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Acosta-Colman I, Morel Z, Ayala Lugo A, Jolly V, De Guillén I, Langjahr P, Vazquez M, Martínez de Filártiga MT, Acosta ME. Clinical features and genetic biomarkers associated with different phenotypes of systemic lupus erythematosus in Paraguayan patients. Reumatismo 2023; 75. [PMID: 37462131 DOI: 10.4081/reumatismo.2023.1541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 06/02/2023] [Indexed: 07/20/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a complex autoimmune disease characterized by a heterogeneous clinical picture that makes the diagnosis and follow-up of these patients difficult. This study aimed to identify correlations between clinical, immunological, and genetic biomarkers and clinical manifestations in SLE. A retrospective study of data from medical records and immunological and genetic studies of SLE patients in Paraguay was carried out. A descriptive analysis was performed based on the type of variable. Human leukocyte antigen (HLA) allele frequencies (DPA1, DPB1, DQA1, DQB1, and DRB1) were calculated, and univariate logistic regression analyses were performed between each of the explanatory variables and the presence or absence of each phenotype. Odds ratios, 95% confidence intervals, and p values were recorded. Associations with p<0.05 were considered statistically significant. 104 SLE patients were included: 86% were female, with a mean age of 32.80±10.36 years. An association was identified between anti-double stranded DNA (anti-dsDNA) and the presence of the renal phenotype and between anti-dsDNA and the absence of the joint and hematological phenotypes. Immunoglobulin M isotype rheumatoid factor was associated with the absence of a renal phenotype. HLA-DQB1*02:02 and HLA-DRB1*07:01 were associated with the cutaneous phenotype. An association was identified between age at disease onset over 30 years and the presence of the joint phenotype. No other associations were identified. Potential clinical, immunological, and genetic biomarkers of phenotypes have been identified in SLE Paraguayan patients.
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Affiliation(s)
- I Acosta-Colman
- Department of Rheumatology, Faculty of Medical Sciences, National University of Asunción, San Lorenzo.
| | - Z Morel
- Department of Rheumatology, Faculty of Medical Sciences, National University of Asunción, San Lorenzo.
| | - A Ayala Lugo
- Molecular Genetics Laboratory, Health Sciences Research Institute, National University of Asunción, San Lorenzo.
| | - V Jolly
- Molecular Genetics Laboratory, Health Sciences Research Institute, National University of Asunción, San Lorenzo.
| | - I De Guillén
- Production Laboratory, Heath Sciences Research Institute, National University of Asunción, San Lorenzo.
| | - P Langjahr
- Production Laboratory, Heath Sciences Research Institute, National University of Asunción, San Lorenzo.
| | - M Vazquez
- Department of Rheumatology, Faculty of Medical Sciences, National University of Asunción, San Lorenzo.
| | | | - M E Acosta
- Production Laboratory, Heath Sciences Research Institute, National University of Asunción, San Lorenzo.
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Grau García E, Fragío Gil JJ, Ivorra Cortes J, Ortiz Sanjuan FM, Chalmeta Verdejo I, Román Ivorra JA. The impact of disease activity on health-related quality of life in patients with systemic lupus erythematosus. Med Clin (Barc) 2023; 160:428-433. [PMID: 36697287 DOI: 10.1016/j.medcli.2022.11.019] [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: 01/11/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVE The aim of this research was to investigate the relationship between disease activity and health-related quality of life (HRQoL) in patients with systemic lupus erythematosus (SLE) considering the increased interest in the management of this disease. MATERIALS AND METHODS HRQoL was measured at clinic visits during a 12-month follow-up period using questionnaires on fatigue (FACIT-FATIGUE); quality of life, EuroQol 5-dimension (EQ-5D-5L) health questionnaire with 5 levels; disability, Health Assessment Questionnaire (HAQ), and a Global Health Status (GHS) scale. Disease activity, organ damage and other clinical factors that could affect HRQoL were recorded. The association between disease activity and HRQoL was assessed using Bayesian linear regression models with monotonic effects. RESULTS Data from 70 patients at the baseline visit and 42 patients with 1 year of follow-up were analyzed. At baseline, 28.57% of patients presented Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)>6. In the 70 baseline patients, disease activity was associated with HRQoL in all four parameters. In the 42 patients with 12 months of follow-up, the positive association of disease activity with GHS, FACIT-FATIGUE and EQ-5D-5L and the negative association with HAQ was maintained. Patients who are smokers and those receiving immunosuppressant therapy presented low GHS and FACIT-FATIGUE scores. Moreover, older age at inclusion was significantly associated to low GHS, while low leucocyte and 25-OH-vitamin D levels were associated to fatigue perception in SLE patients. CONCLUSION Our results showed a statistically significant association between disease activity and HRQoL parameters.
