Prevalence of pulmonary hypertension in systemic lupus erythematosus: a meta-analysis

Systemic Lupus Erythematosus-related Lung Disease

Systemic Lupus Erythematosus (SLE) is a multifaceted, multisystem autoimmune disorder with diverse clinical expressions. While prevalence reports vary widely, pulmonary involvement accounts for significant morbidity and mortality in SLE. This comprehensive review explores the spectrum of pulmonary disease in SLE, including upper airway manifestations (e.g., laryngeal affection), lower airway conditions (e.g., bronchitis, bronchiolitis, bronchiectasis), parenchymal diseases (e.g., interstitial lung disease, acute lupus pneumonitis, diffuse alveolar hemorrhage), pleural diseases (e.g., serositis, shrinking lung syndrome), and vascular diseases (e.g., pulmonary arterial hypertension, pulmonary embolism, acute reversible hypoxemia syndrome). We discuss diagnostic modalities, treatment strategies, and prognosis for each pulmonary manifestation. With diagnostics remaining a challenge and with the absence of standardized treatment guidelines, we emphasize the need for evidence-based guidelines to optimize patient care and improve outcomes in this complex disease.

Quantitative Assessment of Right Ventricular Function in Patients With Systemic Lupus Erythematosus Using the Novel Non-invasive Pressure-Strain Loop

OBJECTIVE

Current echocardiography evaluation of right ventricular (RV) function, which heralds the prognosis in patients with systemic lupus erythematosus (SLE), is of limited utility. The non-invasive pressure-strain loop (PSL), an emerging technique, has been found to feasible, sensitive and accurate in the diagnosis of cardiovascular diseases. The aim of this study was to quantitatively evaluate, using the non-invasive PSL, the right ventricular myocardial work (RVMW) in SLE patients.

METHODS

Seventy-five SLE patients were recruited and grouped by pulmonary artery systolic pressure (PASP) into normal (group A, N = 26), mild (group B, N = 22) and moderate to severe (group C, N = 27) groups. Twenty-five healthy volunteers undergoing physical examination were recruited as the control group. Right ventricular global myocardial work index (RVGWI), global constructive work (RVGCW), global wasted work (RVGWW), global work efficiency (RVGWE), global longitudinal strain (RVGLS) and other conventional parameters were measured.

DISCUSSION

There were no differences between group A and the control group with respect to RVLS, RVGLS and all RVMW parameters (all p values > 0.05). RVGWI and RVGCW significantly differed among the other groups (all p values < 0.05). RVGWE was significantly lower and RVGWW was significantly higher in group C than in the control group and groups A and B (all p values < 0.05). Compared with the control group, RVGWW was significantly increased and RVGLS was significantly decreased in group B (all p values < 0.05). All but one RVMW parameter moderately to strongly correlated with SLE disease activity index (SLEDAI) and World Health Organization Functional Class (WHO-FC). RVGWW (area under the receiver operating characteristic curve [AUC] = 0.893) and RVGWE (AUC = 0.877) were sensitive parameters in detecting earlier cardiac dysfunction in SLE patients.

CONCLUSION

RVGWW and RVGWE serve as sensitive and promising parameters in the integrative analysis of early right ventricular dysfunction in SLE patients. To conclude, non-invasive PSL, the novel method, facilitates the quantitative assessment of RVMW in SLE patients.

Cathepsin S Inhibition Suppresses Experimental Systemic Lupus Erythematosus-Associated Pulmonary Arterial Remodeling

Patients with systemic lupus erythematosus (SLE) associated with pulmonary arterial hypnertension (PAH) receive targeted therapy for PAH to decrease pulmonary arterial systolic pressure and significantly prolong their survival. Cysteine cathepsin proteases play critical roles in the progression of cardiovascular disease. Inhibition of cathepsin S (Cat S) has been shown to improve SLE and lupus nephritis. However, the effect of Cat S inhibitors on SLE-associated PAH (SLE-PAH) remains unclear, and there is no animal model for translational research on SLE-PAH. We hypothesized that the inhibition of Cat S may affect PAH development and arterial remodeling associated with SLE. A female animal model of SLE-PAH, female MRL/lpr (Lupus), was used to evaluate the role of pulmonary arterial remodeling in SLE. The key finding of the research work is the establishment of an animal model of SLE associated with PAH in female MRL/lpr mice that is able to evaluate pulmonary arterial remodeling starting from the age of 11 weeks to 15 weeks. Cat S protein level was identified as a marker of experimental SLE. Pulmonary hypertension in female MRL/lpr (Lupus) mice was treated by administering the selective Cat S inhibitor Millipore-219393, which stimulated peroxisome proliferator-activated receptor-gamma (PPARγ) in the lungs to inhibit Cat S expression and pulmonary arterial remodeling. Studies provide an animal model of female MRL/lpr (Lupus) associated with PAH and a deeper understanding of the pathogenesis of SLE-PAH. The results may define the role of cathepsin S in preventing progressive and fatal SLE-PAH and provide approaches for therapeutic interventions in SLE-PAH.

