Systemic lupus erythematosus in northwestern Spain: a 20-year epidemiologic study

Clinical and laboratory characteristics of early-onset and delayed-onset lupus nephritis patients: A single-center retrospective study

BACKGROUND

Lupus nephritis (LN) manifests systemic lupus erythematosus (SLE) and is characterized by various clinical and laboratory features. This study aimed to comprehensively evaluate the characteristics of LN patients according to the time of LN diagnosis: early-onset (LN diagnosed within one year from SLE diagnosis) vs. delayed-onset (LN diagnosed more than one year after SLE diagnosis).

METHODS

We conducted a retrospective analysis of medical records from all SLE patients treated at the University Hospital in Kraków, Poland, from 2012 to 2022. We collected data on demographic, clinical, and laboratory characteristics, including histological findings, treatment modalities, and disease outcomes. Statistical analyses were performed to identify factors impacting LN development and prognosis.

RESULTS

Among 331 LN patients, early-onset was diagnosed in 207 (62.54%) and delayed-onset was documented in 122 cases (36.86%). In 2 (0.6%) LN cases, the time of first kidney manifestation in the SLE course was unknown. Delayed-onset LN had a higher female-to-male ratio and younger age at SLE diagnosis. This group was associated with more severe clinical manifestations. In turn, studied subgroups did not differ in internist comorbidities, kidney histopathology, and family history regarding autoimmune diseases. Delayed-onset LN exhibited a higher frequency of anti-dsDNA, anti-Smith, anti-Ro, anti-RNP, and anti-cardiolipin IgG autoantibodies. During a 14-year follow-up period, 16 patients died. Mortality rate and causes of death were comparable in both analyzed subgroups.

CONCLUSIONS

More severe clinical manifestations in delayed-onset LN prompt strict monitoring of non-LN SLE patients to diagnose and treat kidney involvement early. Also, recognizing the higher frequency of autoantibodies such as anti-dsDNA or anti-Smith in delayed-onset LN underscores the potential value of autoantibody profiling as a diagnostic and prognostic tool.

Clinical features of flare in Japanese patients with new-onset SLE and risk factors for SLE flare in daily clinical practice: a single-center cohort study

This study aimed to elucidate the clinical features, outcomes and risk factors of flares in patients with systemic lupus erythematosus (SLE). Data were collected from patients with newly diagnosed SLE at the Fukushima Medical University Hospital between 2011 and 2022. Patients who experienced a flare during the study period constituted the flare group, and their clinical features were compared with those of the no-flare group. The cumulative flare-free survival regarding several clinical items was compared between the two groups using Kaplan-Meier's curves. Among 387 patients with SLE, 83 patients with newly diagnosed SLE were included. Their mean age was 37.9 years, and 29 patients experienced flares during the study period. The general characteristics were similar between the two groups, with the exception of the observation period and anti-SS-A antibody positivity. Regarding therapy, a significantly increased frequency of hydroxychloroquine intake and combination with immunosuppressive agents were observed in the no-flare group. The Kaplan-Meier analysis revealed a significantly higher cumulative flare-free survival in the anti-SS-A negative group and combination immunosuppressive therapy group. In conclusion, anti-SS-A positivity may be a risk factor for SLE flare. In turn, combination immunosuppressive therapy may be beneficial for SLE treatment in daily clinical practice.

Declining Incidence of Systemic Lupus Erythematosus in Norway 1999-2017: Data From a Population Cohort Identified by International Classification of Diseases, 10th Revision Code and Verified by Classification

OBJECTIVE

The goal of this study was to provide complete, robust data on annual systemic lupus erythematosus (SLE) incidence rates over nearly two decades from the Southeast Norway area (2.9 million inhabitants) and assess accuracy of SLE-specific International Classification of Diseases (ICD) codes for SLE diagnosis.

METHODS

From administrative databases, we identified all cases International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) coded as SLE during 1999 through 2017 in Southeast Norway. We manually reviewed the chart of every case ICD-10 coded as SLE to either confirm or reject SLE diagnosis. Using SLE classification criteria, we classified all cases with confirmed SLE. We estimated annual incidence rates of classified SLE, and subsets, defined by age at diagnosis, sex, and parental country of birth. The chi-square test was applied for linear time-trend analyses of incidence.

RESULTS

Among the 3,488 cases ICD-10 coded as SLE, chart reviews confirmed SLE diagnosis in 1,558 (45%), of which 797 had new-onset disease during 1999 through 2017. Annual SLE incidence rates fell during 1999 to 2017. The fall was most pronounced in female persons 50 to 59 years old at diagnosis, in whom incidence fell from 3.4 to 1.1 per 100,000 persons (P trend < 0.001). Concurrent ecological data from the study area showed a 74% reduction in prescriptions of menopausal hormone treatment. Accuracy of ICD-10 codes for incident SLE diagnosis was acceptable in juveniles and young adults (up to 20 years) but otherwise low.

CONCLUSION

In a presumably complete population-based cohort, we identified decreasing incidence of SLE, especially among female persons 50 to 59 years old. Although reasons for declining incidence are not clear, ecological data indicate a possible role of environmental factors, for example, menopausal hormone treatments.

Incidence and medical costs of lupus in Spanish hospitals: a retrospective database analysis

BACKGROUND

This study aimed to assess the comorbidity profile, use of healthcare resources and medical costs of patients with systemic lupus erythematosus (SLE) and cutaneous lupus erythematosus (CLE) treated at the hospital level in Spain.

METHODS

Admission records of patients with SLE and CLE that were registered between January 2016 and December 2020 were obtained from a Spanish hospital discharge database and analyzed in a retrospective multicenter study.

RESULTS

329 patients met the criteria; 64.44% were female and 35.56% were male, with a median age of 54.65 years. Mean Charlson comorbidity index (CCI) was 2.75 in the index admission. 31.61% of the patients suffered essential hypertension, 21.96% suffered asthma and 19.76% suffered hyperlipidemia. Mortality rate was 3.95%. The most common medical procedure was heart ultrasound (19.45%) and introduction in peripheral vein of anti-inflammatory with a percutaneous approach (17.93%). Mean admission cost was €6355.99.

CONCLUSIONS

Lupus patients showed a higher incidence and prevalence in the female population, with associated cardiac diseases as the main secondary conditions.

Rising incidence and prevalence of systemic lupus erythematosus: a population-based study over four decades

OBJECTIVES

To determine the trends in incidence, prevalence and mortality of systemic lupus erythematosus (SLE) in a US population over four decades.

METHODS

We identified all the patients with SLE in Olmsted County, Minnesota who fulfilled the European Alliance of Associations for Rheumatology (EULAR)/American College of Rheumatology (ACR) criteria for SLE during 1976-2018. Age-specific and sex-specific incidence and prevalence rates were adjusted to the standard 2000 projected US population. The EULAR/ACR score was used as a proxy for disease severity. Standardised mortality ratio (SMR) was estimated.

RESULTS

There were 188 incident SLE cases in 1976-2018 (mean age 46.3±SD 16.9; 83% women). Overall age-adjusted and sex-adjusted annual SLE incidence per 100 000 population was 4.77 (95% CI 4.09 to 5.46). Incidence was higher in women (7.58) than men (1.89). The incidence rate increased from 3.32 during 1976-1988 to 6.44 during 2009-2018. Incidence rates were higher among the racial and ethnic minority populations than non-Hispanic whites. The EULAR/ACR score did not change significantly over time. Overall prevalence increased from 30.6 in 1985 to 97.4 in 2015. During the study period, there was no improvement in SMR over time (p=0.31).

