Temporal trends in characteristics and outcome of intensive care unit patients with systemic lupus erythematosus in Taiwan: a national population-based study

Risk factors for hospitalization in Mexican patients with systemic lupus erythematosus

INTRODUCTION

Systemic lupus erythematosus (SLE) is an autoimmune disease that often requires hospitalization. Most hospitalizations are due to infections and/or disease activity, for which several risk factors have been described in non-Mestizo patients.

OBJECTIVE

To identify risk factors for hospitalization in patients with systemic lupus erythematosus (SLE).

METHODS

This was an observational case-control study of patients with SLE in San Luis Potosí, Mexico, evaluated from January 2019 to October 2020. We compared hospitalized lupus patients with non-hospitalized lupus patients. We used descriptive statistics and logistic regression to describe potential risk factors.

RESULTS

Of a total of 202 patients, 89 (45.1%) were hospitalized; these patients were younger, had shorter disease duration, higher disease activity scores (systemic lupus erythematosus disease activity index-SLEDAI), and more accumulated damage than non-hospitalized patients. The primary reasons for hospitalization were disease activity (60.7%), kidney disease, infection, and drug toxicity (5.6%). Multivariate analysis revealed several risk factors associated with hospitalization, including elevated creatinine, C-reactive protein, neutrophil levels, and constitutional symptoms, while prolonged international normalized ratio (INR), longer stay in the intensive care unit (ICU), and vasopressor use were associated with mortality. The use of antimalarials was a protective factor against hospitalization. Survival analysis revealed that patients with hospital-acquired infections had a lower probability of survival.

CONCLUSIONS

Disease activity was the most common reason for hospitalization; kidney, constitutional, and hematological factors were associated with hospitalization; and the use of antimalarial was a protective factor for hospitalization.

Severe pneumonia in patients with systemic lupus erythematosus admitted to the intensive care unit

BACKGROUND

The aim of this study was to investigate clinical characters and prognosis of patients with systemic lupus erythematosus (SLE) and severe pneumonia admitted to the intensive care unit (ICU).

MATERIALS AND METHODS

We conducted a retrospective study that reviewed all clinical records of patients with SLE and severe pneumonia admitted to the ICU between 2008 and 2020.

RESULTS

A total of 86 SLE patients with severe pneumonia during their first ICU admission were enrolled in this study. Most patients were female (n = 71, 82.5%), and the median age was 42.3 ± 14.7 years. The most common organisms were gram-positive bacteria (20.9%), followed by gram-negative bacteria (18.6%) and fungi (10.4%). A total of 31 patients died within 30 days of ICU admission, and the 30-day mortality was 36%. In binary logistic regression analysis, Acute Physiologic and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score and mechanical ventilation were dependently associated with 30-day mortality (odds ratio [OR] 2.97, P = 0.016; OR = 4.02, P = 0.023; OR = 1.52, P = 0.036; respectively). Among the other 55 patients, 5 patients died after discharge from the ICU during the long-term follow-up.

CONCLUSIONS

Mortality was high in SLE patients with severe pneumonia admitted to the ICU, and most of the patients died within 30 days of ICU admission.

Outcome of critically ill patients with systemic lupus erythematosus from a medical intensive care unit in Southern India

OBJECTIVE

Systemic lupus erythematosus (SLE) has become the most prevalent autoimmune condition requiring admission in the intensive care units (ICU) in the last two decades. Here we analysed the clinical outcomes of SLE patients admitted to our ICU between 2011 and 2021, and studied the prognostic role of high-density lipoprotein (HDL) and procalcitonin in those enrolled after August 2019.

METHODS

Systemic lupus erythematosus (ACR/SLICC 2012) were enrolled, 72 retrospectively and 30 prospectively. Data on indications for ICU admission, complications, infections, and disease activity were recorded. Outcome was mortality at 90 days (prospective) whereas in the retrospective analysis outcome was hospital discharge or death in hospital. Serum HDL and procalcitonin (PCT) was estimated in the prospectively enrolled 30 patients and compared with 30 non ICU-SLE patients.

