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Sharafaldin ENK, Sim MS, Lim SK, Alhussieni K, Huri HZ. Precision medicine in lupus nephritis. Clin Chim Acta 2024; 562:119894. [PMID: 39068963 DOI: 10.1016/j.cca.2024.119894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 07/30/2024]
Abstract
Lupus nephritis (LN) is a prominent manifestation of systemic lupus erythematosus (SLE), characterized by diverse clinical and histopathological features, imposing a substantial burden on patients. Although the exact cause of SLE remain undetermined, several genetic, epigenetics, hormonal, and other factors are implicated in LN pathogenesis. The management of LN rely on invasive renal biopsies, while the standard therapy of the proliferative form of LN remains empirical and relies on indiscriminate immunosuppressants (IS). These treatments exhibit unsatisfactory remission rates, trigger recurrent renal flares, and entail grave adverse effects (ADEs). The advent of precision medicine into LN entails a concentrated effort to pinpoint essential biomarkers, reshaping the landscape of LN management. The primary objective of this review is to synthesize and summarize existing research findings by elucidating the most prevalent immunological, genetic, and epigenetic alterations and deliberate on management strategies that can pave the way for precision medicine in tackling LN. Novel clinical biomarker such as serum anti-complement component 1q (anti-C1q), with urinary markers including neutrophil gelatinase-associated lipocalin (NGAL), monocyte chemoattractant protein-1 (MCP1) and tumour necrosis-like weak inducers of apoptosis (TWEAK) are strongly correlated with LN. These biomarkers have good sensitivity and specificity and perform better than conventional biomarkers in assessing LN activity. Similarly, more renal-specific genetic and epigenetic alteration have been correlated with LN susceptibility and severity. This includes variants of hyaluronan synthase 2 (HAS2), and platelet-derived growth factor receptor alpha (PDGFRA). In the future, integrating clinical, genetic, epigenetic, and targeted therapies holds promise for guiding precision medicine and improving LN outcomes.
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Affiliation(s)
| | - Maw Shin Sim
- Precision Medicine and Omics Centre (PrOmiC), Faculty of Pharmacy, Universiti Malaya, Kuala Lumpur 50603, Malaysia; Department of Pharmaceutical Life Sciences, Faculty of Pharmacy, Universiti Malaya, Kuala Lumpur 50603, Malaysia
| | - Soo Kun Lim
- Renal Division, Department of Medicine, Faculty of Medicine, Universiti Malaya, 59100 Kuala Lumpur, Malaysia
| | - Kawthar Alhussieni
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Universiti Malaya, Kuala Lumpur 50603, Malaysia
| | - Hasniza Zaman Huri
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Universiti Malaya, Kuala Lumpur 50603, Malaysia; Precision Medicine and Omics Centre (PrOmiC), Faculty of Pharmacy, Universiti Malaya, Kuala Lumpur 50603, Malaysia.
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Zhu Y, Zhu K, Zhang X, Qian Z, Guo Q, Xu X, Yao G, Tang X, Wang D, Zhang H, Feng X, Jin Z, Sun L. Risk factors for initial and recurrent severe infections in first hospitalized patients with systemic lupus erythematosus: A retrospective study of a Chinese cohort. Int J Rheum Dis 2024; 27:e15131. [PMID: 38563679 DOI: 10.1111/1756-185x.15131] [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: 01/29/2024] [Revised: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE To evaluate the incidence and associated factors of initial and recurrent severe infections in hospitalized patients with systemic lupus erythematosus (SLE). METHODS SLE patients that first hospitalized between 2010 and 2021 were studied retrospectively and divided into SLE with and without baseline severe infection groups. The primary outcome was the occurrence of severe infection during follow-up. Cox regression models were used to calculate the hazard ratio (HR) and 95% confidence interval (CI) for initial and recurrent severe infections. RESULTS Among 1051 first hospitalized SLE patients, 164 (15.6%) had severe infection on admission. During a median follow-up of 4.1 years, 113 (10.8%) patients reached severe infection outcomes, including 27 with reinfection and 86 with initial severe infection (16.5% vs. 9.7%, p = .010). Patients with baseline severe infection had a higher cumulative incidence of reinfection (p = .007). After adjusting for confounding factors, renal involvement, elevated serum creatinine, hypoalbuminemia, cyclophosphamide, and mycophenolate mofetil treatment were associated with an increased risk of severe infection, especially initial severe infection. Low immunoglobulin, anti-dsDNA antibody positivity, and cyclophosphamide use significantly increased the risk of recurrent severe infection, with adjusted HR (95% CI) of 3.15 (1.22, 8.14), 3.60 (1.56, 8.28), and 2.14 (1.01, 5.76), respectively. Moreover, baseline severe infection and low immunoglobulin had a multiplicative interaction on reinfection, with adjusted RHR (95% CI) of 3.91 (1.27, 12.09). CONCLUSION In this cohort of SLE, patients with severe infection had a higher risk of reinfection, and low immunoglobulin, anti-dsDNA antibody positivity, and cyclophosphamide use were independent risk factors for recurrent severe infection.
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Affiliation(s)
- Ying Zhu
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
| | - Kexin Zhu
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
| | - Xueyi Zhang
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Zhijie Qian
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Qingqing Guo
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Xuefeng Xu
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Genhong Yao
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiaojun Tang
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Dandan Wang
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Huayong Zhang
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xuebing Feng
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Ziyi Jin
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lingyun Sun
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Kavadichanda C, Ganapathy S, Kounassegarane D, Rajasekhar L, Dhundra B, Srivastava A, Manuel S, Shobha V, Swarna CB, Mathew AJ, Singh D, Rathi M, Tripathy SR, Das B, Akhtar MD, Gupta R, Jain A, Ghosh P, Negi VS, Aggarwal A. Clusters based on demography, disease phenotype, and autoantibody status predicts mortality in lupus: data from Indian lupus cohort (INSPIRE). Rheumatology (Oxford) 2023; 62:3899-3908. [PMID: 37018148 DOI: 10.1093/rheumatology/kead148] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/06/2023] [Accepted: 03/15/2023] [Indexed: 04/06/2023] Open
Abstract
OBJECTIVES SLE is associated with significant mortality, and data from South Asia is limited. Thus, we analysed the causes and predictors of mortality and hierarchical cluster-based survival in the Indian SLE Inception cohort for Research (INSPIRE). METHODS Data for patients with SLE was extracted from the INSPIRE database. Univariate analyses of associations between mortality and a number of disease variables were conducted. Agglomerative unsupervised hierarchical cluster analysis was undertaken using 25 variables defining the SLE phenotype. Survival rates across clusters were assessed using non-adjusted and adjusted Cox proportional-hazards models. RESULTS Among 2072 patients (with a median follow-up of 18 months), there were 170 deaths (49.2 deaths per 1000 patient-years) of which cause could be determined in 155 patients. 47.1% occurred in the first 6 months. Most of the mortality (n = 87) were due to SLE disease activity followed by coexisting disease activity and infection (n = 24), infections (n = 23), and 21 to other causes. Among the deaths in which infection played a role, 24 had pneumonia. Clustering identified four clusters, and the mean survival estimates were 39.26, 39.78, 37.69 and 35.86 months in clusters 1, 2, 3 and 4, respectively (P < 0.001). The adjusted hazard ratios (HRs) (95% CI) were significant for cluster 4 [2.19 (1.44, 3.31)], low socio-economic-status [1.69 (1.22, 2.35)], number of BILAG-A [1.5 (1.29, 1.73)] and BILAG-B [1.15 (1.01, 1.3)], and need for haemodialysis [4.63 (1.87,11.48)]. CONCLUSION SLE in India has high early mortality, and the majority of deaths occur outside the health-care setting. Clustering using the clinically relevant variables at baseline may help identify individuals at high risk of mortality in SLE, even after adjusting for high disease activity.