CONCLUSIONS

The incidence and prevalence of SLE are increasing in this US population. The increase in incidence may be at least partially explained by the rising ethnic/racial diversity of the population. There was no evidence that the severity of SLE has changed over time. The survival gap between SLE and the general population remains unchanged. As the US population grows more diverse, we might continue to see an increase in the incidence of SLE.

Use of belimumab in real-world in Spain: a scoping review about characteristics of SLE patients

Background

Belimumab was the first biological drug approved for Systemic Lupus Erythematosus (SLE). There is not a review focusing on all real-life experience with belimumab to date that could help to describe how this drug behaves in the Spanish clinical setting.

Objective

To describe the characteristics of SLE patients treated with belimumab added to standard of care in real-clinical setting in Spain.

Methods

We conducted a comprehensive scoping review of real-world data (RWD) according to PRISMA Scoping Reviews Checklist and the framework proposed by Arksey and O’Malley. PubMed and EMBASE were searched without language restriction and hand searches of relevant articles were examined.

Results

We included data from 222 patients treated with belimumab for SLE included in 19 RWD studies conducted in Spain. The mean age was 40.9 years, 84.2% were female, and baseline scores SELENA-SLEDAI ranged between 5.9 and 12. Lupus nephritis basal prevalence was of 2.7%. The main reason for belimumab initiation was previous treatments lack of efficacy (69.7%) and the most common laboratory abnormalities were hypocomplementemia (40.9%), ANA + (34.2%), and anti-DNA (33.3%). The addition of belimumab to standard therapy was associated with a reduction of daily glucocorticoids intake in 1.4–11.1 mg at 6 months. Belimumab discontinuation was observed in 18.6% of patients.

Conclusion

Our study helps to further explore the profile of SLE patients most likely to be treated with belimumab.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10067-022-06287-9.

Twenty-year trends in all-cause mortality of patients with systemic lupus erythematosus in Mexico: Results from a nationwide health registry

Objective

Regional variations in systemic lupus erythematosus (SLE) mortality may be due to different spectra of local environmental factors. The aim of this study was to assess mortality trends in adults with SLE using a nationwide health registry.

Methods

Data came from the Dynamic Cubes of the General Direction of Health Information for 1998–2017 for mortality. In patients aged ≥15 years, SLE as the principal cause of death was defined according to ICD-10 code M32 and was classified by sex and age. Joinpoint trend analyses of annual age-standardized mortality rates (ASMR) for SLE patients and non-SLE people were made.

Results

We identified 11 449 SLE deaths and 9,989,874 non-SLE deaths. The SLE ASMR increased more than the non-SLE ASMR, with a 98.2% cumulative increase in the ratio of SLE to non-SLE deaths. Whereas the non-SLE ASMR remained relatively stable throughout the study period (overall and by sex), the SLE ASMR significantly increased between 1998 and 2009, non-significantly decreased between 2009 and 2013 and non-significantly increased thereafter. Both women and men had a large cumulative increase in the SLE ASMR/non-SLE ASMR ratio (73.9 and 191.3%, respectively). The Southeast region had the largest cumulative increases in the ratio of SLE to non-SLE ASMR (108.8%). Of the 11,449 deaths, 445 (3.8%) were in geographical areas where ≥40% of the population is indigenous.

Conclusion

SLE mortality rates have increased since 1998 and remain high compared with non-SLE mortality: significant sex and regional disparities persist.

What can we learn from DNA methylation studies in lupus?

During the past twenty years, a wide range of studies have established the existence of epigenetic alterations, particularly DNA methylation changes, in lupus. Epigenetic changes might have different contributions in children-onset versus adult-onset lupus. DNA methylation alterations have been identified and characterized in relation to disease activity and damage, different lupus subtypes and responses to drugs. However, to date there has been no practical application of these findings in the clinical milieu. In this article, we provide a review of key studies showing the relationship between DNA methylation and the many clinical aspects related to lupus. We also propose several options, in relation to the range of methodological developments and experimental design, that could optimize these findings and make them amenable for use in clinical practice.

Trends in Hospital Admissions and Death Causes in Patients with Systemic Lupus Erythematosus: Spanish National Registry

Background: the admission and death causes of SLE patients might have changed over the last years. Methods: Analysis of the Spanish National Hospital Discharge database. All individuals admitted with SLE, according to ICD-9, were selected. The following five admission categories were considered: SLE, cardiovascular disease (CVD), neoplasm, infection, and venous-thromboembolic disease (VTED), along four periods of time (1997–2000, 2001–2005, 2006–2010, and 2011–2015). Results: The admissions (99,859) from 43.432 patients with SLE were included. The absolute number of admissions increased from 15,807 in 1997–2000 to 31,977 in 2011–2015. SLE decreased as a cause of admission (from 47.1% to 20.8%, p < 0.001), while other categories increased over the time, as follows: 5% to 8.6% for CVD, 8.2% to 13% for infection, and 1.4% to 5.5% for neoplasm (p < 0.001 for all). The admission mortality rate rose from 2.22% to 3.06% (p < 0.001) and the causes of death evolved in parallel with the admission categories. A significant trend to older age was observed over time in the overall population and deceased patients (p < 0.001). Conclusions: Better control of SLE over the past two decades has led to a decrease in early admissions, and disease chronification. As a counterpart, CVD, infections, and neoplasm have become the main causes of admissions and mortality.

Long-Term Outcome in Systemic Lupus Erythematosus; Knowledge from Population-Based Cohorts

Background: Accurate knowledge of outcomes in Systemic Lupus Erythematosus (SLE) is crucial to understanding the true burden of the disease. The main objective of this systematic review was to gather all population-based studies on mortality, end-stage renal disease (ESRD) and cancer in SLE. Method: We performed a systematic literature search in two electronic databases (MEDLINE and Embase) to identify all population-based articles on SLE and survival, mortality, ESRD and cancer. The SLE diagnosis had to be verified. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Results: We included 40/1041 articles on mortality (27), ESRD (11) and cancer (3), of which six were defined as inception studies. In the total SLE cohort, the standardized mortality ratio ranged from 1.9 to 4.6. Cardiovascular disease was the most frequent cause of death in studies with follow-up times over 15 years. SLE progressed to ESRD in 5–11% of all SLE patients. There are no data supporting increased cancer incidence from population-based inception cohorts. Conclusion: There is a need for more population-based studies on outcomes of SLE, especially inception studies, with the use of control groups and follow-up times over 15 years.

Mortality in SLE patients compared with population controls in Finland in years 2000-2015

OBJECTIVE

To estimate the risk of mortality in the Finnish incident SLE cohort in a 16-year period compared with the general population.

METHODS

Adults with new-onset SLE between 1 January 2000 and 31 December 2014 identified from the national drug reimbursement register and their individually matched controls from the Population Register Centre were followed up until death or 31 December 2015. Data on deaths were retrieved from the national causes of death register. Comorbidities and education were obtained by linkage to the other national registries.