Lupus and the Lungs: The Assessment and Management of Pulmonary Manifestations of Systemic Lupus Erythematosus

Pulmonary manifestations of systemic lupus erythematosus (SLE) are wide-ranging and debilitating in nature. Previous studies suggest that anywhere between 20 and 90% of patients with SLE will be troubled by some form of respiratory involvement throughout the course of their disease. This can include disorders of the lung parenchyma (such as interstitial lung disease and acute pneumonitis), pleura (resulting in pleurisy and pleural effusion), and pulmonary vasculature [including pulmonary arterial hypertension (PAH), pulmonary embolic disease, and pulmonary vasculitis], whilst shrinking lung syndrome is a rare complication of the disease. Furthermore, the risks of respiratory infection (which often mimic acute pulmonary manifestations of SLE) are increased by the immunosuppressive treatment that is routinely used in the management of lupus. Although these conditions commonly present with a combination of dyspnea, cough and chest pain, it is important to consider that some patients may be asymptomatic with the only suggestion of the respiratory disorder being found incidentally on thoracic imaging or pulmonary function tests. Treatment decisions are often based upon evidence from case reports or small cases series given the paucity of clinical trial data specifically focused on pulmonary manifestations of SLE. Many therapeutic options are often initiated based on studies in severe manifestations of SLE affecting other organ systems or from experience drawn from the use of these therapeutics in the pulmonary manifestations of other systemic autoimmune rheumatic diseases. In this review, we describe the key features of the pulmonary manifestations of SLE and approaches to investigation and management in clinical practice.

Autoantibody clustering of lupus-associated pulmonary hypertension

Objective

To define the SLE phenotype associated with pulmonary hypertension using multiple autoantibodies.

Methods

207 (8%) patients with SLE with pulmonary hypertension, defined as a right ventricular systolic pressure greater than 40 mm Hg on transthoracic echocardiogram or as pulmonary artery dilatation on CT of the chest, were identified from the Hopkins Lupus Cohort (94.2% female; 56.5% African–American, 39% Caucasian; mean age 45.6 years). 53 patients were excluded from the clustering analysis due to incomplete autoantibody profiles. Agglomerative hierarchical clustering algorithm with Ward’s method was used to cluster the patients with pulmonary hypertension, based on their autoantibodies. Autoantibodies used in the clustering analysis included lupus anticoagulant, anticardiolipin, anti-beta 2 glycoprotein I, antidouble-stranded DNA, anti-Sm (anti-Smith), antiribonucleoprotein, false positive-rapid plasma reagin, anti-Ro, anti-La and hypocomplementaemia (C3 ever low or C4 ever low). The Dunn index was used to internally validate the clusters. Bootstrap resampling derived the mean Jaccard coefficient for each cluster. All analyses were performed in R V.3.6.1 using the packages cluster, fpc and gplots.

Results

A significantly higher prevalence of pulmonary hypertension in African–American patients with SLE, compared with Caucasian patients with SLE (11.5% vs 5.9%, p<0.0001), was found. Based on equivalent Dunn indices, the 154 patients with SLE-associated pulmonary hypertension with complete autoantibody data were divided into five clusters, three of which had mean Jaccard coefficients greater than 0.6. Hypocomplementaemia, renal disorder and age at diagnosis significantly differed across clusters. One cluster was defined by antiphospholipid antibodies. One cluster was defined by anti-Ro and anti-La. One cluster had low frequencies of all antibodies.

Conclusion

SLE-associated pulmonary hypertension disproportionately affects African–American patients. Pulmonary hypertension in SLE is defined by five autoantibody clusters. Antiphospholipid antibodies, anti-Ro and anti-La positivity, serological activity, and age at pulmonary hypertension diagnosis significantly differed across clusters, possibly indicating different pathophysiological mechanisms.