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Affiliation(s)
- Chengappa Kavadichanda
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sachit Ganapathy
- Department of Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Deepika Kounassegarane
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Liza Rajasekhar
- Department of Rheumatology, Nizam Institute of Medical Sciences, Hyderabad, India
| | - Bhavani Dhundra
- Department of Rheumatology, Nizam Institute of Medical Sciences, Hyderabad, India
| | - Akansha Srivastava
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sandra Manuel
- Department of Clinical Immunology and Rheumatology, St John's Medical College Hospital, Bengaluru, India
| | - Vineeta Shobha
- Department of Clinical Immunology and Rheumatology, St John's Medical College Hospital, Bengaluru, India
| | - C Brilly Swarna
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - Ashish J Mathew
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - Dalbir Singh
- Department of Nephrology, PGIMER, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, PGIMER, Chandigarh, India
| | | | - Bidyut Das
- Department of Medicine, SCB Medical College, Cuttack, India
| | - Md Dilshad Akhtar
- Department of Rheumatology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Ranjan Gupta
- Department of Rheumatology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Avinash Jain
- Division of Clinical Immunology and Rheumatology, SMS Medical College & Hospital, Jaipur, India
| | - Parasar Ghosh
- Department of Clinical Immunology and Rheumatology, IPGMER, Kolkata, India
| | - Vir Singh Negi
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Amita Aggarwal
- Department of Rheumatology, Nizam Institute of Medical Sciences, Hyderabad, India
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Zhou A, Wang Y, Chen Y, Zhong H, Chen B, Tan C. A case report of systemic lupus erythematosus and intestinal tuberculosis with lower gastrointestinal bleeding: A treatment approach utilizing parenteral nutrition. Medicine (Baltimore) 2023; 102:e35374. [PMID: 37832049 PMCID: PMC10578696 DOI: 10.1097/md.0000000000035374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 09/04/2023] [Indexed: 10/15/2023] Open
Abstract
RATIONALE Limited literatures are available on lower gastrointestinal bleeding in systemic lupus erythematosus (SLE) combined with intestinal tuberculosis. Sharing the treatment experiences of a 26-year-old female patient diagnosed with this complex condition in this report may contribute valuable insights. PATIENT CONCERNS The patient initially presented with abdominal pain and active gastrointestinal bleeding, leading to admission to the hospital. Over a 2-week period, she experienced persistent bleeding, with daily volumes ranging from 300 mL to 800 mL. DIAGNOSES Lower gastrointestinal bleeding was diagnosed in this patient with concurrent systemic lupus erythematosus and intestinal tuberculosis. INTERVENTIONS As her symptoms rapidly progressed, food and water intake had to be completely restricted. The parenteral nutrition was implemented. OUTCOMES The medical team effectively controlled the bleeding, leading to a notable improvement in the patient's condition. Consequently, she was able to resume oral intake and was discharged from the hospital. LESSONS This case highlights the significance of using parenteral nutrition in the management of lower gastrointestinal bleeding in patients with concurrent systemic lupus erythematosus and intestinal tuberculosis. Close monitoring and collaborative efforts among healthcare professionals are crucial to achieve successful outcomes in similar cases.
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Affiliation(s)
- Aiping Zhou
- West China School of Nursing, Sichuan University/Department of Rheumatism and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Ying Wang
- West China School of Nursing, Sichuan University/Department of Rheumatism and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Yanling Chen
- West China School of Nursing, Sichuan University/Department of Rheumatism and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Hua Zhong
- West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Bo Chen
- Department of Rheumatism and Immunology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Chunyu Tan
- Department of Rheumatism and Immunology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Han JY, Cho SK, Sung YK. Epidemiology of systemic lupus erythematosus in Korea. JOURNAL OF RHEUMATIC DISEASES 2023; 30:211-219. [PMID: 37736591 PMCID: PMC10509641 DOI: 10.4078/jrd.2023.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/10/2023] [Accepted: 08/10/2023] [Indexed: 09/23/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by diverse organ system disabilities, predominantly affecting young females. The clinical manifestations of SLE encompass various organs, including the kidney, cardiovascular system, and central nervous system. Young females with SLE experience higher mortality rates than the general population, making it imperative to gain insights into the disease patterns and associated factors. The current review examines the epidemiological studies to analyze the prevalence, incidence, and mortality trends of SLE in Korea and compares them with the findings from other countries. We aim to identify potential similarities, differences, and factors contributing to the burden of SLE in different populations by exploring the comparative epidemiological aspects. The knowledge derived from this comparison would aid in advancing the overall management of SLE in Korea.
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Affiliation(s)
- Jung-Yong Han
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Korea
| | - Soo-Kyung Cho
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Korea
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Restrepo-Escobar M, Granda-Carvajal PA, Aguirre-Acevedo DC, Jaimes F, Vásquez GM. Predictive Factors of Hospital-Acquired Bacterial Infections in Patients With Systemic Lupus Erythematosus. J Clin Rheumatol 2023; 29:240-244. [PMID: 37092894 DOI: 10.1097/rhu.0000000000001977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
OBJECTIVE We aimed to identify the predictive factors of hospital-acquired bacterial infections in patients with systemic lupus erythematosus (SLE). METHODS This chart review study included patients with SLE who were hospitalized between 2009 and 2020 for reasons other than infection. The outcome was defined as any infection confirmed using any bacterial isolation method or diagnosed by treating physicians and required treatment with intravenous antibiotics. For statistical analysis, logistic regression analyses were performed. RESULTS In total, 1678 patients (87.6% women) were included. The median age was 33 years (interquartile range, 24-47 years). The incidence of hospital-acquired infections was 13.9% (233 infections). Age, Systemic Lupus Erythematosus Disease Activity Index score, Systemic Lupus International Collaborating Clinics damage score, blood urea nitrogen and C-reactive protein levels, dosage of steroid in the previous month, recent use of 1 or more immunosuppressants, admission with a central venous catheter (or dialysis catheter), and use of central venous catheter or bladder catheter in the first 5 days were the predictive factors of nosocomial infections. CONCLUSION The patients' infection risk profile should be assessed to accurately determine the risk-benefit balance of any therapeutic intervention, minimize exposure to steroids and immunosuppressants, and maintain a low threshold for the early diagnosis of infections. Further studies should assess whether the modification of some identified factors could reduce the incidence of nosocomial infections.
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Thomas K, Tsioulos G, Kotsogianni C, Banos A, Niemela JE, Cheng A, DiMaggio T, Holland S, Rosenzweig SD, Tziolos N, Papadopoulos A, Lionakis MS, Boumpas DT. NF-kappa-B essential modulator (NEMO) gene polymorphism in an adult woman with systemic lupus erythematosus and recurrent non-tuberculous mycobacterial disseminated infections. RMD Open 2023; 9:e003149. [PMID: 37364928 PMCID: PMC10410970 DOI: 10.1136/rmdopen-2023-003149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/11/2023] [Indexed: 06/28/2023] Open
Abstract
Infections are among the most serious complications in patients with systemic lupus erythematosus (SLE), with bacterial and viral infections being the most common. Non-tuberculous mycobacterial (NTM) infections are quite rare and are typically seen in older patients with SLE with longstanding disease duration treated with corticosteroids. Here, we describe a 39-year-old woman with SLE and an unusual pattern of recurrent NTM disseminated infections. After excluding the presence of autoantibodies against interferon-γ, whole exome sequencing revealed a homozygous polymorphism in the NF-kappa-B essential modulator (NEMO) gene. Primary immunodeficiencies should be included in the differential diagnosis of patients with recurrent opportunistic infections, even in those with iatrogenic immunosuppression.