RESULTS

A total of 1006 patients with incident SLE and 3005 population controls were found (mean follow-up 8.6 years). Of these, 98 SLE patients subsequently died. Their 5 -, 10-, and 15-year survival rates were 95.0% (95% CI: 93.3, 96.2), 88.8% (86.2, 91.0), and 82.1% (77.6, 85.8), respectively. Crude hazard ratio (HR) was 1.61 (95% CI: 1.26, 2.06), adjusted for education level was almost the same 1.61 (95% CI: 1.26, 2.05). After adjustment for comorbidities and education at baseline, the difference in mortality disappeared: HR 1.14 (95% CI: 0.88, 1.48). The leading causes of death were cardiovascular diseases (CVDs) (33%), malignancies (27%) and neurological diseases (10%). Subhazard ratio for CVD deaths was 1.28 (95% CI: 0.85, 1.93), adjusted for comorbidities and education 0.88 (95% CI: 0.56, 1.39).

CONCLUSIONS

These results suggest that the increased mortality in SLE patients is highly associated with comorbidities present at diagnosis. This underlines the importance to screen and treat comorbidities and disease actively without delays.

Incidence and prevalence of systemic lupus erythematosus among Korean women in childbearing years: A nationwide population-based study

BACKGROUND

Most women with systemic lupus erythematosus (SLE) are diagnosed with the disease in their reproductive years, but the incidence and prevalence of SLE among women of childbearing age have not been studied. The objective of this study was to estimate the incidence and prevalence of SLE among the Korean women of childbearing age.

METHODS

Women aged 20 to 44 years with SLE were identified from National Health Insurance Service - National Health Information Database (2009-2016), which contain health information of approximately 97% of the Korean population. SLE was defined by International Classification of Diseases, 10th revision code, M32. Incidence and prevalence were calculated per 100,000 person-years and stratified by year and age.

RESULTS

A total of 12,756 women with SLE were identified. The incidence of SLE from 2011 to 2016 among women in childbearing years was 8.18/100,000 person-years (95% CI 7.94-8.43), with the highest incidence in 2016 (8.56/100,000 person-years, 95% CI 7.95-9.17) and the lowest incidence in 2012 (7.85/100,000 person-years, 95% CI 7.28-8.42). The prevalence of SLE from 2009 to 2016 among women in childbearing years was 77.07/100,000 person-years (95% CI 75.76-78.39), with the highest prevalence in 2014 (79.47/100,000 person-years, 95% CI 77.64-81.30) and the lowest in 2010 (74.19/100,000 person-years, 95% CI 72.45-75.93). The peak age for SLE incidence was between 25-39 years, and lower incidence was seen in the early (20-24 years) and late (40-44 years) childbearing age periods. There was an increasing trend in prevalence according to age in women of childbearing age, with the highest prevalence occurring in the 40-44 age group.

CONCLUSIONS

The risk and burden of SLE are high among women during their childbearing years. This calls for special attention to this particular population group when allocating health resources.

Trends in mortality from lupus in Spain from 1980 to 2018

BACKGROUND

Recent studies suggest that Systemic lupus erythematosus (SLE) mortality rates in Spain are decreasing. However, SLE mortality in Spain has been poorly studied. The purpose of study is to assess the temporal trends of mortality rates in the Spanish population with SLE from 1980 to 2018.

METHODS

Death records and mid-year population data were collected from the National Statistics Institute. Age-standardized mortality rates were calculated for overall population and for each sex and age group. Significant changes in mortality trends were identified by Joinpoint regressions. Also, an Age-period-cohort (APC) and Potential Years of Life Lost (PYLL) analysis was carried out to know the burden of SLE disease.

RESULTS

The overall SLE mortality rates in Spain has experimented an increased through the last 39 years. Mortality rates from the period 1980-1984 was 0.83 per 1.000.000 inhabitants, reaching the value to 1.77 cases per 1.000.000 from the period 2014-2018. A decreasing trend has been observed since 1999.

CONCLUSIONS

SLE mortality rate has increased in Spain between 1980 and 1999, with a sustained decrease up to our days.

Trend of prevalence and incidence of systemic lupus erythematosus in South Korea, 2005 to 2015: a nationwide population-based study

BACKGROUND/AIMS

The aim of this study was to evaluate the trend of incidence and prevalence of systemic lupus erythematosus (SLE) in South Korea from 2005 to 2015.

METHODS

From 2005 to 2015, individuals with SLE were identified from the National Health Insurance database, which records information on almost all Koreans. SLE was defined according to the International Classification of Diseases, 10th revision (ICD-10), code M32. The incidence was calculated per 100,000 person-years. The prevalence was calculated per 100,000 people and stratified by year, age group, sex, region, and income.

RESULTS

The annual prevalence of SLE increased slightly from 21.25/100,000 people in 2005 to 35.45/100,000 people in 2015. In contrast, the annual incidence of SLE decreased slightly from 5.42/100,000 person-years in 2005 to 3.6/100,000 person-years in 2015. The prevalence and incidence of SLE were 10- and 6-fold higher in women than in men, respectively. The peak age of prevalence and incidence was 30 to 39 years in 2005; in 2015, the peak age of prevalence was 30 to 49 years and of incidence was 20 to 49 years. Regional variation was observed in both incidence and prevalence of SLE. Jeju province showed the highest prevalence of SLE (44.54/100,000 person-years), and Gwangju province showed the highest incidence of SLE (6.98/100,000 person-years) in 2015. The income status did not affect the prevalence or incidence of SLE except in patients without income who received medical aid.

CONCLUSION

The incidence of SLE has declined, but the prevalence has increased in Korea in recent years. Peak age of SLE trend to right shift in Korea.

El embarazo en mujeres con lupus eritematoso sistémico: una revisión integrativa

Introducción: En la actualidad, se conoce que el lupus eritematoso sistémico no afecta a la fertilidad; sin embargo, el embarazo en mujeres que lo padecen se asocia a riesgos, tanto maternos como fetales. Objetivo: Determinar las variables que intervienen en la preparación y control de la gestación en mujeres con lupus eritematoso sistémico, así como las medidas de enfermería más importantes. Material y Método: Se ha realizado una revisión integrativa mediante una búsqueda en las bases de datos Proquest, Pubmed y Web of Science. Se incluyeron artículos científicos originales, observacionales y de revisión, en inglés y español, excluyendo aquellos artículos anteriores a 2009 o que no estuviesen en texto completo. Resultados: Se han incluido 15 artículos publicados entre el año 2009 y 2019. El embarazo en pacientes con lupus eritematoso sistémico es complejo, ya que necesita de un control exhaustivo y continuo para conseguir buenos resultados. Un cambio de tratamiento, test de laboratorio cada cierto tiempo y la vigilancia de un equipo multidisciplinar, harán que la enfermedad se encuentre controlada y los riesgos de complicaciones maternas y fetales disminuyan. Conclusiones: En la actualidad, la mayoría de las mujeres con lupus eritematoso sistémico pueden conseguir el objetivo de la maternidad, siempre y cuando la enfermedad se encuentre controlada al menos 6 meses antes de la concepción y durante todo el embarazo. Las variables más determinantes en el embarazo de la mujer con lupus eritematoso sistémico son la fertilidad, las complicaciones o el tratamiento, que influyen de forma directa sobre el embarazo.

Differences in clinical manifestations and increased severity of systemic lupus erythematosus between two groups of Hispanics: European Caucasians versus Latin American mestizos (data from the RELESSER registry)

Background

Systemic lupus erythematosus (SLE) is regarded as a prototype autoimmune disease because it can serve as a means for studying differences between ethnic minorities and sex. Traditionally, all Hispanics have been bracketed within the same ethnic group, but there are differences between Hispanics from Spain and those from Latin America, not to mention other Spanish-speaking populations.

