. Levy, MD, MS, FRCPC: The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Earl D Silverman
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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Sozeri B, Atikan BY, Ozdemir K, Mir S. Assessment of vascular function in systemic onset juvenile idiopathic arthritis. Clin Rheumatol 2016; 35:1699-703. [DOI: 10.1007/s10067-016-3254-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 03/28/2016] [Accepted: 03/31/2016] [Indexed: 10/22/2022]
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Campbell JF, Swartz SJ, Wenderfer SE. Nocturnal Hypertension and Attenuated Nocturnal Blood Pressure Dipping is Common in Pediatric Lupus. F1000Res 2015; 4:164. [PMID: 26664705 PMCID: PMC4654458 DOI: 10.12688/f1000research.6532.2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2015] [Indexed: 01/22/2023] Open
Abstract
Hypertension is an important manifestation of systemic lupus erythematosus (SLE) but reports of prevalence vary between 20-70% in published reports of adult and pediatric patients. For both children and adults with SLE, the clinical diagnosis and management of hypertension has traditionally been based on guidelines developed for the general population. In clinical trials, the criteria used for defining participants with hypertension are mostly undefined. As a first step towards formally assessing the blood pressure (BP) patterns of children diagnosed with SLE, 24-hr ambulatory BP monitoring data was analyzed on clinic patients who presented with prehypertension or stage I hypertension. In this pediatric SLE cohort (n=10), 20% met daytime criteria for a diagnosis of hypertension. Patterns of BP elevation varied widely with white coat, masked, isolated systolic, and diastolic nocturnal hypertension all identified. Nocturnal hypertension was detected in 60% and attenuated nocturnal BP dipping in 90% of both hypertensive and normotensive SLE patients. In SLE patients, the median nighttime systolic and diastolic loads were 25% and 15.5% compared with median daily loads of 12.5% and 11.5%. Daytime and nighttime systolic and diastolic BP load and nocturnal dipping was compared to a control population consisting of 85 non-SLE patients under 21 years old with prehypertension or stage 1 hypertension presenting to hypertension clinic. Median systolic BP dipped 5.3 mmHg in SLE patients compared to 11.9 mmHg in non-lupus ( p-value = 0.001). Median diastolic BP dipped 12.9 mmHg versus 18.5 mmHg in non-lupus ( p-value = 0.003). Patterns of BP dysregulation in pediatric SLE merit further exploration. Children with or without SLE displaying prehypertensive or stage 1 casual BP measurements had similar rates of hypertension by ambulatory BP monitoring. However, regardless of BP diagnosis, and independent of kidney involvement, there was an increased proportion with attenuated nocturnal dipping and nocturnal hypertension in SLE patients.
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Affiliation(s)
- J Fallon Campbell
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Sarah J Swartz
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Scott E Wenderfer
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, 77030, USA
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Leal GN, Silva KF, Lianza AC, Giacomin MF, Andrade JL, Kozu K, Bonfá E, Silva CA. Subclinical left ventricular dysfunction in childhood-onset systemic lupus erythematosus: a two-dimensional speckle-tracking echocardiographic study. Scand J Rheumatol 2015; 45:202-9. [DOI: 10.3109/03009742.2015.1063686] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- GN Leal
- Department of Radiology, Children’s Institute, Hospital das Clínicas, São Paulo University Medical School
| | - KF Silva
- Department of Radiology, Children’s Institute, Hospital das Clínicas, São Paulo University Medical School
| | - AC Lianza
- Department of Radiology, Children’s Institute, Hospital das Clínicas, São Paulo University Medical School
| | - MF Giacomin
- Rheumatology Unit, Children’s Institute, Hospital das Clínicas, Faculty of Medicine, University of São Paulo
| | - JL Andrade
- Institute of Radiology, Hospital das Clínicas, São Paulo University Medical School
| | - K Kozu
- Rheumatology Unit, Children’s Institute, Hospital das Clínicas, Faculty of Medicine, University of São Paulo
| | - E Bonfá
- Department of Rheumatology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - CA Silva
- Rheumatology Unit, Children’s Institute, Hospital das Clínicas, Faculty of Medicine, University of São Paulo