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Affiliation(s)
- Konstantinos Thomas
- 4th Department of Internal Medicine, University of Athens School of Medicine, Attikon University General Hospital, Chaidari, Attica, Greece
| | - Georgios Tsioulos
- 4th Department of Internal Medicine, University of Athens School of Medicine, Attikon University General Hospital, Chaidari, Attica, Greece
| | - Christina Kotsogianni
- 4th Department of Internal Medicine, University of Athens School of Medicine, Attikon University General Hospital, Chaidari, Attica, Greece
| | - Agellos Banos
- Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Julie E Niemela
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Aristine Cheng
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Tom DiMaggio
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Steven Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Sergio D Rosenzweig
- Immunology Service, Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Nikolaos Tziolos
- 4th Department of Internal Medicine, University of Athens School of Medicine, Attikon University General Hospital, Chaidari, Attica, Greece
| | - Antonios Papadopoulos
- 4th Department of Internal Medicine, University of Athens School of Medicine, Attikon University General Hospital, Chaidari, Attica, Greece
| | - Michail S Lionakis
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Dimitrios T Boumpas
- 4th Department of Internal Medicine, University of Athens School of Medicine, Attikon University General Hospital, Chaidari, Attica, Greece
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Huang WN, Chuo CY, Lin CH, Chen YM, Lin WS, Tuckwell K, Jones NS, Galanter J, Lindsay L. Serious Infection Rates Among Patients with Select Autoimmune Conditions: A Claims-Based Retrospective Cohort Study from Taiwan and the USA. Rheumatol Ther 2023; 10:387-404. [PMID: 36572758 PMCID: PMC10011274 DOI: 10.1007/s40744-022-00525-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/13/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Serious infections are an important concern for patients with autoimmune conditions. We sought to estimate serious infection rates among patients with select autoimmune conditions relative to the general population in Taiwan and the USA. METHODS This retrospective cohort study estimated setting-specific standardized serious infection incidence rates and ratios among patients with systemic lupus erythematosus, including extra-renal lupus and lupus nephritis, rheumatoid arthritis and primary membranous nephropathy, compared with the general population using insurance claims for hospitalizations between 2000 and 2013. Multivariable Cox proportional hazard models were used to estimate adjusted hazard ratios for serious infections, adjusting for age, sex, index year, prior serious infection, comorbidities and medications. RESULTS In Taiwan, serious infection rates were 22.7, 28.7, 70.6, 43.4 and 215.3 per 1000 person-years among the general population and among cohorts of patients with primary membranous nephropathy, rheumatoid arthritis, extra-renal lupus and lupus nephritis, respectively. In the USA, serious infection rates were 2.6, 9.0, 15.6, 21.0 and 63.3 per 1000 person-years among the general population and among cohorts of patients with primary membranous nephropathy, rheumatoid arthritis, extra-renal lupus and lupus nephritis, respectively. Patients had significantly higher serious infection rates than the general population in both settings, largely driven by bacterial, respiratory, urinary tract and opportunistic infections. Patients with lupus nephritis had the highest burden of serious infections relative to the general population, with 7- to 25-fold higher adjusted hazard ratios in Taiwan and the USA, respectively. CONCLUSION This study identified a significant excess serious infection burden among patients with targeted autoimmune conditions compared with the general populations in Taiwan and the USA.
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Affiliation(s)
- Wen-Nan Huang
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Business Administration, Ling-Tung University, Taichung, Taiwan
- College of Medicine National Chung Hsing University, Taichung, Taiwan
| | - Ching-Yi Chuo
- RWD Enabling Platform, Product Development Data Science, Genentech Inc, South San Francisco, CA, USA
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
- Institute of Public Health and Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Yi-Ming Chen
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- College of Medicine National Chung Hsing University, Taichung, Taiwan
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wei-Szu Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Katie Tuckwell
- Early Clinical Development, Genentech Inc, South San Francisco, CA, USA
| | - Nicholas S Jones
- Early Clinical Development, Genentech Inc, South San Francisco, CA, USA
| | - Joshua Galanter
- Early Clinical Development, Genentech Inc, South San Francisco, CA, USA
- Product Development Safety, Genentech Inc, South San Francisco, CA, USA
| | - Lisa Lindsay
- RWD Enabling Platform, Product Development Data Science, Genentech Inc, South San Francisco, CA, USA.
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Muacevic A, Adler JR. Septic Shock Due to Urinary Tract Infection in an Immunosuppressed Patient Prescribed Dapagliflozin. Cureus 2022; 14:e30552. [PMID: 36415370 PMCID: PMC9674186 DOI: 10.7759/cureus.30552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2022] [Indexed: 01/25/2023] Open
Abstract
Urinary tract infection (UTI) is one of the adverse effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors. We describe a rare case of septic shock due to UTI in an immunosuppressed patient prescribed dapagliflozin. A 69-year-old woman was admitted to our hospital for the treatment of pyelonephritis. She was prescribed immunosuppressive drugs for systemic lupus erythematosus and was newly prescribed dapagliflozin for heart failure two weeks prior. One hour after admission, the patient developed hypotension and was diagnosed with septic shock due to UTI. She was administered norepinephrine, hydrocortisone and meropenem. Afterward, she underwent emergent transurethral lithotomy for her right urinary tract stones. The following clinical course was uneventful, and she was discharged on day 17. She had no recurrence of UTI or exacerbation of heart failure without dapagliflozin administration. This case report emphasizes the importance of considering the possibility of UTIs and cases in which SGLT2 inhibitors should be used. If a patient is female and immunocompromised, dapagliflozin should be prescribed more carefully after considering the increased risk of UTIs.
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Ko T, Koelmeyer R, Li N, Yap K, Yeo AL, Kent J, Pellicano R, Golder V, Kitching AR, Morand E, Hoi A. Predictors of infection requiring hospitalization in patients with systemic lupus erythematosus: a time-to-event analysis. Semin Arthritis Rheum 2022; 57:152099. [PMID: 36155969 DOI: 10.1016/j.semarthrit.2022.152099] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the predictors of serious infection in patients with systemic lupus erythematosus (SLE). METHODS Serious infections were identified in SLE patients in a prospectively-followed single centre cohort. Associations of serious infection with disease-related variables and medication use were analysed using Cox and related regression models. RESULTS 346 patients were followed for a mean (SD) of 6.6 (3.7) years. 86 episodes of serious infection were observed, with an incidence rate of 3.8 episodes per 100 person-years. Patients who had serious infection had higher baseline SLE Damage Index (SDI) and Charlston Comorbidity Index (CCI); they were also more likely to have high disease activity status (HDAS), and higher disease activity in multiple clinical domains, higher flare rates, higher time-adjusted prednisolone dose exposure, and less time in lupus low disease activity state (LLDAS). Patients who have received cyclophosphamide, rituximab and mycophenolate were more likely to have experienced serious infection. After multivariable adjustment in Cox regression analysis, cyclophosphamide, higher SDI score, and higher disease activity were associated with an increased hazard of first serious infection. History of previous serious infection conferred the highest risk. Lymphopenia was also a modest but statistically significant predictor of serious infection. CONCLUSION History of previous serious infection was the strongest predictor of serious infection in our SLE cohort. This study also suggests that clinical factors such as damage accrual, disease activity, and choice of immunosuppressant, can each have an independent risk in predicting serious infection particularly the first episode.