Objectives

This study aimed to determine the demographic and clinical characteristics, severity, activity, damage, mortality and co-morbidity of SLE in Hispanics belonging to the two ethnic groups resident in Spain, and to identify any differences.

Methods

This was an observational, multi-centre, retrospective study. The demographic and clinical variables of patients with SLE from 45 rheumatology units were collected. The study was conducted in accordance with Good Clinical Practice guidelines. Hispanic patients from the registry were divided into two groups: Spaniards or European Caucasians (EC) and Latin American mestizos (LAM). Comparative univariate and multivariate statistical analyses were carried out.

Results

A total of 3490 SLE patients were included, 90% of whom were female; 3305 (92%) EC and 185 (5%) LAM. LAM patients experienced their first lupus symptoms four years earlier than EC patients and were diagnosed and included in the registry younger, and their SLE was of a shorter duration. The time in months from the first SLE symptoms to diagnosis was longer in EC patients, as were the follow-up periods. LAM patients exhibited higher prevalence rates of myositis, haemolytic anaemia and nephritis, but there were no differences in histological type or serositis. Anti-Sm, anti-Ro and anti-RNP antibodies were more frequently found in LAM patients. LAM patients also had higher levels of disease activity, severity and hospital admissions. However, there were no differences in damage index, mortality or co-morbidity index. In the multivariate analysis, after adjusting for confounders, in several models the odds ratio (95% confidence interval) for a Katz severity index >3 in LAM patients was 1.45 (1.038–2.026; p = 0.02). This difference did not extend to activity levels (i.e. SLEDAI >3; 0.98 (0.30–1.66)).

Conclusion

SLE in Hispanic EC patients showed clinical differences compared to Hispanic LAM patients. The latter more frequently suffered nephritis and higher severity indices. This study shows that where lupus is concerned, not all Hispanics are equal.

Population-based Study of 24 Autoimmune Diseases Carried Out in a Brazilian Microregion

In Brazil, epidemiological data on autoimmune diseases are scarce due to the lack of a specific policy of attention to this group of diseases. This study aimed to estimate the general and relative prevalence of the diseases presented, as well as to know the sociodemographic profile of the identified cases. This cross-sectional study was conducted with an epidemiological survey of patients with confirmed diagnosis of autoimmune diseases from primary health care in the Aguas Formosas microregion, Minas Gerais, Brazil. We have included all new and old cases found of individuals of both sexes and all ages, including those who died and emigrated during this period. A total of 407 carriers and 24 different autoimmune diseases were identified. The prevalence of autoimmune diseases in this region was 673.6 cases per 100,000 inhabitants [95% confidence interval (CI): 609.8-742.4]. Highest prevalence was identified for Hashimoto's thyroiditis 140.6 cases per 100,000 (95% CI: 112.4-173.9), followed by vitiligo 132.4 cases per 100,000 (95% CI: 105.0-164.8), and rheumatoid arthritis 105.9 cases per 100,000 (95% CI: 81.6-135.3). The sex ratio was higher in females (69%), the most affected age group was over 60 years (30.5%), with greater predominance in the urban area (81.3%). Our data showed the general and relative prevalence of the identified diseases, allowing to know the sociodemographic profile of the identified cases and the epidemiological trend of these morbidities in a low-income Brazilian region.

Effectiveness and cost-effectiveness of a multicomponent intervention to implement a clinical practice guideline for systemic lupus erythematosus: protocol for a cluster-randomized controlled trial

Background

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease with significant potential morbidity and mortality. Substantial gaps have been documented between the development and dissemination of clinical practice guidelines (CPG) and their implementation in practice. The aim of this study is to assess the effectiveness and cost-effectiveness of a multi-component knowledge transfer intervention to implement a CPG for the management of SLE (CPG-SLE).

Methods

The study is an open, multicentre, controlled trial with random allocation by clusters to intervention or control. Clusters are four public university hospitals of the Canary Islands Health Service where rheumatologists are invited to participate. Patients diagnosed with SLE at least one year prior to recruitment are selected. Rheumatologists in intervention group receive a short educational group programme to both update their knowledge about SLE management according to CPG-SLE recommendations and to acquire knowledge and training on use of the patient-centred approach, a decision support tool embedded in the electronic clinical record and a quarterly feedback report containing information on management of SLE patients. Primary endpoint is change in self-perceived disease activity. Secondary endpoints are adherence of professionals to CPG-SLE recommendations, health-related quality of life, patient perception of their participation in decision making, attitudes of professionals towards shared decision making, knowledge of professionals about SLE and use of healthcare resources. Calculated sample size is 412 patients. Data will be collected from questionnaires and clinical records. Length of follow-up will be 18 months. Multilevel mixed models with repeated time measurements will be used to analyze changes in outcomes over time. Cost-effectiveness, from both social and healthcare services perspectives, will be analyzed by measuring effectiveness in terms of quality-adjusted life years gained. Deterministic and probabilistic sensitivity analyses are planned.

Discussion

Impact of CPGs in clinical practice could be improved by applying proven value interventions to implement them. The results of this ongoing trial are expected to generate important scientifically valid and reproducible information not only on clinical effectiveness but also on cost-effectiveness of a multi-component intervention for implementation of a CPG based on communication technologies for chronic patients in the hospital setting.

Trial registration

ClinicalTrial.gov NCT03537638. Registered on 25 May 2018.

Lupus: the new epidemic

Is systemic lupus erythematosus (SLE) is occurring more frequently now than in decades past? Despite improvements in the identification of patients with SLE, the development of new classification criteria, and the recognition of several biomarkers used alone or in combination, the diagnosis of SLE is still a challenge for clinicians, in particular early in the course of the disease, which makes the recognition of secular trends difficult to ascertain. Lacking a uniform definition of preclinical lupus or incomplete lupus, it is difficult to predict accurately which patients would go on to develop SLE. We will briefly review the classification criteria, early or preclinical SLE, the epidemiology of SLE, antinuclear antibodies-negative SLE, and biomarkers of the disease.

SLE mortality remains disproportionately high, despite improvements over the last decade

Despite a marked improvement in 10-year survival for systemic lupus erythematosus (SLE) patients over the past five decades, mortality rates from SLE remain high compared to those in the general population. SLE was also among the leading causes of death in young women in the United States during 2000-2015. However, it is encouraging that SLE mortality rates and the ratios of SLE mortality rates to non-SLE mortality rates have decreased every year since the late 1990s. Despite this improvement, disparities in SLE mortality persist according to sex, race, age, and place of residence. Furthermore, demographic and geographic variables seem to modify the effect of each other in influencing SLE mortality, leading to interactions between sex/race/ethnicity-associated factors and geographic differences. In other words, individuals of the same sex/race/ethnicity had differences in SLE mortality depending on where they lived. These observations highlight SLE as an important public health issue. The recognition of SLE as a leading cause of death in the general population might spur targeted public health programs and research funding to address the high lupus mortality.