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Quinlan C, Kari J, Pilkington C, Deanfield J, Shroff R, Marks SD, Tullus K. The vascular phenotype of children with systemic lupus erythematosus. Pediatr Nephrol 2015; 30:1307-16. [PMID: 26001699 DOI: 10.1007/s00467-015-3059-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 01/09/2015] [Accepted: 01/23/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND The increased risk of cardiovascular disease (CVD) in adults with systemic lupus erythematosus (SLE) has been known since the 1970s, but studies in juvenile-onset SLE (JSLE) have reported conflicting results and more data are needed. The aim of this cross-sectional study was to establish the baseline risk of CVD in a cohort of UK patients with JSLE. METHODS Data were collected to establish disease duration, disease activity, medication use and activity levels, as well as demographic data, including family history of CVD. Vascular phenotype was established using well-validated measures of carotid intima media thickness (cIMT) and pulse wave velocity (PWV). RESULTS In total, 45 children (39 female; mean age 13.5 ± 2.9 years) with JSLE were recruited to the study. Of these, 24 had a history of biopsy-proven lupus nephritis and five had an estimated glomerular filtration rate of <90 ml/min/1.73 m(2). Comparison of these JSLE patients with healthy controls previously scanned at our hospital revealed that the cIMT value was significantly higher in the former (0.45 vs. 0.37 mm, respectively; p < 0.0001). This difference was associated with the use of antihypertensives (p = 0.04) and higher or lower doses of prednisolone (p < 0.0001). PWV was not significantly different in the patient and control group (5.27 vs. 5.34 m/s, respectively; p = 0.77). In the patient group, the mean body mass index percentile was 65.63 ± 28.8, and the median physical activity score was 1,773 (676-2,854) metabolic equivalents of task (METs). None of the patients admitted to cigarette smoking, and ten had a positive family history of cardiovascular disease (CVD). CONCLUSION This study shows that our patients with JSLE had increased cIMT without an increase in PWV, suggesting possible early adaptive changes in JSLE. Follow-up data are needed to determine whether these changes result in clinically significant CVD.
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Affiliation(s)
- Catherine Quinlan
- Department of Nephrology, The Royal Children's Hospital, Parkville, Victoria, 3052, Australia,
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Legein B, Temmerman L, Biessen EAL, Lutgens E. Inflammation and immune system interactions in atherosclerosis. Cell Mol Life Sci 2013; 70:3847-69. [PMID: 23430000 PMCID: PMC11113412 DOI: 10.1007/s00018-013-1289-1] [Citation(s) in RCA: 218] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 01/30/2013] [Accepted: 02/04/2013] [Indexed: 12/15/2022]
Abstract
Cardiovascular disease (CVD) is the leading cause of mortality worldwide, accounting for 16.7 million deaths each year. The underlying cause of the majority of CVD is atherosclerosis. In the past, atherosclerosis was considered to be the result of passive lipid accumulation in the vessel wall. Today's picture is far more complex. Atherosclerosis is considered a chronic inflammatory disease that results in the formation of plaques in large and mid-sized arteries. Both cells of the innate and the adaptive immune system play a crucial role in its pathogenesis. By transforming immune cells into pro- and anti-inflammatory chemokine- and cytokine-producing units, and by guiding the interactions between the different immune cells, the immune system decisively influences the propensity of a given plaque to rupture and cause clinical symptoms like myocardial infarction and stroke. In this review, we give an overview on the newest insights in the role of different immune cells and subtypes in atherosclerosis.
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Affiliation(s)
- Bart Legein
- Experimental Vascular Pathology, Department of Pathology, Cardiovascular Research Institute Maastricht (CARIM), University of Maastricht, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Lieve Temmerman
- Experimental Vascular Pathology, Department of Pathology, Cardiovascular Research Institute Maastricht (CARIM), University of Maastricht, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Erik A. L. Biessen
- Experimental Vascular Pathology, Department of Pathology, Cardiovascular Research Institute Maastricht (CARIM), University of Maastricht, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Esther Lutgens
- Experimental Vascular Biology, Department of Medical Biochemistry, Academic Medical Center (AMC), University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Institute for Cardiovascular Prevention (IPEK), Ludwig Maximilian’s University, Pettenkoferstrasse 8a/9, 80336 Munich, Germany
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