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Affiliation(s)
- Tina Ko
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia
| | - Rachel Koelmeyer
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia
| | - Ning Li
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia
| | - Kristy Yap
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia
| | - Ai Li Yeo
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia
| | - Joanna Kent
- Department of Nephrology, Monash Health, Clayton VIC 3168, Australia
| | - Rebecca Pellicano
- Department of Nephrology, Monash Health, Clayton VIC 3168, Australia
| | - Vera Golder
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia; Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia
| | - A Richard Kitching
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia; Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia
| | - Eric Morand
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia; Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia
| | - Alberta Hoi
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia; Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia.
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11
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Hamijoyo L, Sahiratmadja E, Ghassani NG, Darmawan G, Susandi E, van Crevel R, Hill PC, Alisjahbana B. Tuberculosis among Patients with Systemic Lupus Erythematosus in Indonesia: a Cohort study. Open Forum Infect Dis 2022; 9:ofac201. [PMID: 35794932 PMCID: PMC9251660 DOI: 10.1093/ofid/ofac201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/10/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Previous studies have identified systemic lupus erythematosus (SLE) as a risk factor for tuberculosis (TB), but data from TB endemic countries are still relatively scarce. We examined TB in a large cohort of SLE patients in Indonesia.
Methods
All patients registered in a lupus registry of the top-referral hospital for West-Java between 2008 and 2020 were included. Data on SLE characteristics and treatment were retrieved from the registry, and data on TB diagnosis, localization and outcome were extracted from medical records. Cox-proportional hazard model was used to examine risk factors for development of TB.
Results
Among 1278 SLE patients followed over a total of 4804 patient years, 131 patients experienced 138 episodes of TB, a median 2 years (IQR 0.6–5.4) after diagnosis of SLE. A total of 113 patients (81.9%) had pulmonary and 61 (44.2%) had extra-pulmonary involvement, with disseminated disease in 26 of 138 episodes (18.8%), and 13 of 131 patients (9.9%) died from TB. The estimated TB incidence was 2,873 cases per 100,000 person years. In multivariate cox regression analysis, development of TB was associated with household TB contact (HR 7.20; 95%CI 4.05-12.80), pulse methylprednisolone therapy (HR 1.64; 95%CI 1.01-2.67) and age ≤ 25 years old at SLE diagnosis (HR 1.54; 95%CI 1.00-2.35).
Conclusion
There is a high burden of TB in SLE patients in this TB endemic setting, underlining the need for evaluation or implementation of TB preventive strategies.
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Affiliation(s)
- Laniyati Hamijoyo
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran / Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
- Study Center of Immunology, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Edhyana Sahiratmadja
- Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
| | - Nadia G. Ghassani
- Study Center of Immunology, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Guntur Darmawan
- Department of Internal Medicine, Faculty of Medicine, Krida Wacana Christian University, Jakarta, Indonesia
| | - Evan Susandi
- Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philip C. Hill
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Bachti Alisjahbana
- Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
- Division of Tropical Diseases, Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran / Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
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12
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Valviesse DMDJ, Monteiro DLM, Jésus NRD, Jésus GRRD, Santos FC, Lacerda MI, Rodrigues NCP, Klumb EM. Risk factors associated with infections in pregnant women with systemic lupus erythematosus. Rev Assoc Med Bras (1992) 2022; 68:536-541. [DOI: 10.1590/1806-9282.20220074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/25/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
| | | | - Nilson Ramires de Jésus
- Universidade do Estado do Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro, Brazil
| | | | - Flavia Cunha Santos
- Universidade do Estado do Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro, Brazil
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13
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Jayne D, Rovin B, Mysler EF, Furie RA, Houssiau FA, Trasieva T, Knagenhjelm J, Schwetje E, Chia YL, Tummala R, Lindholm C. Phase II randomised trial of type I interferon inhibitor anifrolumab in patients with active lupus nephritis. Ann Rheum Dis 2022; 81:496-506. [PMID: 35144924 PMCID: PMC8921596 DOI: 10.1136/annrheumdis-2021-221478] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/28/2021] [Indexed: 12/19/2022]
Abstract
Objective To assess the efficacy and safety of the type I interferon receptor antibody, anifrolumab, in patients with active, biopsy-proven, Class III/IV lupus nephritis. Methods This phase II double-blinded study randomised 147 patients (1:1:1) to receive monthly intravenous anifrolumab basic regimen (BR, 300 mg), intensified regimen (IR, 900 mg ×3, 300 mg thereafter) or placebo, alongside standard therapy (oral glucocorticoids, mycophenolate mofetil). The primary endpoint was change in baseline 24-hour urine protein–creatinine ratio (UPCR) at week (W) 52 for combined anifrolumab versus placebo groups. The secondary endpoint was complete renal response (CRR) at W52. Exploratory endpoints included more stringent CRR definitions and sustained glucocorticoid reductions (≤7.5 mg/day, W24–52). Safety was analysed descriptively. Results Patients received anifrolumab BR (n=45), IR (n=51), or placebo (n=49). At W52, 24-hour UPCR improved by 69% and 70% for combined anifrolumab and placebo groups, respectively (geometric mean ratio=1.03; 95% CI 0.62 to 1.71; p=0.905). Serum concentrations were higher with anifrolumab IR versus anifrolumab BR, which provided suboptimal exposure. Numerically more patients treated with anifrolumab IR vs placebo attained CRR (45.5% vs 31.1%), CRR with UPCR ≤0.5 mg/mg (40.9% vs 26.7%), CRR with inactive urinary sediment (40.9% vs 13.3%) and sustained glucocorticoid reductions (55.6% vs 33.3%). Incidence of herpes zoster was higher with combined anifrolumab vs placebo (16.7% vs 8.2%). Incidence of serious adverse events was similar across groups. Conclusion Although the primary endpoint was not met, anifrolumab IR was associated with numerical improvements over placebo across endpoints, including CRR, in patients with active lupus nephritis. Trial registration number NCT02547922.
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Affiliation(s)
- David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Brad Rovin
- Department of Internal Medicine-Nephrology, The Ohio State University, Columbus, Ohio, USA
| | - Eduardo F Mysler
- Rheumatology, Organizacion Medica de Investigacion SA, Buenos Aires, Argentina
| | - Richard A Furie
- Division of Rheumatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Frederic A Houssiau
- Rheumatology Department, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Universite catholique de Louvain, Brussels, Belgium
| | | | | | - Erik Schwetje
- BioPharmaceuticals R&D, AstraZeneca US, Gaithersburg, Maryland, USA
| | - Yen Lin Chia
- BioPharmaceuticals R&D, AstraZeneca US, South San Francisco, California, USA.,Clinical Pharmacology, Seagen Inc, South San Francisco, California, USA
| | - Raj Tummala
- BioPharmaceuticals R&D, AstraZeneca US, Gaithersburg, Maryland, USA
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14
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Silva JE, Silva C, Pacheco M, Pereira E, Almeida JS. Simultaneous Systemic Lupus Erythematosus Flare and Disseminated Tuberculosis: Balancing Anti-Mycobacterial and Autoimmune Treatments. Cureus 2021; 13:e18944. [PMID: 34815895 PMCID: PMC8605789 DOI: 10.7759/cureus.18944] [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] [Accepted: 10/21/2021] [Indexed: 11/05/2022] Open
Abstract
Here, we report the case of a 53-year-old man with suspected autoimmune arthritis on low-dose corticosteroid therapy. He was recently hospitalized due to presumed bacterial pneumonia and a seizure episode attributed to high fever. His condition deteriorated after discharge, and he presented to our institution with a persistent cough, weight loss, skin rash, arthralgias, fever, and altered mental status. The investigation led to the simultaneous diagnosis of a systemic lupus erythematosus (SLE) flare and disseminated tuberculosis (TB), both pulmonary and intracranial. Proteinuria and peripheral edema were identified, suggesting renal involvement of SLE. Anti-mycobacterial drugs and high-dose corticosteroid therapy were initiated. Given the risk of starting other immunosuppressive drugs in the presence of intracranial TB, in a patient with stable renal function and a significant decrease in proteinuria with corticosteroids and supportive therapy alone, renal biopsy was postponed. Prednisolone was progressively tapered down during the next six months, always maintaining anti-mycobacterial therapy, which resulted in a second SLE flare and the need to increase corticosteroids again. At this time, a renal biopsy was performed, showing class II lupus nephritis and confirming the diagnosis of SLE. After one year of anti-mycobacterial therapy with complete resolution of cerebral and pulmonary TB lesions, we chose to initiate mycophenolate mofetil as an immunosuppressive steroid-sparing agent with increased SLE control, allowing for corticosteroid reduction.