RESULTS

Indications for ICU admissions were respiratory causes in 78/102 (76.5%) patients; for haemodynamic monitoring and for invasive procedures in the remaining. Pneumonia was the primary reason for mechanical ventilation, followed by diffuse alveolar haemorrhage (DAH). Eighty-three (81.3%) patients died; infections (n = 54) and SLE related causes (n = 29). APACHE-II >16 (p = .026), lymphopenia (p = .021), infection (p = .002), creatinine >1.3 mg/dL (p = .023), and hypotension requiring vasopressor support (p = .006) emerged as significant predictors of non-survival on multivariable analysis. HDL (mg/dL) day 1 was significantly lower in SLE-ICU patients compared to non ICU-SLE (31.8 ± 14.3 vs 38.8 ± 11.4 mg/dl); p = .045. On day 1, PCT (ng/mL) in SLE-ICU was significantly higher when compared to non-ICU SLE; median (IQR): 0.53 (0.26-5.27) versus 0.13 (0.05-0.47), p < .001), respectively. It was also significantly higher on day 5 in SLE-ICU than non-ICU SLE (median (IQR): 4.18 (0.20-14.67) versus 0.10 (0.08-0.46), p = .004.

CONCLUSION

The mortality of SLE patients admitted to the ICU in this study is high, and infections were the principal reason for death. Baseline low HDL and higher procalcitonin are potential biomarkers to identify critically ill SLE patients.

Mortality and its risk factors in critically ill patients with connective tissue diseases: A meta-analysis

BACKGROUND

Systemic lupus erythematosus (SLE), primary Sjögren's syndrome (pSS), systemic sclerosis (SSc), idiopathic inflammatory myopathies (IIM) and rheumatoid arthritis (RA) are connective tissue diseases (CTD) whose complications can lead to management in the intensive care unit (ICU).

OBJECTIVES

To estimate by meta-analysis ICU mortality rates for CTD.

METHODS

A systematic literature review was performed to identify articles studying critically ill CTD patients. A random-effects model was chosen for analysis. Pooled proportion mortality was calculated using aggregated-data meta-analysis with a random-effects model and assessment of heterogeneity with the I² statistic. Risk of bias was assessed using the quality assessment tool.

RESULTS

Of the 5694 individual publications, a sample of 31 independent cohorts was used for the meta-analysis totalling 5007 patients. The main cause for admission was sepsis (43%) followed by "flare-ups" (40%). The overall pooled proportion of mortality of CTD patients across all 31 studies was 33% (95%CI: 28-38%). In the IIM subgroup and that of SSc, mortality was 70% (95%CI: 46-86%) and 40% (95%CI: 25-47%), respectively. In the SLE subgroup, mortality was similar to the overall pooled mortality of 35% (95%CI: 29-42%). Subgroup mortality for RA and pSS patients was respectively 20% (95%CI: 11-33%) and 17% (95%CI: 6-41%); lower than the overall pooled mortality. Heterogeneity in each subgroup remained high.

CONCLUSION

The overall pooled proportion of mortality of ICU patients with CTD was 33% (95%CI: 28-38%), with a high heterogeneity (I²= 89%). In the subgroup analysis, mortality was higher for patients with IIM and SSc.

Systemic lupus erythematosus in the intensive care unit: a systematic review

Systemic lupus erythematosus (SLE) is an autoimmune disease with heterogeneous pathophysiologic mechanisms and diverse clinical manifestations. SLE is a frequent cause of intensive care unit (ICU) admissions. Multiple studies with controversial findings on the causes, evolution and outcomes of ICU-admitted patients with SLE have been published. The aim of this paper is to review the literature reporting the clinical characteristics and outcomes, such as mortality and associated factors, in such patients. Among the main causes of ICU admissions are SLE disease activity, respiratory failure, multi-organ failure and infections. The main factors associated with mortality are a high Acute Physiology and Chronic Health Evaluation (APACHE) score, the need for mechanical ventilation, and vasoactive and inotropic agent use. Reported mortality rates are 18.4%-78.5%. Therefore, it is important to evaluate SLE disease severity for optimizing clinical management and patient outcomes.

Clinical characterization, outcomes, and prognosis in patients with systemic lupus erythematosus admitted to the intensive care unit

OBJECTIVE

Systemic lupus erythematosus (SLE) is a clinically heterogeneous autoimmune disease, and in some conditions, admission to the intensive care unit (ICUs) is required. This study describes the clinical and prognostic factors in SLE patients admitted to the ICU.