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Affiliation(s)
- Elena Grau García
- Grupo de Investigación de Reumatología, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
| | - Jorge Juan Fragío Gil
- Grupo de Investigación de Reumatología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Jose Ivorra Cortes
- Grupo de Investigación de Reumatología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | - Jose Andrés Román Ivorra
- Grupo de Investigación de Reumatología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Quintana R, Pons-Estel GJ, Roberts K, Sacnún M, Serrano R, Nieto R, Conti S, Gervasoni V, Catoggio LJ, Soriano ER, Scolnik M, García MA, Alvarellos A, Saurit V, Berbotto GA, Sato EI, Costallat LTL, Neto EFB, Bonfa E, Xavier RM, de Oliveira e Silva Montandon AC, Molina-Restrepo JF, Iglesias-Gamarra A, Guibert-Toledano M, Reyes-Llerena GA, Massardo L, Neira OJ, Cardiel MH, Barile-Fabris LA, Amigo MC, Silveira LH, Torre IGDL, Acevedo-Vásquez EM, Ugarte-Gil MF, Alfaro-Lozano JL, Segami MI, Chacón-Díaz R, Esteva-Spinetti MH, Gomez-Puerta JA, Alarcón GS, Pons-Estel BA. Clinical features, damage accrual, and survival in patients with familial systemic lupus erythematosus: data from a multi-ethnic, multinational Latin American lupus cohort. Lupus 2020; 29:1140-1145. [DOI: 10.1177/0961203320935184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives This study aimed to compare the clinical features, damage accrual, and survival of patients with familial and sporadic systemic lupus erythematosus (SLE). Methods A multi-ethnic, multinational Latin American SLE cohort was studied. Familial lupus was defined as patients with a first-degree SLE relative; these relatives were interviewed in person or by telephone. Clinical variables, disease activity, damage, and mortality were compared. Odds ratios (OR) and 95% confidence intervals (CI) were estimated. Hazard ratios (HR) were calculated using Cox proportional hazard adjusted for potential confounders for time to damage and mortality. Results A total of 66 (5.6%) patients had familial lupus, and 1110 (94.4%) had sporadic lupus. Both groups were predominantly female, of comparable age, and of similar ethnic distribution. Discoid lupus (OR = 1.97; 95% CI 1.08–3.60) and neurologic disorder (OR = 1.65; 95% CI 1.00–2.73) were significantly associated with familial SLE; pericarditis was negatively associated (OR = 0.35; 95% CI 0.14–0.87). The SLE Disease Activity Index and Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) were similar in both groups, although the neuropsychiatric (45.4% vs. 33.5%; p = 0.04) and musculoskeletal (6.1% vs. 1.9%; p = 0.02) domains of the SDI were more frequent in familial lupus. They were not retained in the Cox models (by domains). Familial lupus was not significantly associated with damage accrual (HR = 0.69; 95% CI 0.30–1.55) or mortality (HR = 1.23; 95% CI 0.26–4.81). Conclusion Familial SLE is not characterized by a more severe form of disease than sporadic lupus. We also observed that familial SLE has a higher frequency of discoid lupus and neurologic manifestations and a lower frequency of pericarditis.