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Affiliation(s)
- João E Silva
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Clara Silva
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Mariana Pacheco
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Edite Pereira
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Jorge S Almeida
- Medicine, Faculdade de Medicina da Universidade do Porto, Porto, PRT.,Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
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15
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Chronic use of hydroxychloroquine did not protect against COVID-19 in a large cohort of patients with rheumatic diseases in Brazil. Adv Rheumatol 2021; 61:60. [PMID: 34620246 PMCID: PMC8496137 DOI: 10.1186/s42358-021-00217-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 09/14/2021] [Indexed: 02/08/2023] Open
Abstract
Background There is a lack of information on the role of chronic use of hydroxychloroquine during the SARS-CoV-2 outbreak. Our aim was to compare the occurrence of COVID-19 between rheumatic disease patients on hydroxychloroquine with individuals from the same household not taking the drug during the first 8 weeks of community viral transmission in Brazil.
Methods This baseline cross-sectional analysis is part of a 24-week observational multi-center study involving 22 Brazilian academic outpatient centers. All information regarding COVID-19 symptoms, epidemiological, clinical, and demographic data were recorded on a specific web-based platform using telephone calls from physicians and medical students. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. Mann–Whitney, Chi-square and Exact Fisher tests were used for statistical analysis and two binary Final Logistic Regression Model by Wald test were developed using a backward-stepwise method for the presence of COVID-19. Results From March 29th to May 17st, 2020, a total of 10,443 participants were enrolled, including 5166 (53.9%) rheumatic disease patients, of whom 82.5% had systemic erythematosus lupus, 7.8% rheumatoid arthritis, 3.7% Sjögren’s syndrome and 0.8% systemic sclerosis. In total, 1822 (19.1%) participants reported flu symptoms within the 30 days prior to enrollment, of which 3.1% fulfilled the BMH criteria, but with no significant difference between rheumatic disease patients (4.03%) and controls (3.25%). After adjustments for multiple confounders, the main risk factor significantly associated with a COVID-19 diagnosis was lung disease (OR 1.63; 95% CI 1.03–2.58); and for rheumatic disease patients were diagnosis of systemic sclerosis (OR 2.8; 95% CI 1.19–6.63) and glucocorticoids above 10 mg/ day (OR 2.05; 95% CI 1.31–3.19). In addition, a recent influenza vaccination had a protective effect (OR 0.674; 95% CI 0.46–0.98). Conclusion Patients with rheumatic disease on hydroxychloroquine presented a similar occurrence of COVID-19 to household cohabitants, suggesting a lack of any protective role against SARS-CoV-2 infection. Trial registration Brazilian Registry of Clinical Trials (ReBEC; RBR – 9KTWX6).
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16
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Pulmonary mucormycosis in systemic lupus erythematosus: successful management of a case along with review of literature. Clin Rheumatol 2021; 41:307-312. [PMID: 34606036 PMCID: PMC8488537 DOI: 10.1007/s10067-021-05941-y] [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: 08/07/2021] [Revised: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 11/12/2022]
Abstract
Pulmonary mucormycosis is rare in systemic lupus erythematosus. A 20-year-old lady with lupus nephritis and neuropsychiatric lupus was treated with injection methylprednisolone and cyclophosphamide. After few days, she developed fever, breathlessness, and hoarseness of voice. After neck and chest imaging, possibility of mucormycosis was considered which was later confirmed on microbiological test. Patient was treated with conventional amphotericin B. Literature review was done, and 8 patients with disseminated or pulmonary mucormycosis were identified with SLE. In patients with high index of suspicion, early imaging can help in diagnosis and early and aggressive management even with conventional amphotericin B can result in favorable outcome.Key Points • Pulmonary mucormycosis in systemic lupus erythematosus is rare. • Radiological investigation can guide towards diagnosis. • Early and aggressive treatment can lead to good outcome. |
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17
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Kaneko K, Chen H, Kaufman M, Sverdlov I, Stein EM, Park‐Min K. Glucocorticoid-induced osteonecrosis in systemic lupus erythematosus patients. Clin Transl Med 2021; 11:e526. [PMID: 34709753 PMCID: PMC8506634 DOI: 10.1002/ctm2.526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 07/21/2021] [Accepted: 07/25/2021] [Indexed: 12/24/2022] Open
Abstract
Osteonecrosis (ON) is a complex and multifactorial complication of systemic lupus erythematosus (SLE). ON is a devastating condition that causes severe pain and compromises the quality of life. The prevalence of ON in SLE patients is variable, ranging from 1.7% to 52%. However, the pathophysiology and risk factors for ON in patients with SLE have not yet been fully determined. Several mechanisms for SLE patients' propensity to develop ON have been proposed. Glucocorticoid is a widely used therapeutic option for SLE patients and high-dose glucocorticoid therapy in SLE patients is strongly associated with the development of ON. Although the hips and knees are the most commonly affected areas, it may be present at multiple anatomical locations. Clinically, ON often remains undetected until patients feel discomfort and pain at specific sites at which point the process of bone death is already advanced. However, strategies for prevention and options for treatment are limited. Here, we review the epidemiology, risk factors, diagnosis, and treatment options for glucocorticoid-induced ON, with a specific focus on patients with SLE.
