Infection-related hospitalization after intensive immunosuppressive therapy among lupus nephritis and ANCA glomerulonephritis patients

In-hospital mortality and associated factors in patients with systemic lupus erythematosus: analysis over more than 11 years in a reference hospital center

Systemic lupus erythematosus (SLE) is a disease that affects the immune system, and it can lead to increased morbidity and mortality. The primary causes of mortality for individuals with SLE are disease activity, infections, drug toxicity, and other health conditions. The aim of this study is to estimate the mortality rate of patients with SLE who are hospitalized, describe the causes of death, and identify factors associated with mortality. The study was conducted at a referral hospital from 2009 to 2021, utilizing a nested case-control design. The records of patients with SLE who were hospitalized in the Department of Rheumatology were reviewed. Cases were identified as individuals who died during their hospitalization, while controls were those who were discharged alive during the same period. Elective hospitalizations were not included in the study. The primary causes of death were recorded, and demographic, clinical, laboratory, and immunological variables were analyzed as potential risk factors associated with in-hospital mortality. The study included 105 patients who died while hospitalized and 336 who were discharged alive. The estimated mortality rate was 10.93 deaths per 1000 hospital admissions per year. The leading causes of death were SLE activity (20%), infections (34.2%), or a combination of both (24.8%). Risk factors associated with in-hospital mortality were any infection (OR 2.5, CI 95% 1.2-5.2), nosocomial infections (OR 5.0, CI 95% 1.8-13.7), SLEDAI-2K > 2 (OR 2.0, CI 95% 1.02-3.8), lymphopenia (OR 2.1, CI 95% 1.01-4.6), anemia (OR 2.9, CI 95% 1.4-5.7), and thrombocytopenia (OR 3.3, CI 95% 1.7-6.4). Disease activity and infections, particularly nosocomial infections, are significant causes of mortality in hospitalized patients with SLE. Furthermore, hematological manifestations play a significant role in in-hospital mortality for these patients.

Corticosteroids are the major contributors to the risk for serious infections in autoimmune disorders with severe renal involvement

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.