METHODS

We conducted a retrospective study that reviewed all clinical records of patients with SLE admitted to the ICU between 2011 and 2018.

RESULTS

We evaluated 188 patients, with 279 ICU admissions. Most patients were female (n = 159; 84.57%) with a median age of 35 years (interquartile range (IQR) = 25-48 years). Infection was the leading cause of admission in 77 (27.60%) cases, followed by lupus flare. The average length of hospitalization was 5 days (IQR 3-11 days), and the SLE Disease Activity Index 2000, Acute Physiology, Age and Chronic Health Evaluation (APACHE II), and Sequential Organ Failure Assessment (SOFA) scores were 9 (IQR 2-17), 14 (IQR 10-17), and 3 (IQR 2-5), respectively. Non-survivors presented with higher APACHE II and SOFA scores. Infection was the leading cause of mortality (n = 38; 20.21%), and predictors of mortality included invasive mechanical ventilation, vasoactive medication requirement, higher SOFA scores, and antiphospholipid syndrome comorbidity.

CONCLUSIONS

We found that infection was the leading cause of ICU admissions and mortality in patients with SLE. Factors identified here as predictors of mortality should be accurately identified at admission for the prompt treatment of SLE patients.

Epidemiology and outcomes of sepsis among hospitalizations with systemic lupus erythematosus admitted to the ICU: a population-based cohort study

Background

Sepsis is the most common cause of premature death among patients with systemic lupus erythematosus (SLE) aged ≤ 50 years in the United States, and infection is the most common cause of admission to the ICU among SLE patients. However, there are no population-level data on the patterns of the demand for critical care services among hospitalized septic patients with SLE or the outcomes of those admitted to the ICU.

Methods

We performed a retrospective cohort study, using the Texas Inpatient Public Use Data File, to identify SLE hospitalizations aged ≥ 18 years and the subgroups with sepsis and ICU admission during 2009–2014. The patterns of ICU admission among septic hospitalizations were examined. Logistic regression modeling was used to identify predictors of short-term mortality (defined as hospital death or discharge to hospice) among ICU admissions with sepsis and to estimate the risk-adjusted short-term mortality among ICU admissions with and without sepsis.

Results

Among 94,338 SLE hospitalizations, 17,037 (18.1%) had sepsis and 9409 (55.2%) of the latter were admitted to the ICU. Sepsis accounted for 51.5% of the growth in volume of ICU admissions among SLE hospitalizations during the study period. Among ICU admissions with sepsis, 25.3% were aged ≥ 65 years, 88.6% were female, and 64.4% were non-white minorities. The odds of short-term mortality among septic ICU admissions were increased among those lacking health insurance (adjusted odds ratio 1.40 [95% confidence interval 1.07–1.84]), while being unaffected by gender and race/ethnicity, and remaining unchanged over the study period. On adjusted analyses among ICU admissions, the short-term mortality among those with and without sepsis was 13% (95% CI 12.6–13.3) and 2.7% (95% CI 2.6–2.8), respectively. Sepsis was associated with 63.6% of all short-term mortality events.

Conclusions

Sepsis is a major, incremental driver of the demand for critical care services among SLE hospitalizations. Despite its relatively low mortality, sepsis was associated with most of the short-term deaths among ICU patients with SLE.

Causes and factors related to hospitalizations in patients with systemic lupus erythematosus: analysis of a 20-year period (1995-2015) from a single referral centre in Catalonia

INTRODUCTION

Although extensively characterized in the outpatient setting, systemic lupus erythematosus (SLE) in the hospitalization wards is still scarcely portrayed, particularly in the perspective of its evolution over the years.

METHODS

Retrospective analysis of SLE patients hospitalized in the Department of Autoimmune Diseases of a university hospital during a 20-year period (1995-2015), describing hospitalization characteristics, causes and predictors of outcome.