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Affiliation(s)
- Kaichi Kaneko
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomics Research CenterHospital for Special SurgeryNew YorkNew York10021USA
| | - Hao Chen
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomics Research CenterHospital for Special SurgeryNew YorkNew York10021USA
- Department of OrthopedicsBeijing Friendship HospitalBeijing100050China
| | - Matthew Kaufman
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomics Research CenterHospital for Special SurgeryNew YorkNew York10021USA
- Case Western Reserve School of MedicineClevelandOhio44106USA
| | - Isaak Sverdlov
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomics Research CenterHospital for Special SurgeryNew YorkNew York10021USA
- Tuoro College of Osteopathic Medicine‐New York CampusNew YorkNew York10027USA
| | - Emily M. Stein
- Endocrinology Service, Hospital for Special SurgeryNew YorkNew YorkUSA
- Metabolic Bone Disease Service, Hospital for Special SurgeryNew YorkNew YorkUSA
| | - Kyung‐Hyun Park‐Min
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomics Research CenterHospital for Special SurgeryNew YorkNew York10021USA
- Department of MedicineWeill Cornell Medical CollegeNew YorkNew YorkUSA
- BCMB allied programWeill Cornell Graduate School of Medical SciencesNew YorkNew York10021USA
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18
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王 秀, 左 晓, 谢 晓, 罗 卉, 张 卫, 段 力, 赵 洪, 李 懿, 周 亚, 李 通, 谢 艳, 刘 思, 蒋 莹, 巫 世, 黄 婧, 朱 红, 吴 俊, 宁 旺. Risk factors for serious infections in inpatients with systemic lupus erythematosus. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2021; 46:704-710. [PMID: 34382586 PMCID: PMC10930123 DOI: 10.11817/j.issn.1672-7347.2021.200631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To investigate the risk factors for serious infections among hospitalized systemic lupus erythematosus (SLE) patients, and to provide the advice for preventing serious infections in SLE patients. METHODS Information of SLE patients hospitalized from March 2017 to February 2019 at the Department of Rheumatology and Immunology, Xiangya Hospital, Central South University was obtained. The patients were assigned into a serious infection group and a non-serious infection group. The risk factors for serious infections among SLE inpatients were identified by comparison between the 2 groups and multivariate logistic regression analysis. RESULTS There were 463 SLE inpatients in total, and 144 were in the serious infection group and 319 in the non-serious infection group. Multivariate logistic regression analysis showed that age ≥54.50 years old (OR=4.958, P<0.001), cardiovascular involvement (OR=6.287, P<0.001), hematologic involvement (OR=2.643, P=0.003), serum albumin <20 g/L (OR=2.340, P=0.036), C-reaction protein (CRP)/erythrocyte sedimentation rate (ESR)≥0.12 (OR=2.430, P=0.002), glucocorticoid dose ≥8.75 mg/d prednisone-equivalent (OR=2.465, P=0.002), and the combined use of immunosuppressive agents (OR=2.847, P=0.037) were the risk factors for serious infections in SLE inpatients. CONCLUSIONS SLE patients with older age, cardiovascular involvement, hematologic involvement, low serum albumin are prone to suffering serious infections. Increased CRP/ESR ratio indicates serious infections in SLE inpatients. High-dose glucocorticoid and the combined use of immunosuppressive agents can increase the risk of serious infections in SLE inpatients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - 旺斌 宁
- 宁旺斌,, ORCID: 0000-0003-1615-3215
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19
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Sari MK, Satria CD, Arguni E. Predictors of Infection in Children with Systemic Lupus Erythematosus: A Single Center Study in Indonesia. Glob Pediatr Health 2021; 8:2333794X211005609. [PMID: 33889678 PMCID: PMC8040617 DOI: 10.1177/2333794x211005609] [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: 01/15/2021] [Accepted: 03/02/2021] [Indexed: 11/16/2022] Open
Abstract
Patients with Systemic Lupus Erythematosus (SLE) are susceptible to infection due to defects in their immune system. Corticosteroids and immunosuppressant drugs used as SLE therapy also contribute to infection. This study aimed is to determine predictors of infection in pediatric patients with SLE. This retrospective cohort study was conducted at Dr. Sardjito Hospital, a referral hospital in Yogyakarta, Indonesia between 2013 and 2019. Logistic regression analysis was performed to identify predictor variables for the occurrence of infection. A total of 109 SLE patients were included in this study. The incidence of infection in children with SLE was 27.5%. The most common types of infection in hospitalized SLE patients were urinary tract infections (41%), skin and soft tissue infections (20.5%), and pneumonia (20.5%). Multivariate regression analysis showed that the use of methylprednisolone pulse dose (RR 3.204; 95% CI 1.234-8.318) was a predictor of infection. Clinician should closely observe SLE patients with predictors for infection.
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Affiliation(s)
- Maria Kristianti Sari
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Cahya Dewi Satria
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Eggi Arguni
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
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20
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Obrișcă B, Vornicu A, Jurubiță R, Achim C, Bobeică R, Andronesi A, Sorohan B, Herlea V, Procop A, Dina C, Ismail G. Corticosteroids are the major contributors to the risk for serious infections in autoimmune disorders with severe renal involvement. Clin Rheumatol 2021; 40:3285-3297. [PMID: 33595739 DOI: 10.1007/s10067-021-05646-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/30/2021] [Accepted: 02/07/2021] [Indexed: 01/20/2023]
Abstract
INTRODUCTION We sought to investigate the infection profile and associated risk factors in a compiled cohort of patients with autoimmune disorders with severe renal involvement treated with aggressive immunosuppressive (IS) regimens. METHODS A total of 162 patients with aggressive glomerulonephritis [101 with lupus nephritis (LN), 24 with cryoglobulinemic vasculitis (CryoVasc), and 37 with ANCA-associated vasculitis (AAV)] were retrospectively reviewed for any infection occurrence. Infection incidence, type, site, and grade (1-5) were recorded. Multivariate Cox proportional hazard regression analysis was performed to identify independent risk factors for infections. RESULTS A total of 179 infection episodes occurred during a follow-up of 468 patient-years. Eighty-two patients (50.6%) had at least one infection. The incidence rates of infections and severe infections were 38.2 and 14.3 events per 100 patient-years. Patients with AAV had more infections than those with CryoVasc and LN (100.6, 47.5, and 26.6 infections per 100-patient-years, respectively; p = 0.002). Most patients developed infections early during the initial induction therapy (62.1% in the first 6 months of follow-up). In multivariate Cox regression analysis, high-dose oral corticosteroids (≥ 0.5 mg/kg/day in the first month of induction therapy) was an independent predictor of any infection (HR 2.66; 95% CI, 1.5-4.73), severe infections (HR 2.45; 95% CI, 1.03-5.82), and pulmonary infections (HR 2.91; 95% CI, 1.05-8.01). Pulmonary involvement increased the risk for pulmonary infections (HR 3.67; 95% CI, 1.32-10.1) and severe infections (HR 2.45; 95% CI, 1.01-5.92). CONCLUSION Infections occur frequently with current IS regimens in aggressive glomerulonephritis. Pulmonary involvement and high-dose corticosteroid regimen were the most significant risk factors for infections. Key Points • Infections occur frequently with current immunosuppressive regimens in autoimmune aggressive glomerulonephritis. • High-dose corticosteroids are the major contributors to the risk for serious infections.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania. .,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
| | - Alexandra Vornicu
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Roxana Jurubiță
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Camelia Achim
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Raluca Bobeică
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Andreea Andronesi
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Bogdan Sorohan
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Vlad Herlea
- Department of Pathology, Fundeni Clinical Institute, Bucharest, Romania
| | - Alexandru Procop
- Department of Pathology, Fundeni Clinical Institute, Bucharest, Romania
| | - Constantin Dina
- Department of Anatomy, Ovidius University, Constanța, Romania
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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21
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Andrade SDO, Julio PR, Nunes de Paula Ferreira D, Appenzeller S. Predicting lupus flares: epidemiological and disease related risk factors. Expert Rev Clin Immunol 2021; 17:143-153. [PMID: 33393397 DOI: 10.1080/1744666x.2020.1865156] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder, characterized by a relapsing and remitting pattern of disease activity in majority of the patients. Areas covered: This narrative review provides an overview of flare definition, major flare mimics, and the burden of flares in SLE. The authors highlight epidemiology and disease-related risk factor for flares and discuss strategies to reduce flares in SLE. Articles were selected from Pubmed searches conducted between June 2020 and September 2020. Expert opinion: Prolonged clinical remission is observed in approximately 20% of SLE patients flare over the course of the disease. Studies have shown that low disease activity is a good target in SLE, with similar risk of flares, mortality, and quality of life when compared to patients in remission. Clinical and immunological features have shown inconsistent results to identify patients at risk of flares in different cohorts. Cytokine, in serum and urine, has shown promising results to predict flares. However to be useful in clinical practice, they have to be simple, easy, and cost-effective. Future efforts in this direction will allow a more personalized treatment plan for SLE patients, reducing the burden associated with flares.