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Affiliation(s)
- Rosana Quintana
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
- Hospital Provincial de Rosario, Rosario, Argentina
| | - Guillermo J Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
- Hospital Provincial de Rosario, Rosario, Argentina
| | | | | | - Rosa Serrano
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Romina Nieto
- Hospital Provincial de Rosario, Rosario, Argentina
| | | | | | | | | | - Marina Scolnik
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mercedes A García
- Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | | | | | | | - Emilia I Sato
- Universidade Federal da Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | | | | | | | - Ricardo M Xavier
- Hospital da Clinicas da Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | | | | | | | | | | | - Loreto Massardo
- Facultad de Medicina, Universidad San Sebastián, Santiago, Chile
| | - Oscar J Neira
- Hospital del Salvador, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Mario H Cardiel
- Centro de Investigación Clínica de Morelia SC, Morelia, Mexico
| | | | | | - Luis H Silveira
- Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, Mexico
| | | | | | - Manuel F Ugarte-Gil
- Servicio de Reumatología, Hospital General Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
- Universidad Científica del Sur, Lima, Peru
| | | | | | - Rosa Chacón-Díaz
- Centro Nacional de Enfermedades Reumáticas, Hospital Universitario de Caracas, Caracas, Venezuela
| | | | | | - Graciela S Alarcón
- The University of Alabama at Birmingham, Birmingham, USA
- Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Bernardo A Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
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Study of familial aggregation of autoimmune rheumatic diseases in Asian Indian patients with systemic lupus erythematosus. Rheumatol Int 2019; 39:2053-2060. [PMID: 31263994 DOI: 10.1007/s00296-019-04355-z] [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: 05/08/2019] [Accepted: 06/20/2019] [Indexed: 10/26/2022]
Abstract
Systemic lupus erythematosus (SLE) and other autoimmune rheumatic diseases (AIRD) tend to co-aggregate in families, making positive familial history a risk factor. We aimed to estimate familial aggregation of AIRD in SLE patients and to compare between ones having a positive and negative family history of autoimmunity in our cohort. We included families of 157 consecutive SLE patients in a hospital-based, cross-sectional design for a three-generation pedigree study. Clinical and laboratory parameters of these patients were recorded. AIRD was seen in families of 39 SLE patients amounting to a familial prevalence of 24.8% [95% confidence interval (CI) 18.1, 31.6] with a relative risk (λ) of 4.3 for first-degree relatives (FDRs) and 1.1 for second-degree relatives (SDRs). SLE was the commonest AIRD seen in families of 19 patients with a familial prevalence of 12.1% (95% CI 7.0, 17.2) and λ of 78.2 for FDRs and 18.1 for SDRs. AIRD as a whole and SLE alone were seen more commonly with parental consanguinity (p < 0.05). Familial aggregation in SLE patients also showed a relatively higher percentage of affected males and lesser presentation with constitutional features (p < 0.05) than sporadic SLE patients. Rheumatoid arthritis (RA) was the second most common AIRD seen in 16/39 (41%) families with a RR of 3.1 in FDRs of SLE patients. In conclusion, Asian Indian SLE patients seem to have a high familial aggregation of AIRD, which is more pronounced in the background of parental consanguinity. SLE is the commonest AIRD seen amongst FDRs and SDRs of SLE patients, followed by RA, with FDRs being at highest risk.