RESULTS

A total of 814 hospitalizations concerning 339 patients were analysed. The main causes of admission were flare (40.2%), infection (19.2%), diagnostic procedures (18.8%) and thrombotic events (5.4%). Therapy with cyclophosphamide (odds ratio (OR) 1.908, p = 0.047) was associated with admission due to infection, while antimalarials displayed a protective effect (OR 0.649, p = 0.024). Nearly 3.9% of patients required admission to an intensive care unit, with associated antiphospholipid syndrome (OR 7.385, p = 0.04) standing as a predicting factor for this outcome. Readmission at 30 days occurred in 5.8% of patients, with thrombocytopenia (OR 6.007, p = 0.002) and renal involvement (OR 3.362, p = 0.032) featuring as predicting factors. Eight patients died, with antiphospholipid syndrome (OR 26.814, p = 0.02) and thrombocytopenia (OR 31.523, p = 0.01) being associated with mortality. There was no significant variation in patients' demographics or admission causes across the 20-year period, except for a decrease in admissions due to thrombotic and musculoskeletal causes. Recently, an increase in the use of mycophenolate mofetil and lower doses of glucocorticoids were noted.

CONCLUSION

While demographics of SLE hospitalizations have not markedly changed over the past 20 years, changes in therapy patterns were observed. Thrombocytopenia, antiphospholipid syndrome and renal involvement featured as predictors of poor outcome.

Mortality of patients with rheumatoid arthritis requiring intensive care: a single-center retrospective study

BACKGROUND

Patients with rheumatoid arthritis (RA) are at a high risk for life-threatening conditions requiring admission to the intensive care unit (ICU), but the data regarding the outcomes of these patients is limited. The present study investigated the clinical characteristics and outcomes of RA patients admitted to an ICU.

METHODS

This retrospective cohort study included RA patients admitted to the general ICU of the Sheba Medical Center during 2002-2018. The main outcome was 30-day mortality. Using Student's t test, χ², and multivariable analyses, we compared the demographic, clinical, and laboratory parameters of the survivors and the non-survivors. Figures with p value < 0.05 were considered statistically significant.

RESULTS

Forty-three RA patients were admitted to the ICU during the study period (mean age, 64.0 ± 13.1 years; 74.4% female). The leading causes of ICU admission were infection (72.1%), respiratory failure (72.1%), renal failure (60.5%), and septic shock (55.8%). The 30-day mortality rate was 34.9%, with infection (9/15, 60%) as the most frequent cause. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores were 19.7 ± 12.5 and 7.0 ± 4.5, respectively. Multivariable analysis showed that heart failure (p = 0.023), liver failure (p = 0.012), SOFA score (p = 0.007), and vasopressor treatment in ICU (p = 0.039) were significantly associated with overall mortality. SOFA score was linked with overall mortality (area under the curve (AUC) = 0.781 ± 0.085, p = 0.003) and mortality from respiratory failure (AUC = 0.861 ± 0.075, p = 0.002), while APACHE II score was only correlated with mortality from infection (AUC = 0.735 ± 0.082, p = 0.032).

CONCLUSIONS

Our study demonstrated a relatively high mortality rate among RA patients who were admitted to the general ICU. RA patients with risk factors such as heart failure, liver failure, elevated SOFA score, and vasopressor treatment in ICU should be promptly identified and treated accordingly. Key Points • The 30-day mortality rate of patients with RA that were admitted to the general ICU of a tertiary hospital was 34.9%. • The most common causes of ICU admission among patients with RA were infections and respiratory failure. Infections were the most common cause of death among these patients. • Patients with RA that present to the ICU with heart failure, liver failure, elevated SOFA score, and/or require vasopressor treatment in ICU should be promptly identified and treated accordingly.

Mortality of patients with systemic lupus erythematosus admitted to the intensive care unit - A retrospective single-center study