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Affiliation(s)
- Samuel de Oliveira Andrade
- Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science-University of Campinas, Brazil.,Autoimmunity Lab- School of Medical Science- University of Campinas, Brazil
| | - Paulo Rogerio Julio
- Autoimmunity Lab- School of Medical Science- University of Campinas, Brazil.,Graduate Student at Child and Adolescent Health Program- School of Medical Science- University of Campinas, Brazil
| | - Diego Nunes de Paula Ferreira
- Graduate Student at Child and Adolescent Health Program- School of Medical Science- University of Campinas, Brazil.,Rheumatology Unit-Department of Medicine School of Medical Sciences and University of Campinas (UNICAMP), São Paulo, Brazil
| | - Simone Appenzeller
- Autoimmunity Lab- School of Medical Science- University of Campinas, Brazil.,Rheumatology Unit-Department of Medicine School of Medical Sciences and University of Campinas (UNICAMP), São Paulo, Brazil
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22
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Restrepo-Escobar M, Granda-Carvajal PA, Aguirre DC, Hernández-Zapata J, Vásquez GM, Jaimes F. Predictive models of infection in patients with systemic lupus erythematosus: A systematic literature review. Lupus 2021; 30:421-430. [PMID: 33407048 DOI: 10.1177/0961203320983462] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Having reliable predictive models of prognosis/the risk of infection in systemic lupus erythematosus (SLE) patients would allow this problem to be addressed on an individual basis to study and implement possible preventive or therapeutic interventions. OBJECTIVE To identify and analyze all predictive models of prognosis/the risk of infection in patients with SLE that exist in medical literature. METHODS A structured search in PubMed, Embase, and LILACS databases was carried out until May 9, 2020. In addition, a search for abstracts in the American Congress of Rheumatology (ACR) and European League Against Rheumatism (EULAR) annual meetings' archives published over the past eight years was also conducted. Studies on developing, validating or updating predictive prognostic models carried out in patients with SLE, in which the outcome to be predicted is some type of infection, that were generated in any clinical context and with any time horizon were included. There were no restrictions on language, date, or status of the publication. To carry out the systematic review, the CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies) guideline recommendations were followed. The PROBAST tool (A Tool to Assess the Risk of Bias and Applicability of Prediction Model Studies) was used to assess the risk of bias and the applicability of each model. RESULTS We identified four models of infection prognosis in patients with SLE. Mostly, there were very few events per candidate predictor. In addition, to construct the models, an initial selection was made based on univariate analyses with no contraction of the estimated coefficients being carried out. This suggests that the proposed models have a high probability of overfitting and being optimistic. CONCLUSIONS To date, very few prognostic models have been published on the infection of SLE patients. These models are very heterogeneous and are rated as having a high risk of bias and methodological weaknesses. Despite the widespread recognition of the frequency and severity of infections in SLE patients, there is no reliable predictive prognostic model that facilitates the study and implementation of personalized preventive or therapeutic measures.Protocol registration number: PROSPERO CRD42020171638.
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Affiliation(s)
| | - Paula A Granda-Carvajal
- Department of Internal Medicine and Subspecialties, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Daniel C Aguirre
- Medical Research Institute, Universidad de Antioquia, Medellín, Colombia
| | | | - Gloria M Vásquez
- Department of Internal Medicine, Universidad de Antioquia, Medellín, Colombia
| | - Fabián Jaimes
- Department of Internal Medicine, Universidad de Antioquia, Medellín, Colombia
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23
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Battaglia M, Garrett-Sinha LA. Bacterial infections in lupus: Roles in promoting immune activation and in pathogenesis of the disease. J Transl Autoimmun 2020; 4:100078. [PMID: 33490939 PMCID: PMC7804979 DOI: 10.1016/j.jtauto.2020.100078] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/11/2020] [Accepted: 12/16/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Bacterial infections of the lung, skin, bloodstream and other tissues are common in patients with systemic lupus erythematosus (lupus) and are often more severe and invasive than similar infections in control populations. A variety of studies have explored the changes in bacterial abundance in lupus patients, the rates of infection and the influence of particular bacterial species on disease progression, using both human patient samples and mouse models of lupus. OBJECTIVE The aim of this review is to summarize human and mouse studies that describe changes in the bacterial microbiome in lupus, the role of a leaky gut in stimulating inflammation, identification of specific bacterial species associated with lupus, and the potential roles of certain common bacterial infections in promoting lupus progression. METHODS Information was collected using searches of the Pubmed database for articles relevant to bacterial infections in lupus and to microbiome changes associated with lupus. RESULTS The reviewed studies demonstrate significant changes in the bacterial microbiome of lupus patients as compared to control subjects and in lupus-prone mice compared to control mice. Furthermore, there is evidence supporting the existence of a leaky gut in lupus patients and in lupus-prone mice. This leaky gut may allow live bacteria or bacterial components to enter the circulation and cause inflammation. Invasive bacterial infections are more common and often more severe in lupus patients. These include infections caused by Staphylococcus aureus, Salmonella enterica, Escherichia coli, Streptococcus pneumoniae and mycobacteria. These bacterial infections can trigger increased immune activation and inflammation, potentially stimulating activation of autoreactive lymphocytes and leading to worsening of lupus symptoms. CONCLUSIONS Together, the evidence suggests that lupus predisposes to infection, while infection may trigger worsening lupus, leading to a feedback loop that may reinforce autoimmune symptoms.
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Affiliation(s)
- Michael Battaglia
- Department of Biochemistry, State University of New York at Buffalo, Buffalo, NY, 14203, USA
| | - Lee Ann Garrett-Sinha
- Department of Biochemistry, State University of New York at Buffalo, Buffalo, NY, 14203, USA
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24
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Singh JA, Cleveland JD. Hospitalized Infections in Lupus: A Nationwide Study of Types of Infections, Time Trends, Health Care Utilization, and In-Hospital Mortality. Arthritis Rheumatol 2020; 73:617-630. [PMID: 33142044 DOI: 10.1002/art.41577] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 10/29/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To examine the time trends in hospitalized infections in patients with systemic lupus erythematosus (SLE), and the factors associated with health care utilization and in-hospital mortality. METHODS US National Inpatient Sample data from 1998-2016 were used to examine the epidemiology, time trends, and outcomes of 5 common hospitalized infections in patients with SLE, namely, pneumonia, sepsis/bacteremia, urinary tract infection (UTI), skin and soft tissue infections (SSTIs), and opportunistic infections (OIs). Time trends were compared using the Cochran-Armitage test. Multivariable-adjusted logistic regression models were used to examine the factors associated with health care utilization (hospital stay >3 days, hospital charges above the median, or discharge to a nonhome setting) and in-hospital mortality. RESULTS Hospitalization rates per 100,000 claims among SLE patients in 1998-2000 versus in 2015-2016 were as follows: for OIs, 1.13 versus 1.61 (1.2-fold increase); for SSTIs, 4.78 versus 12.2 (2.5-fold increase); for UTI, 1.94 versus 6.12 (3.2-fold increase); for pneumonia, 15.09 versus 17.05 (1.1-fold increase); and for sepsis, 6.31 versus 39.64 (6.3-fold increase). In 2011-2012, sepsis surpassed pneumonia as the most common hospitalized infection in patients with SLE. In multivariable-adjusted models, a diagnosis of sepsis, older age, a Deyo-Charlson common comorbidities score of ≥2, having Medicare or Medicaid insurance, and urban hospital location were significantly associated with increased odds of in-hospital mortality and with all health care utilization outcomes. African American race was significantly associated with increased odds of health care utilization. CONCLUSION The results of this study indicate that the rates of hospitalized infections increased over time in patients with SLE, and that pneumonia was surpassed by sepsis as the most common hospitalized infection. In addition, associations of risk factors with poorer outcomes were identified. These findings may help inform patients, providers, and policy makers with regard to the burden of infection in SLE, and could lead to interventions/pathways to improve outcomes.