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Hartman EAR, van Royen-Kerkhof A, Jacobs JWG, Welsing PMJ, Fritsch-Stork RDE. Performance of the 2012 Systemic Lupus International Collaborating Clinics classification criteria versus the 1997 American College of Rheumatology classification criteria in adult and juvenile systemic lupus erythematosus. A systematic review and meta-analysis. Autoimmun Rev 2018; 17:316-322. [PMID: 29366725 DOI: 10.1016/j.autrev.2018.01.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 11/20/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the performance in classifying systemic lupus erythematosus by the 2012 Systemic Lupus International Collaborating Clinics criteria (SLICC'12), versus the revised American College of Rheumatology criteria from 1997 (ACR'97) in adult and juvenile SLE patients. METHODS A systematic literature search was conducted in PubMed and Embase for studies comparing SLICC'12 and ACR'97 with clinical diagnosis. A meta-analysis was performed to estimate the sensitivity and specificity of SLICC'12 and ACR'97. To assess classification earlier in the disease by either set, sensitivity and specificity were compared for patients with disease duration <5years. Sensitivity and specificity of individual criteria items were also assessed. RESULTS In adult SLE (nine studies: 5236 patients, 1313 controls), SLICC'12 has higher sensitivity (94.6% vs. 89.6%) and similar specificity (95.5% vs. 98.1%) compared to ACR'97. For juvenile SLE (four studies: 568 patients, 339 controls), SLICC'12 demonstrates higher sensitivity (99.9% vs. 84.3%) than ACR'97, but much lower specificity (82.0% vs. 94.1%). SLICC'12 classifies juvenile SLE patients earlier in disease course. Individual items contributing to diagnostic accuracy are low complement, anti-ds DNA and acute cutaneous lupus in SLICC'12, and the immunologic and hematologic disorder in ACR'97. CONCLUSION Based on sensitivity and specificity SLICC'12 is best for adult SLE. Following the view that higher specificity, i.e. avoidance of false positives, is preferable, ACR'97 is best for juvenile SLE even if associated with lower sensitivity. Our results on the contribution of the individual items of SLICC'12 and ACR´97 may be of value in future efforts to update classification criteria.
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Affiliation(s)
- Esther A R Hartman
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annet van Royen-Kerkhof
- Department of Pediatric Immunology & Rheumatology, Wilhelmina Children's Hospital University Medical Center, Utrecht, The Netherlands
| | - Johannes W G Jacobs
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paco M J Welsing
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - Ruth D E Fritsch-Stork
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands; 1st Medical Department & Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, Hanusch Hospital, Vienna, Austria; Sigmund Freud University, Vienna, Austria.
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Pons-Estel GJ, Wojdyla D, McGwin G, Magder LS, Petri MA, Pons-Estel BA, Alarcón GS. The American College of Rheumatology and the Systemic Lupus International Collaborating Clinics Classification criteria for systemic lupus erythematosus in two multiethnic cohorts: a commentary. Lupus 2014; 23:3-9. [DOI: 10.1177/0961203313512883] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
The authors offer some comments on the advantages and possible drawbacks of using the SLICC criteria in longitudinal observational studies and clinical trials after applying and comparing them to the ACR criteria in two multinational, multiethnic lupus cohorts.
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Affiliation(s)
- GJ Pons-Estel
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Spain
- Departments of Medicine, (Division of Clinical Immunology and Rheumatology) and Epidemiology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, USA
| | - D Wojdyla
- Escuela de Estadística, Universidad Nacional de Rosario, Argentina
| | - G McGwin
- Departments of Medicine, (Division of Clinical Immunology and Rheumatology) and Epidemiology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, USA
| | - LS Magder
- University of Maryland Dental School, USA
| | - MA Petri
- Johns Hopkins University School of Medicine, USA
| | | | - GS Alarcón
- Departments of Medicine, (Division of Clinical Immunology and Rheumatology) and Epidemiology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, USA
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Li M, Zhang W, Leng X, Li Z, Ye Z, Li C, Li X, Zhu P, Wang Z, Zheng Y, Li X, Zhang M, Zhang F, Zhao Y, Zeng X. Chinese SLE Treatment and Research group (CSTAR) registry: I. Major clinical characteristics of Chinese patients with systemic lupus erythematosus. Lupus 2013; 22:1192-9. [PMID: 23963101 DOI: 10.1177/0961203313499086] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Chinese systemic lupus erythematosus (SLE) treatment and research group (CSTAR) provides major clinical characteristics of SLE in China and establishes a platform to provide resources for future basic and clinical studies. CSTAR originated as a multicentre, consecutive, and prospective design. The data were collected online from 104 rheumatology centers, which covered 30 provinces in China. The registered patients were required to meet four or more of the American College of Rheumatology (ACR) criteria for the classification of SLE. All CSTAR centers use the same protocol-directed methods to provide