Frequency and predictors of pulmonary hypertension in patients with Systemic Lupus Erythematosus

Objective:

To determine the frequency and predictors of pulmonary hypertension in patients with Systemic Lupus Erythematosus in a Pakistani population, presenting at a tertiary care hospital

Methods:

This cross-sectional study was conducted at the Department of Rheumatology, Shiekh Zayed Hospital, Lahore from March to June 2018. A total of 97 patients, who fulfilled the Systemic Lupus Erythematosus (SLE) criteria of American College of Rheumatology (ACR) 1992 were enrolled. Pulmonary Arterial Hypertension (PAH) was measured by calculating pulmonary arterial systolic pressure through echocardiography by a single consultant cardiologist. Disease characteristics and demography was collected in a self-administered proforma. PAH was defined as mean pulmonary arterial pressure of 25mmHg or above by calculating with a formula. SPSS version 20 was used for analysis of data.

Results:

Out of 97 patients, 89.7% (n=87) were females and 10.3% (n=10) were males, with mean age of 31.29± 8.824 years. The mean disease duration was 24.21 ± 30.46 months. PAH was found in 23.3% (n=23) patients, including 19 females and 4 males. On further analysis of data, Raynaud phenomenon, rheumatoid factor and nephritis were assessed as predictors of PAH and all of these showed statistical significance for presence of PAH as per Chi-square test (p<0.05).

Conclusion:

In this study, 23.3% SLE patients showed evidence of PAH and positive statistical significance was found between predictors like Raynaud phenomenon, rheumatoid factor, nephritis and presence of PAH. So it is imperative to detect PAH early and start prompt treatment to achieve better quality of life.

Prevalence of pulmonary hypertension in peritoneal dialysis patients: a meta-analysis

PURPOSE

Recent epidemiological evidence indicates an association between peritoneal dialysis (PD) patients and pulmonary hypertension (PH). However, the true prevalence of PH associated with PD has not been well described. So we conducted a meta-analysis to summarize the point prevalence of PH in adults with PD.

METHODS

PubMed, EMBASE, the Cochrane Collaboration, and the reference lists of relevant articles were searched to identify eligible studies. We used a random-effect meta-analysis model to estimate the prevalence of PH. We also performed sensitivity analyses and assessments of publishing bias.

RESULTS

Fourteen observational studies (n = 1483 participants) were included in this meta-analysis. The result of analysis in random-effect model showed that the pooled prevalence was 21% (95% CI 16-28), with significant heterogeneity between these studies (I² = 84%, p < 0.01). Sensitivity analysis further demonstrated the results to be robust. Besides, the Egger's test (p = 0.287) showed no significant publication bias.

CONCLUSIONS

PH is highly prevalent in patients with PD. Further studies are encouraged to definitively clarify the relationship between PH and PD.

Prevalence of pulmonary hypertension in patients with chronic kidney disease without dialysis: a meta-analysis

PURPOSE

Recent epidemiological evidence attempts to demonstrate the risk of pulmonary hypertension (PH) among patients with chronic kidney disease (CKD) without dialysis, but prevalence estimates of PH in CKD without dialysis vary widely in the existing studies. This meta-analysis was to summarize the point prevalence of PH in adults with CKD without dialysis.

METHODS

PubMed, EMBASE, the Cochrane Collaboration, and the reference lists of relevant articles were searched to identify eligible studies. We used a random-effect meta-analysis model to estimate the prevalence of PH. Associations were tested in subgroups and meta-regression analyses. We also performed sensitivity analyses and assessments of publishing bias.

RESULTS

Twenty-one observational studies (n = 8012 participants) were included in this meta-analysis. The result of analysis in random-effect model showed that the pooled prevalence was 32% (95% CI 23-42%), with significant heterogeneity between these studies (I² = 98%, P < 0.01). Stratified analyses found that the study design, region, sample size, year of publication, and definition of PH based on PASP ≥ 35 mmHg may explain the variation between studies. Sensitivity analysis further demonstrated the results to be robust. There was no evidence of publication bias.

CONCLUSIONS

PH is highly prevalent in patients with CKD without dialysis. Owing to the high heterogeneity, future well-designed and large prospective studies are encouraged to confirm the findings and definitively clarify the potential biological mechanisms.