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Affiliation(s)
- Jasvinder A Singh
- University of Alabama at Birmingham and Birmingham VA Medical Center
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25
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Mason A, Rose E, Edwards CJ. Clinical management of Lupus patients during the COVID-19 pandemic. Lupus 2020; 29:1661-1672. [DOI: 10.1177/0961203320961848] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Severe acute respiratory syndrome coronavirus (SARS-CoV-2), the virus causing Coronavirus disease 2019 (COVID-19), has had a huge impact on health services with a high mortality associated with complications including pneumonia and acute respiratory distress syndrome. Historical evidence suggests that Lupus patients have a higher incidence of several viral infections. This is likely due to a combination of immune dysfunction, immunosuppressive therapy and excess co-morbidities. In this context there has been concern that Lupus patients may be at a higher risk of developing COVID-19 and suffering a severe disease course. As a result, many Lupus patients have been advised to ‘shield’ by isolating from social contact in the hope that this will reduce the likelihood of infection. Early clinical data does not appear to show that the incidence of COVID-19 is higher in Lupus patients. Reassuringly, the clinical course of COVID-19 in Lupus does not generally seem to be more severe than in the general population. There has been huge interest in repurposing existing drugs as potential treatments, including several used to treat Lupus. Of these, corticosteroids and hydroxychloroquine are the most well researched so far. The current evidence suggests that the corticosteroid dexamethasone improves outcome for the sickest COVID-19 patients requiring respiratory support. Initial reports suggested that hydroxychloroquine could have a positive impact on the course of COVID-19, however larger prospective studies have not supported this. Janus kinase inhibitors, currently being investigated for efficacy in lupus, have been shown to have anti-viral effects in vitro and inhibiting the JAK-STAT pathway may dampen down the host hyper-inflammatory response. Several trials are ongoing to assess the outcome of the use of JAK inhibitors in COVID-19 positive patients. For most patients continuing with their existing therapies to prevent a lupus flare or adverse events associated with sudden corticosteroid withdrawal is important whilst an Individualised risk assessment remains vital.
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Affiliation(s)
- Alice Mason
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Emily Rose
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Christopher J Edwards
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- MSK Research Unit, NIHR Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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26
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Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects almost every organ system and it is treated with immunomodulation and immunosuppression. SLE patients have an intrinsically dysfunctional immune system which is exacerbated by disease activity and leaves them vulnerable to infection. Treatment with immunosuppression increases susceptibility to infection, while hydroxychloroquine use decreases this risk. Infectious diseases are a leading cause of hospitalization and death. AREAS COVERED This narrative review provides an overview of recent epidemiology and predictors of infections in SLE, delineates the risk of infection by therapeutic agent, and provides suggestions for risk mitigation. Articles were selected from Pubmed searches conducted between September 2019 and January 2020. EXPERT OPINION Despite the large burden of infection, effective and safe preventative care such as universal hydroxychloroquine use and vaccination are underutilized. Future efforts should be directed to quality improvement, glucocorticoid reduction, and validation of risk indices that identify patients at the highest risk of infection.
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Affiliation(s)
- Megan R W Barber
- Division of Rheumatology, University of Calgary , Calgary, Alberta, Canada
| | - Ann E Clarke
- Division of Rheumatology, University of Calgary , Calgary, Alberta, Canada
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27
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Felten R, Arnaud L. Is it possible to stop glucocorticoids in systemic lupus? Joint Bone Spine 2020; 87:528-530. [PMID: 32222323 DOI: 10.1016/j.jbspin.2020.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/18/2020] [Indexed: 01/24/2023]
Affiliation(s)
- Renaud Felten
- Service de rhumatologie, centre national de référence des maladies auto-immunes et systémiques rares Est/Sud-Ouest (RESO), centre hospitalier universitaire de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France
| | - Laurent Arnaud
- Service de rhumatologie, centre national de référence des maladies auto-immunes et systémiques rares Est/Sud-Ouest (RESO), centre hospitalier universitaire de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France.
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28
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Wu W, Ma J, Zhou Y, Tang C, Zhao F, Sun F, Xu W, Chen J, Ye S, Chen Y. Mortality risk prediction in lupus patients complicated with invasive infection in the emergency department: LUPHAS score. Ther Adv Musculoskelet Dis 2019; 11:1759720X19885559. [PMID: 31723357 PMCID: PMC6831971 DOI: 10.1177/1759720x19885559] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 09/29/2019] [Indexed: 12/26/2022] Open
Abstract
Background: Infection remains a major cause of morbidity and mortality in patients with
systemic lupus erythematosus (SLE). This study aimed to establish a clinical
prediction model for the 3-month all-cause mortality of invasive infection
events in patients with SLE in the emergency department. Methods: SLE patients complicated with invasive infection admitted into the emergency
department were included in this study. Patient’s demographic, clinical, and
laboratory characteristics on admission were retrospectively collected as
baseline data and compared between the deceased and the survivors.
Independent predictors were identified by multivariable logistic regression
analysis. A prediction model for all-cause mortality was established and
evaluated by receiver operating characteristic (ROC) curve analysis. Results: A total of 130 eligible patients were collected with a cumulative 38.5%
3-month mortality. Lymphocyte count <800/ul, urea >7.6mmol/l, maximum
prednisone dose in the past ⩾60 mg/d, quick Sequential Organ Failure
Assessment (qSOFA) score, and age at baseline were independent
predictors for all-cause mortality (LUPHAS). In contrast, a history of
hydroxychloroquine use was protective. In a combined, odds ratio-weighted
LUPHAS scoring system (score 3–22), patients were categorized to three
groups: low-risk (score 3–9), medium-risk (score 10–15), and high-risk
(score 16–22), with mortalities of 4.9% (2/41), 45.9% (28/61), and 78.3%
(18/23) respectively. ROC curve analysis indicated that a LUPHAS score could
effectively predict all-cause mortality [area under the curve (AUC) = 0.86,
CI 95% 0.79–0.92]. In addition, LUPHAS score performed better than the qSOFA
score alone (AUC = 0.69, CI 95% 0.59–0.78), or CURB-65 score (AUC = 0.69, CI
95% 0.59–0.80) in the subgroup of lung infections
(n = 108). Conclusions: Based on a large emergency cohort of lupus patients complicated with invasive
infection, the LUPHAS score was established to predict the short-term
all-cause mortality, which could be a promising applicable tool for risk
stratification in clinical practice.
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Affiliation(s)
- Wanlong Wu
- Department of Rheumatology, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Ma
- Department of Emergency Medicine, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuhong Zhou
- Department of Emergency Medicine, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chao Tang
- Department of Emergency Medicine, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Feng Zhao
- Department of Emergency Medicine, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fangfang Sun
- Department of Rheumatology, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wenwen Xu
- Department of Rheumatology, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jie Chen
- Department of Rheumatology, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shuang Ye
- Department of Rheumatology, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi Chen
- Department of Emergency Medicine, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 2000, Jiangyue Road, Minhang District, Shanghai 201112, China
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