The role of ophthalmic imaging in central nervous system degeneration in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune connective tissue disorder that can involve any organ system. Central nervous system involvement can be a severe life threatening complication, ultimately resulting in severe neurodegenerative changes. Magnetic resonance imaging suggests that neurodegeneration, which may have deleterious effects on brain function, may occur early in SLE and experimental models suggest that neuroprotection may be feasible and beneficial. The retina is an extension of the brain. Recent ophthalmic imaging technologies are capable of identifying early changes in retinal and choroidal morphology and circulation that may reflect CNS degeneration. However, their utility in monitoring CNS involvement in SLE has been poorly studied as these have only been performed in small cohorts, in a cross-sectional design, non-quantitatively and without correlation to disease activity. The authors aim to review the current understanding of neurodegeneration associated with SLE, with particular focus on the visual pathway. We describe the neuropathology of the visual system in SLE and the evidence for retinal and choroidal neurodegenerative and microvascular changes using optical coherence tomography technology. We aim to describe the potential role of optical imaging modalities in NPSLE diagnosis and their likely impact on the study of neuronal function.

Cardiorespiratory fitness and age-related arterial stiffness in women with systemic lupus erythematosus

BACKGROUND

The aim of this study was twofold: (i) to examine the association of cardiorespiratory fitness with arterial stiffness in women with systemic lupus erythematosus; (ii) to assess the potential interaction of cardiorespiratory fitness with age on arterial stiffness in this population.

MATERIALS AND METHODS

A total of 49 women with systemic lupus erythematosus (mean age 41.3 [standard deviation 13.8] years) and clinical stability during the previous 6 months were included in the study. Arterial stiffness was assessed through pulse wave velocity (Mobil-O-Graph® 24 hours pulse wave velocity monitor). Cardiorespiratory fitness was estimated with the Siconolfi step test and the 6-minute walk test.

RESULTS

Cardiorespiratory fitness was inversely associated with pulse wave velocity in crude analyses (P < .05), although this relationship was attenuated when age and other cardiovascular risk factors were controlled. There was a cardiorespiratory fitness × age interaction effect on pulse wave velocity, regardless of the test used to estimate cardiorespiratory fitness (P < .001 for the Siconolfi step test; P = .005 for the 6-minute walk test), indicating that higher cardiorespiratory fitness was associated with a lower increase in pulse wave velocity per each year increase in age.

CONCLUSIONS

The results of this study suggest that cardiorespiratory fitness might attenuate the age-related arterial stiffening in women with systemic lupus erythematosus and might thus contribute to the primary prevention of cardiovascular disease in this population. As the cross-sectional design precludes establishing causal relationships, future clinical trials should confirm or contrast these findings.

46-Year Trends in Systemic Lupus Erythematosus Mortality in the United States, 1968 to 2013: A Nationwide Population-Based Study

BACKGROUND

No large population-based studies have been done on systemic lupus erythematosus (SLE) mortality trends in the United States.

OBJECTIVE

To identify secular trends and population characteristics associated with SLE mortality.

DESIGN

Population-based study using a national mortality database and census data.

SETTING

United States.

PARTICIPANTS

All U.S. residents, 1968 through 2013.

MEASUREMENTS

Joinpoint trend analysis of annual age-standardized mortality rates (ASMRs) for SLE and non-SLE causes by sex, race/ethnicity, and geographic region; multiple logistic regression analysis to determine independent associations of demographic variables and period with SLE mortality.

RESULTS

There were 50 249 SLE deaths and 100 851 288 non-SLE deaths from 1968 through 2013. Over this period, the SLE ASMR decreased less than the non-SLE ASMR, with a 34.6% cumulative increase in the ratio of the former to the latter. The non-SLE ASMR decreased every year starting in 1968, whereas the SLE ASMR decreased between 1968 and 1975, increased between 1975 and 1999, and decreased thereafter. Similar patterns were seen in both sexes, among black persons, and in the South. However, statistically significant increases in the SLE ASMR did not occur among white persons over the 46-year period. Females, black persons, and residents of the South had higher SLE ASMRs and larger cumulative increases in the ratio of the SLE to the non-SLE ASMR (31.4%, 62.5%, and 58.6%, respectively) than males, other racial/ethnic groups, and residents of other regions, respectively. Multiple logistic regression showed independent associations of sex, race, and region with SLE mortality risk and revealed significant racial/ethnic differences in associations of SLE mortality with sex and region.

LIMITATIONS

Underreporting of SLE on death certificates may have resulted in underestimates of SLE ASMRs. Accuracy of coding on death certificates is difficult to ascertain.

CONCLUSION

Rates of SLE mortality have decreased since 1968 but remain high relative to non-SLE mortality, and significant sex, racial, and regional disparities persist.

PRIMARY FUNDING SOURCE

None.

The worldwide incidence and prevalence of systemic lupus erythematosus: a systematic review of epidemiological studies

Objectives

The aim was to review the worldwide incidence and prevalence of SLE and variation with age, sex, ethnicity and time.

Methods

A systematic search of MEDLINE and EMBASE search engines was carried out using Medical Subject Headings and keyword search terms for Systemic Lupus Erythematosus combined with incidence, prevalence and epidemiology in August 2013 and updated in September 2016. Author, journal, year of publication, country, region, case-finding method, study period, number of incident or prevalent cases, incidence (per 100 000 person-years) or prevalence (per 100 000 persons) and age, sex or ethnic group-specific incidence or prevalence were collected.

Results

The highest estimates of incidence and prevalence of SLE were in North America [23.2/100 000 person-years (95% CI: 23.4, 24.0) and 241/100 000 people (95% CI: 130, 352), respectively]. The lowest incidences of SLE were reported in Africa and Ukraine (0.3/100 000 person-years), and the lowest prevalence was in Northern Australia (0 cases in a sample of 847 people). Women were more frequently affected than men for every age and ethnic group. Incidence peaked in middle adulthood and occurred later for men. People of Black ethnicity had the highest incidence and prevalence of SLE, whereas those with White ethnicity had the lowest incidence and prevalence. There appeared to be an increasing trend of SLE prevalence with time.

Conclusion

There are worldwide differences in the incidence and prevalence of SLE that vary with sex, age, ethnicity and time. Further study of genetic and environmental risk factors may explain the reasons for these differences. More epidemiological studies in Africa are warranted.

Epidemiology and burden of systemic lupus erythematosus in a Southern European population: data from the community-based lupus registry of Crete, Greece

Objectives

Several population-based studies on systemic lupus erythematosus (SLE) have been reported, yet community-based, individual-case validated, comprehensive reports are missing. We studied the SLE epidemiology and burden on the island of Crete during 1999–2013.

Methods

Multisource case-finding included patients ≥15 years old. Cases were ascertained by the ACR 1997, SLICC 2012 criteria and rheumatologist diagnosis, and validated through synthesis of medical charts, administrative and patient-generated data.

Results

Overall age-adjusted/sex-adjusted incidence was 7.4 (95% CI 6.8 to 7.9) per 100 000 persons/year, with stabilising trends in women but increasing in men, and average (±SD) age of diagnosis at 43 (±15) years. Adjusted and crude prevalence (December 2013) was 123.4 (113.9 to 132.9) and 143 (133 to 154)/105 (165/105 in urban vs 123/105 in rural regions, p<0.001), respectively. Age-adjusted/sex-adjusted nephritis incidence was 0.6 (0.4 to 0.8) with stable trends, whereas that of neuropsychiatric SLE was 0.5 (0.4 to 0.7) per 100 000 persons/year and increasing. Although half of prevalent cases had mild manifestations, 30.5% developed organ damage after 7.2 (±6.6) years of disease duration, with the neuropsychiatric domain most frequently afflicted, and 4.4% of patients with nephritis developed end-stage renal disease. The ACR 1997 and SLICC 2012 classification criteria showed high concordance (87%), yet physician-based diagnosis occurred earlier than criteria-based in about 20% of cases.