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease that results in increased morbidity and mortality. Under certain conditions, patients with SLE may be admitted to the intensive care unit (ICU) secondary to infectious disease flare-ups or other non-SLE disease conditions that are aggravated by SLE. The aim of our study was to investigate the causes and outcomes of ICU-admitted patients with SLE. This is a retrospective cohort study involving paitents with SLE that were admitted to the general ICU at Sheba Medical Center between 2002 and 2015. Outcome was measured by the 30-day mortality and the Acute Physiology and Chronic Health Evaluation (APACHE) II score. Demographic, diagnostic, physiological, and laboratory variables of survivors and nonsurvivors were compared using univariate and multivariate Cox regression analyses. A receiver operating characteristic curve was plotted for significant variables to illustrate their diagnostic capabilities. Twenty-seven patients were admitted to the ICU (female: 21 [77%], mean age ± SD: 51.1 ± 15.4 years). The mean ± SD APACHE II score and 30-day mortality rate were 23.4 ± 8.3 and 29.6%, respectively. Infections, especially lower respiratory tract infections, were the cause of 66.7% of admissions and accounted for 87.5% of deaths. APACHE II scores, bacteremia, and gram-negative infections were significantly associated with mortality (p = 0.033, p = 0.022, and p = 0.01, respectively). An APACHE II score of 27 and above was the strongest predictor of mortality with a sensitivity and specificity of 83.3% and 84.2%, respectively (AUC = 0.82, p = 0.022). Patients with SLE that were admitted to the ICU with gram-negative infections, sepsis, or an APACHE II score of 27 and above have a higher mortality rate and thus should be promptly identified and treated accordingly.

Prognostic factors of mortality in Iranian patients with systemic lupus erythematosus admitted to intensive care unit

The aim was to determine the course, outcome, and determinants of mortality in patients with systemic lupus erythematosus (SLE) in intensive care unit (ICU). SLE patients admitted to ICU from 2004 to 2015 were recruited retrospectively. Demographic data, disease characteristics, causes of admission, baseline SLE disease activity index-2K (SLEDAI-2K) and Acute Physiologic and Chronic Health Evaluation II (APACHE) score, the outcome, and the causes of death were recorded. Predictors of mortality were compared between alive and dead patients by Cox regression analysis. Ninety-four patients with SLE were enrolled. Mean age at the time of ICU admission was 29.6 years. Average scores of SLEDAI and APACHE II were 11.3 and 19.8, respectively. The most common causes of ICU admission were pneumonia, diffuse alveolar hemorrhage (DAH), and seizure. Forty-seven patients (50%) died in ICU. The principal causes of death were septic shock (25.5%), multi-organ failure (12.5%), DAH (10.6%), and pneumonia (10.6%). After multivariate analysis, high APACHE II, septic shock, and duration of mechanical ventilation were indicators of survival outcome. Mean (95% CI) survival days in ICU in patients with and without respiratory failure were 14.6 (10.4-18.9) and 28.7 (17.9-39.5) days, respectively (P = 0.001). This figure for those with and without septic shock was 13.5 (4.9-11.1) and 22.3 (9.3-24.7) days, respectively (P = 0.016). High APACHE II, septic shock, and duration of mechanical ventilation were the main predictors of death in patients with SLE in ICU. Multicenter studies are needed to draw a fine picture of SLE behavior in ICU.

Prognosis of patients with rheumatic diseases admitted to intensive care

Variable mortality rates have been reported for patients with rheumatic diseases admitted to an intensive care unit (ICU). Due to the absence of appropriate control groups in previous studies, it is not known whether the presence of a rheumatic disease constitutes a risk factor. Moreover, the accuracy of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score for predicting outcome in this group of patients has been questioned. The primary goal of this study was to compare outcome of patients with rheumatic diseases admitted to a medical ICU to those of controls. The records of all patients admitted between 1 April 2003 and 30 June 2014 (n=4020) were screened for the presence of a rheumatic disease during admission (n=138). The diagnosis of a rheumatic disease was by standard criteria for these conditions. An age- and gender-matched control group of patients without a rheumatic disease was extracted from the patient population in the database during the same period (n=831). Mortality in ICU, in hospital and after 180 days did not differ significantly between patients with and without rheumatic diseases. There was no difference in the performance of the APACHE II score for predicting outcome in patients with rheumatic diseases and controls. This score, as well as a requirement for the use of inotropes or vasopressors, accurately predicted hospital mortality in the group of patients with rheumatic diseases. In conclusion, patients with a rheumatic condition admitted to intensive care do not do significantly worse than patients without such a disease.