uniform evaluations, which included demographic data, clinical features, laboratory examinations, and disease activity evaluations. The patient samples, including DNA samples and sera, were also collected for further quality controls and additional studies. Preliminary analysis from 2104 baseline evaluations was available for this analysis. Of 1914 female and 190 male patients (F:M=10.1), the mean age at onset was 29.2 y with confirmed diagnosis one year later at the age of 30.3 y. Eighty four (4.2%) of 2002 patients had a family history of rheumatic diseases, including 34 (1.7%) cases with SLE. In addition, one hundred and seven (5.2%) abnormal pregnancies were recorded among 2026 experiences. The characteristics of the CSTAR cohort were compared to similarly sized cohorts from other studies. We found that 56.1% of patients presented with concurrent hematological disorders compared to only 18.2% of European patients. Moreover, 47.4% of patients presented with nephropathy compared to 27.9% of European patients. Conversely, neurological manifestations were only seen in 4.8% of Chinese SLE patients compared to 19.4% of European patients, 12.1% of U.S. patients, 22.8% of Malaysian patients and 26.4% of Latin Americans. Pulmonary arterial hypertension and interstitial lung diseases were complications identified in 3.8% and 4.2% of Chinese lupus patients, respectively. The CSTAR registry has provided epidemiological data and phenotypes of Chinese patients with SLE, and has demonstrated several differences between ethnicities. Clinical data and biologic samples would be valuable resources for future translational studies with national and international collaboration.
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Affiliation(s)
- M Li
- 1Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Mazzoni D, Cicognani E. Social support and health in patients with systemic lupus erythematosus: A literature review. Lupus 2011; 20:1117-25. [DOI: 10.1177/0961203311412994] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In the last decades, with the improvement of life expectancies for systemic lupus erythematosus (SLE) patients, the relationship between social support and health in this population has received a considerable amount of attention in behavioural medicine and health psychology. This paper is the first to review research studies which specifically investigated perceived social support in relation to SLE patients’ health outcomes (quality of life, disease activity and damage). Starting with a descriptive approach to social support perceived by patients with SLE, the research evidence on the impact of social support on health is presented. These studies demonstrate that the consideration of social support is critical in predicting disease activity, damage and quality of life (both physical and psychological components) although the precise ways in which social support contributes to health are not yet completely understood. Discussing the results, the authors offer some suggestions which could guide further research in this field. Finally, clinical and non-clinical implications of the findings are discussed.
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Affiliation(s)
- D Mazzoni
- Department of Education Sciences, University of Bologna, Italy
| | - E Cicognani
- Department of Education Sciences, University of Bologna, Italy
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Lin F, Zhang C, Zhang D, Wu X, Zhu C, Jiang G. Simultaneous presentation of systemic lupus erythematosus and lupus nephritis in mother and son. Lupus 2011; 20:1541-6. [PMID: 21813591 DOI: 10.1177/0961203311409274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The pathogenesis of systemic lupus erythematosus (SLE) has been attributed to complex interactions between genetic, hormonal and environmental factors. The influence of a genetic predisposition to SLE is supported by family aggregation and a high concordance rate in monozygotic twins. Here we present a rare case of simultaneous presentation of SLE and lupus nephritis in a mother and son. Both patients had nephrotic-range proteinuria, and the renal pathological classifications of the son and his mother were Class IV-G (A) and Class III (A/C), respectively, according to the International Society of Nephrology/Renal Pathology Society (ISN/RPS) 2003 classification of lupus nephritis. Apart from the renal involvement, both patients had leucopenia and anemia, and the mother also had typical cutaneous lesions and secondary Sjögren’s syndrome. This case supports the genetic role in the etiology of SLE, and displayed different clinical presentations and disease severity in familial SLE patients of different gender and age.
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Affiliation(s)
- F Lin
- Department of Nephrology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai,China
| | - C Zhang
- Department of Nephrology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai,China
- Department of Nephrology, Xinhua Hospital Chongming Branch, School of Medicine, Shanghai Jiao Tong University, Shanghai,China
| | - D Zhang
- Department of Nephrology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai,China
| | - X Wu
- Department of Pathology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai,China
| | - C Zhu
- Department of Nephrology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai,China
| | - G Jiang
- Department of Nephrology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai,China
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