Conclusions

By the use of a comprehensive methodology, we describe the full spectrum of SLE from the community to tertiary care, with almost half of the cases having mild disease, yet with significant damage accrual. SLE is not rare, affects predominantly middle-aged women and is increasingly recognised in men. Neuropsychiatric disease is an emerging frontier in lupus prevention and care.

Epidemiology of systemic lupus erythematosus

INTRODUCTION

Systemic lupus erythematosus (SLE) is a disease distributed worldwide, which occurs in both genders, and across racial/ethnic and age groups; however, higher rates are observed in adults, in women and in non-Caucasians. Genetic, environmental, sociodemographic and methodological issues are responsible not only for these differences but for the variable course and outcome of the disease. Non-Caucasians have a more severe disease with a higher risk for early mortality and damage accrual. Males also have a more severe disease; however, a negative impact of male gender on lupus outcomes has not been firmly established. Childhood-onset is associated with a more severe disease; moreover, it is also associated with higher damage and diminished survival; finally, late-onset lupus is mild but it is associated with higher damage accrual and a diminished survival. Areas covered: In this review, we discuss the incidence and prevalence of SLE, the impact of age, gender and race/ethnicity in SLE and in the survival of those affected. Expert commentary: Age, gender and race/ethnicity impact disease expression in SLE patients; despite improvements in survival, mortality in SLE remains almost three times higher than in the general population.

Flares in systemic lupus erythematosus: diagnosis, risk factors and preventive strategies

Despite advances in the treatment, patients with systemic lupus erythematosus (SLE) often experience disease exacerbations (flares) of varying severity. Their diagnosis is primarily made on clinical grounds after exclusion of other diseases or disturbances, primarily infections, and can be assisted by the use of validated clinical indices. Serological tests such as serum complement fractions and anti-dsDNA autoantibodies, are helpful in monitoring SLE activity, but they lack high diagnostic accuracy. Flares are more frequent in patients with persistent immunological and clinical activity, and have been described as significant risk factor for development of irreversible end-organ damage. Accordingly, prevention of flares has been recognized as a distinct therapeutic target in SLE and involves adequate control of disease activity, use of hydroxychloroquine, maintaining immunosuppressive or biologic therapy for several years, and avoiding non-compliance issues. The future holds promise for the discovery of biomarkers that will accurately predict or diagnose SLE flares, thus allowing for the implementation of patient-tailored preventive strategies.

Lupus nephritis in the Western Cape, a high prevalence area: an experience over three decades

Background

Systemic lupus erythematosus is a multisystem disease with serious complications, including lupus nephritis. Systemic lupus erythematosus is prevalent in the Western Cape, predominantly affecting women in the prime of their lives. Renal biopsy is an important tool for the management of the lupus patient with kidney disease, guiding treatment and assessing prognosis.

Aims

The aim of this study was to ascertain if there has been a change in the spectrum of renal pathology, patient characteristics and long-term outcomes in patients with lupus nephritis in our region over three decades.

Methods

We reviewed 315 records of systemic lupus erythematosus patients with suspected renal disease who underwent renal biopsy in the Renal Unit at Tygerberg Hospital over three decades between January 1983 and December 2012.

Results

Lupus nephritis consistently affected young women. Class IV lupus nephritis remained the most common pattern throughout the three decades. The overall five-year survival for this cohort was 67% (95% confidence interval (CI), 60–72%).

Conclusion

Class IV lupus nephritis remained the most frequent class in our cohort of patients with the poorest survival rates compared to other classes. The prognosis of lupus nephritis in our region is considerably worse than that reported elsewhere in the world.

Incidence and prevalence of systemic lupus erythematosus among the native Arab population in UAE

Background and objectives There is a paucity of information about the epidemiology of systemic lupus erythematosus (SLE) amongst Arabs. The objective of this study was to determine the incidence and prevalence of SLE among the native Arab population of United Arab Emirates (UAE). Methods Patients with SLE were identified from three sources: medical records of two local tertiary hospitals (four years; 2009 to 2012), laboratory requests for serum double stranded deoxyribonucleic acid and serum anti-nuclear antibody and confirmed histopathologic diagnosis of SLE (skin and kidney biopsy specimens). All the patients identified with SLE met the criteria of the American College of Rheumatology. Incidence and prevalence were calculated using the state records of the UAE native population as the denominator. The age-adjusted incidence was calculated by direct standardization using the World Health Organization world standard population 2000-2025. Results Sixteen new cases (13 females and three males) fulfilled the American College of Rheumatology SLE criteria. The mean (±SD) age at time of diagnosis was 28.6 ± 12.4 years. The crude incidence ratio (per 100,000 population) was 3.5, 1.1, 2.1 and 2.1 in years 2009, 2010, 2011, 2012, respectively. The age-standardized incidence per 100,000 population for the four years was 8.6 (95% confidence interval 4.2-15.9). The age-standardized prevalence of SLE among the native population according to the 2012 population consensus was 103/100,000 population (95% confidence interval 84.5-124.4). Conclusion The age-adjusted incidence and prevalence among UAE Arabs is higher than has been reported among most other Caucasian populations. Furthermore, the prevalence of SLE in UAE seems much higher than other similar Arab countries in the Gulf region.

The global burden of SLE: prevalence, health disparities and socioeconomic impact

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that can potentially lead to serious organ complications and even death. Its global burden - in terms of incidence and prevalence, differential impact on populations, economic costs and capacity to compromise health-related quality of life - remains incompletely understood. The reported worldwide incidence and prevalence of SLE vary considerably; this variation is probably attributable to a variety of factors, including ethnic and geographic differences in the populations being studied, the definition of SLE applied, and the methods of case identification. Despite the heterogeneous nature of the disease, distinct patterns of disease presentation, severity and course can often be related to differences in ethnicity, income level, education, health insurance status, level of social support and medication compliance, as well as environmental and occupational factors. Given the potential for the disease to cause such severe and widespread organ damage, not only are the attendant direct costs high, but these costs are sometimes exceeded by indirect costs owing to loss of economic productivity. As an intangible cost, patients with SLE are, not surprisingly, likely to endure considerably reduced health-related quality of life.

Impact of sex disparities on the clinical manifestations in patients with systemic lupus erythematosus: A systematic review and meta-analysis

BACKGROUND

Systemic lupus erythematosus (SLE) is a chronic autoimmune multiorgan disorder of unknown etiology. It affects both men and women, but with different disease manifestations of differing disease severity and in varying proportion, with a female predominance of approximately 90%. There have been numerous studies addressing this issue, especially its implications in relation to optimal sex-tailored treatment and improvement of survival rate; however, further research is warranted. A meta-analysis of studies was performed to compare the impact of sex on the clinical outcomes of SLE in different populations.

METHODS

A literature search of the MEDLINE/PubMed and EMBASE databases (until January 2016) was conducted to identify relevant articles. Clinical manifestations reported in these patients were considered as endpoints for this meta-analysis. Two independent reviewers determined eligibility criteria. A fixed-effect model has been used where a small heterogeneity was observed, or else, a random-effect model has been used among the studies. Odd ratio (OR) with 95% confidence interval (CI) was used to express the pooled effect on dichotomous variables, and the pooled analyses were performed with RevMan 5.3.