Impact of follow-up visits on disease outcome in Chinese systemic lupus erythematosus

The objective of this study is to determine whether the frequency of visits would affect disease activity and disease damage in patients with systemic lupus erythematosus (SLE). We recruited 147 patients who met the 1997 American College of Rheumatology (ACR) criteria for SLE. Patients were divided into three groups based on follow-up frequency: ≤ 6 visits/year (group 1), 6-12 visits/year (group 2), and > 12 visits/year (group 3). Disease activity and organ damage were evaluated using the SLE disease activity index (SLEDAI) and Systemic Lupus International Collaborative Clinics (SLICC)/ACR criteria, respectively. Data on disease features, patient characteristics, and treatment were retrospectively reviewed. We found that the SLICC score was significantly lower in patients with > 12 visits/year (P = 0.008), while the SLEDAI score showed no significant difference. The age at symptom onset (32.68 ± 13.53) and the age at SLE diagnosis (33.32 ± 13.81) in group 3 were significantly older than those in the other two groups. In univariate regression analysis, the frequency of visits, the age at symptom onset, and the age at SLE diagnosis were found to be associated with the SLICC scores. Visit frequency has no impact on SLE disease activity, but may be associated with less disease damage, an important outcome.

Changes in referral, treatment and outcomes in patients with systemic lupus erythematosus in Germany in the 1990s and the 2000s

Objective

To evaluate trends in the referral, treatment and outcome of patients with systemic lupus erythematosus (SLE) in Germany over two decades.

Methods

From 1993 to 2012, ∼1200 patients with SLE were recorded annually in the national database of the German Collaborative Arthritis Centres. Treatment patterns, healthcare use and outcomes, such as disease activity, function and work participation, were evaluated over time. Furthermore, two distinct cohorts of patients (enrolment 1994–1998, n=467; and 2004–2008, n=376) observed over 5 years were assessed for changes in outcomes.

Results

The mean disease duration at the first visit to a rheumatologist decreased from 2.6 (1994) to 1.5 (2012) years. Glucocorticoids (69%), antimalarials (56%), azathioprine (22%), non-steroidal anti-inflammatory drugs (23%) and mycophenolate mofetil (15%) were the most frequently used treatments in 2012. A significant increase was observed in the use of antimalarials and mycophenolate mofetil. The use of glucocorticoids at >7.5 mg/day decreased from 27% (1994) to 10% (2012). The average length of sick leave taken due to SLE declined from 9 weeks (1997) to 6 weeks (2012). When comparing the two longitudinal cohorts, in the cohort from the 2000s, the intraindividual decline of disease activity was significantly stronger (p<0.001), and fewer patients retired early (36% vs 46%).

Conclusions

The disease activity and resource use declined considerably over the observation period, and more patients remained in the labour force. Earlier treatment onset, faster modification of the treatment regimen and more intensive use of anti-inflammatory therapy may account for the improved outcomes in patients with SLE across the years.

Validity of LupusQoL-China for the assessment of health related quality of life in Chinese patients with systemic lupus erythematosus

Objectives

To adapt and assess the validity and reliability of LupusQoL for use in Chinese patients with systemic lupus erythematosus (SLE).

Methods

Debriefing interviews of subjects with SLE guided the language modifications of the tool. The process of adaptation proceeded according to the guideline and pre-testing results of LupusQoL-China. 220 SLE patients completed LupusQoL-China and a generic preference-based measurement of health EuroQoL scale (EQ-5D), and 20 patients repeated them after 2 weeks. Internal consistency (ICR) and test-retest (TRT) reliability, convergent and discriminant validity were examined. Factor analysis and Rasch analysis were performed.

Results

The mean (SD) age of the 208 subjects with SLE was 33.93 (±9.19) years. ICR and TRT of the eight domains ranged from 0.811 to 0.965 and 0.836 to 0.974, respectively. The LupusQoL-China domains demonstrated substantial evidence of construct validity when compared with equivalent domains on the EQ-5D (physical health and usual activities r = −0.63, pain and pain/discomfort r = −0.778, emotional health and anxiety/depression r = −0.761, planning and usual activities r = −0.560). Most LupusQoL-China domains could discriminate patients with varied disease activities and end-organ damage (according to SELENA-SLEDAI and SLICC-DI). The principal component analysis revealed six factors, and confirmatory factor analysis result of which is similar to eight factors model.

Conclusions

These results provide evidence that the LupusQoL-China is valid as a disease-specific HRQoL assessment tool for Chinese patients with SLE.