RESULTS

Sixteen studies consisting of a total of 11,934 SLE patients (10,331 females and 1603 males) have been included in this meta-analysis. The average female-to-male ratio of all the included studies is around 9.3:1. Several statistically significant differences were found: alopecia, photosensitivity, and oral ulcers were significantly higher in female patients (OR 0.36, 95% CI 0.29-0.46, P < 0.00001; OR 0.72, 95% CI 0.63-0.83, P < 0.00001; and OR 0.70, 95% CI 0.60-0.82, P < 0.00001, respectively). Malar rash was significantly higher in female patients (OR 0.68, 95% CI 0.53-0.88, P = 0.003), and arthritis was significantly lower in male patients (OR 0.72, 95% CI 1.25-1.84, P < 0.00001). However, serositis and pleurisies were significantly higher in female patients (OR 1.52, 95% CI 1.25-1.84 P < 0.0001; and OR 1.26, 95% CI 1.07-1.48, P = 0.006, respectively). Renal involvement was higher in male patients (OR 1.51, 95% CI 1.31-1.75, P < 0.00001).

CONCLUSION

The results of this meta-analysis suggest that alopecia, photosensitivity, oral ulcers, arthritis, malar rash, lupus anticoagulant level, and low level of C3 were significantly higher in female lupus patients, whereas renal involvement, serositis and pleurisies, thrombocytopenia, and anti-double stranded deoxyribonucleic acid level were predominant in male patients.

Variations in the epidemiology of systemic lupus erythematosus in southern Sweden

Objective

The epidemiology of systemic lupus erythematosus (SLE) within a defined region in southern Sweden was studied during the time period 1981–2006. Furthermore, whether the phenotypic expression of SLE changed during the study period was investigated.

Methods

Patients with suspected SLE were retrieved from diagnosis registries, hospital records and central laboratory databases. All new cases of SLE in this region were identified using validated retrieval methods and observed prospectively in a structured follow-up program. SLE disease manifestations, including classification criteria, were followed over time.

Results

A total of 174 cases were diagnosed with SLE during 1981–2006. In the first period of the study, from 1981 to 1993, the incidence of SLE was 5.0/100,000 inhabitants and in the second period of the study, 1994–2006, the annual incidence decreased to 2.8/100,000. During the first period the highest incidence was among females between the ages of 45 and 54 years; 15.1/100,000 inhabitants, which was reduced in the second period to 3.8/100,000. During the second period the highest age and sex specific incidence was among women between 25 and 34 years (6.6/100,000 inhabitants). The point prevalence of SLE on 31 December 1993 was 55/100,000 inhabitants compared with 31 December 2006, when it was 65/100,000 inhabitants. The phenotype of the disease did not vary significantly during the study period.

Conclusion

The incidence rate of SLE in younger females remained stable from 1981 to 2006. However, in middle-aged women the incidence was substantially reduced in the latter half of the study period.

Epidemiology of systemic lupus erythematosus and cutaneous lupus erythematosus in a predominantly white population in the United States

OBJECTIVE

Epidemiologic studies comparing the incidence and prevalence of systemic lupus erythematosus (SLE) and isolated cutaneous lupus erythematosus (CLE) are few. Olmsted County, Minnesota provides a unique setting for such a study owing to resources of the Rochester Epidemiology Project. We sought to describe and compare the incidence and prevalence of SLE and CLE from 1993-2005.

METHODS

SLE cases were identified from review of medical records and fulfilled the 1982 American College of Rheumatology classification criteria. CLE cases included patients with classic discoid lupus erythematosus, subacute CLE, lupus panniculitis, and bullous lupus erythematosus. Age- and sex-adjusted incidence and prevalence were standardized to the 2000 US white population.

RESULTS

The age- and sex-adjusted incidence of SLE (2.9 per 100,000; 95% confidence interval [95% CI] 2.0-3.7) was similar to that of CLE (4.2 per 100,000; 95% CI 3.1-5.2, P = 0.10). However, the incidence of CLE was 3 times higher than SLE in men (2.4 versus 0.8 per 100,000; P = 0.009). The age- and sex-adjusted prevalence of CLE on January 1, 2006 was higher than that of SLE (70.4 versus 30.5 per 100,000; P < 0.001). The prevalences of CLE and SLE in women were similar, but the prevalence of CLE was higher in men than in women (56.9 versus 1.6 per 100,000; P < 0.001). The incidence of CLE rose steadily with age and peaked at 60-69 years.

CONCLUSION

The incidences of CLE and SLE are similar, but CLE is more common than SLE in men and in older adults. These findings may reflect differences in genetic or environmental etiology of CLE.

Standard medical care of patients with systemic lupus erythematosus (SLE) in large specialised centres: data from the Russian Federation, Ukraine and Republic of Kazakhstan (ESSENCE)

OBJECTIVES

To describe disease characteristics and treatment regimens for adult patients with systemic lupus erythematosus (SLE) with autoantibody positive disease in three countries (the Russian Federation, Ukraine and Republic of Kazakhstan).

METHODS

The Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q wave Coronary Events (ESSENCE) study was a 1-year, retrospective, multicentre, observational study. Data included patients' characteristics, disease activity and severity, and healthcare resource use in 2010.

RESULTS

Twelve centres enrolled 436 eligible patients: 232 in Russia, 110 in Kazakhstan and 94 in Ukraine. Mean age ranged from 36 to 42 years and median SLE duration from 3 to 6.8 years. According to study definitions, 69.2% of patients in Russia, 72.7% in Kazakhstan and 55.4% in Ukraine had severe disease at diagnosis. SLE activity (Nasonova classification, 1972) decreased from diagnosis to the last visit in 2010 in all countries. At the last visit, mean (SD) Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index score was 13.8 (10.5) in Russia, 19.4 (16.9) in Kazakhstan and 7.2 (6.8) in Ukraine, and Systemic Lupus International Collaborative Clinics/American College of Rheumatology damage index was 2.0 (2.2), 3.3 (3.2) and 2.2 (2.0), respectively. Treatment regimens included predominantly glucocorticoids (96.7-99.1%), immunosuppressants or cytotoxic drugs, for example, azathioprine and cyclophosphamide (20.7-53.2%), and antimalarial drugs (18.3-40.8%).

CONCLUSIONS

The study provides reliable insight into the SLE clinical profiles in the referenced countries. Patients were 4-10 years younger in the study and had 3-7 years shorter SLE duration than in Western European countries and both SLE activity and severity were higher with higher rate of hospitalisations, but decreased during treatment. Local and international scales demonstrated correlation in SLE activity and organ damage evaluation. There were differences in clinical characteristics and healthcare features across the countries.

Mortality and causes of death among incident cases of systemic lupus erythematosus in Finland 2000-2008

The objectives of the study were to investigate mortality and causes of death in patients with recent-onset systemic lupus erythematosus (SLE) in Finland. Data for patients with SLE for the study were collected (2000-2007) from the nationwide register on decisions of special reimbursements for drugs, maintained by the Social Insurance Institution (SII) in Finland. Data on deaths of the patients were obtained from the official death certificate statistics of Statistics Finland until the end of 2008. Of the 566 incident SLE patients, median follow-up time was 5.4 (IQR 3.3, 7.1) years, and 30 patients (23 females, seven males) died in the years 2000 through 2008. Mean age at death was 67.8 ± 17.2 years for females and 62.3 ± 15.2 years for males. The 5-year survival rates were 94.8% (95%CI 92.0-96.6%) and 88.2% (95%CI 76.5-94.3%), respectively. The age- and sex-adjusted standardized mortality ratio was 1.48 (95%CI 1.01-2.12). Primary causes of death were cardiovascular diseases, malignancy and SLE itself. In conclusion, survival of the patients with SLE was inferior to that of the general population. Cardiovascular diseases were responsible for 37% of deaths.

Incidence and prevalence of lupus in Buenos Aires, Argentina: a 11-year health management organisation-based study

Objectives

Studies regarding the epidemiology of systemic lupus erythematosus (SLE) are lacking in Argentina. Our purpose was to estimate the incidence and prevalence of SLE in a university hospital-based health management organisation in Buenos Aires (HIMCP).

Methods

For incidence calculation, the population at risk included all adult members of the HIMCP, with continuous affiliation for at least 1 year from January 1998 to January 2009. Each person was followed until he/she voluntarily left the HIMCP, death or finalisation of the study. Multiple methods for case finding were used to ensure complete ascertainment: (a) patients with problem SLE, undifferentiated autoimmune disease or mixed connective tissue disease in the Computer-based Patient Record System, (b) patients with positive antinuclear antibody test, anti-Sm antibodies and/or anti-dsDNA antibodies in the laboratory database and (c) patients who consumed hydroxichloroquine, chloroquine, azathioprine, cyclophosphamide, mycophenolate, cyclosporine or rituximab, from the administrative HIMCP drugs database. Medical records of all patients found were reviewed, and only patients fulfilling ACR criteria for SLE were included. Global and gender incidence rate (IR) was calculated. Prevalence was estimated on 1 January 2009, and the denominator population was the number of active members >18 years at that date (n=127 959).

Results

In the study period, 68 patients developed SLE. The observed IR (per 100 000 person-years, (CI 95%)) was 6.3 (4.9 to 7.7) for total population; 8.9 (CI 6.6 to 11.2) for women and 2.6 (1.2 to 3.9) for men. On 1 January 2009, 75 prevalent cases were identified. Prevalence rates (cases per 100 000 habitants, (CI 95%)) were 58.6 (46.1 to 73.5) for total population; 83.2 (63.9 to 106.4) for women and 23 (CI 11.9 to 40.1) for men.

Conclusions

SLE incidence and prevalence rates in Argentina are in agreement with those of other studies from different parts of the world.

Trends in systemic lupus erythematosus mortality in Spain from 1981 to 2010

Background

Incidence and mortality of systemic lupus erythematosus (SLE) seem to be increasing in the last few decades, in contrast to the survival rate that has improved over time. The objective of this study was to examine the trends in the SLE mortality in Spain over a 30-year period (1981–2010).

Methods

Data on SLE deaths were drawn from the National Statistics Institute of Spain. Crude and overall age-standardized SLE mortality rates were calculated and joinpoint regression models were used to describe trend changes. Mean age of deaths by SLE each year was also assessed.

Results

The overall age-standardized SLE mortality rate was 1.82 per million in 1981 and 2.24 in 2010. It was higher in women, 1.39 vs 0.43 in 1981 and 1.96 vs 0.28 in 2010. There was a statistically significant change in 1999. The overall age-standardized mortality rate increased from 1981 to 1999 and stabilized from 2000 to 2010. Only male rates decreased from 2000 to 2010. The mean age at death increased with time, from 42 years in 1981 to 61 years in 2010.

Conclusions

In conclusion, a slight decrease in SLE mortality has been observed in Spain over the last decade and future studies would be needed to explain the factors contributing to the improvement in the mortality rates.

The prevalence and incidence of Systemic Lupus Erythematosus (SLE) in selected cities from three Commonwealth of Independent States countries (the Russian Federation, Ukraine and Kazakhstan)

We assessed the prevalence and incidence of Systemic Lupus Erythematosus (SLE) in 2010 in adults from four cities in Russia, Kazakhstan and Ukraine. Individuals with SLE were identified retrospectively from the medical records of specialized centers. Prevalent SLE patients were nondeceased city residents, diagnosed prior to December 31, 2010; incident patients were residents newly diagnosed between January 1 and December 31, 2010. Population size was obtained from official census data.

The observed prevalence rates (per 100,000, 95% CI) were 9.0 (7.1–11.2) in Kursk and Yaroslavl, Russian Federation; 20.6 (15.4–27.0) in Semey, Kazakhstan; and 14.9 (10.9–19.9) in Vinnitsa, Ukraine. The cumulative incidence rates (per 100,000, 95% CI) were 1.4 (0.7–2.4); 1.6 (0.4–4.1) and 0.3 (0.0–1.8), correspondingly. All rates were higher among females compared to males, and incidence peaked in the population aged 25–44.

These rates appear slightly lower than those reported from Western Europe and the USA. This could be because of study design (case-ascertainment), local health care practices or true differences in disease risk. Case age and sex distribution was similar to the known epidemiology of SLE. The rates were highest in Kazakhstan, likely because of a predominantly ethnic Asian population.

The clinical manifestations and survival of systemic lupus erythematosus patients in Turkey: report from two centers

Background

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with a variety of clinical features. Survival has become longer as a result of better treatment modalities and better supportive care. There is no information on survival of SLE patients in Turkey. We evaluated clinical features and survival in SLE patients in two rheumatology departments.

Methods

All SLE patients being followed up by the Department of Rheumatology, Trakya University Medical Faculty, and the Department of Rheumatology, Marmara University Medical Faculty, over the 1996–2012 period were included. Patients were diagnosed with SLE if they fulfilled at least four American College of Rheumatology (ACR) criteria. The clinical and laboratory features, mortality data were obtained from medical charts.

Results

We had 428 SLE patients, and women (399 patients, 93.2%) far outnumbered men (29 patients, 6.8%). The mean age at the time of SLE diagnosis was 40.3 ± 12.4 years. The most frequent clinical manifestations were arthritis (76.9%) and photosensitivity (70.1%). Renal disease was present in 32.9% of patients and neurological involvement in 12.9% of patients. After a median follow-up of 60 months, 19 patients died. The most frequent causes of death were ischemic heart disease, chronic renal failure and sepsis. The rate of five-year survival was 96%; 10-year survival, 92%; and 15-year survival, 88.8%. Multivariate Cox analysis showed that serositis at the time of diagnosis, SLE disease activity index (SLEDAI) score 6, and autoimmune hemolytic anemia were independent prognostic factors.

Conclusions

Data from two centers in Northwestern Turkey show that the mortality rate for SLE is similar to the rate in Western countries.

Survival in systemic lupus erythematosus, 1995–2010. A prospective study in a Danish community

Objective

The objective of this paper is to investigate survival and causes of death in a Danish lupus population.

Methods

Two hundred and fifteen SLE patients (94% Caucasians) were followed prospectively for up to 16 years. Thirty-eight patients died. Survival rate and causes of death were analysed.

Results

Overall standardized mortality ratio (SMR) was 2.2. Peak values were recorded for patients aged 20–29 (SMR 21.1). Cumulated survival rates at one, five, 10 and 15 years were 98.6%, 93.6%, 86.5% and 73.0%, respectively. The most common causes of death were cardiovascular events (32%), respiratory system disease (16%) and malignancies (13%). Deaths due to infections and active SLE were rare and predominated within the first seven years after diagnosis and before age 40, while cardiovascular deaths prevailed after 20 years’ follow-up.

Conclusion

This study shows that despite progress in lupus management, including direct access to specialized hospital care and increased use of hydroxychloroquine, mortality in lupus patients is still increased. Main causes of death were active disease and infections among the young and newly diagnosed, while cardiovascular deaths prevailed in longstanding disease.