Prevalence of renal involvement in Indian patients with systemic sclerosis

Exploratory clinical subgroup clustering in systemic sclerosis: Results from the Indian Progressive Systemic Sclerosis Registry

Objective

To conduct an exploratory cluster analysis of systemic sclerosis patients from the baseline data of the Indian systemic sclerosis registry.

Methods

Patients satisfying American College of Rheumatology-European League Against Rheumatism classification criteria for systemic sclerosis were included. The clusters formed using clinical and immunological parameters were compared.

Results

Of the 564 systemic sclerosis registry participants, 404 patients were included. We derived four clusters of which three were anti-topoisomerase I predominant and one was anti-centromere antibody 2 dominant. Cluster 1 (n-82 (20.3%)) had diffuse cutaneous systemic sclerosis patients with the most severe skin disease, anti-topoisomerase I positivity, males, younger age of onset and high prevalence of musculoskeletal, vasculopathic and gastrointestinal features. Cluster 2 (n-141 (34.9%)) was also diffuse cutaneous systemic sclerosis and anti-topoisomerase I predominant but with less severe skin phenotype than cluster 1 and a lesser prevalence of musculoskeletal, vasculopathic and gastrointestinal features. Cluster 3 (n-119 (29.5%)) had limited cutaneous systemic sclerosis patients with anti-topoisomerase I positivity along with other antibodies. The proximal muscle weakness was higher and digital pitting scars were lower, while other organ involvement was similar between clusters 2 and 3. Cluster 4 (n-62 (15.30%)) was the least severe group with limited cutaneous systemic sclerosis and anti-centromere antibody predominance. Age of onset was higher with low musculoskeletal disease and a higher presence of upper gastrointestinal features. The prevalence of interstitial lung disease was similar in the three anti-topoisomerase I predominant clusters.

Conclusion

With exploratory cluster analysis, we confirmed the possibility of subclassification of systemic sclerosis along a spectrum based on clinical and immunological characteristics. We also corroborated the presence of anti-topoisomerase I in limited cutaneous systemic sclerosis and the association of interstitial lung disease with anti-topoisomerase I.

The Relationship between Allergic Disease and Sexual Dysfunction: A Scoping Review

INTRODUCTION

Sexual dysfunction (SD) and allergic disease are common health concerns worldwide and bear a potential relationship. This scoping review is conducted to analyze the currently available data regarding the associations between these two health issues.

METHODS

A comprehensive literature search was performed in the databases of PubMed, MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science to retrieve studies that were published before January 2023. A narrative synthesis was conducted to analyze the effects of allergic diseases on SD based on the evaluation of the Female Sexual Function Index (FSFI) and International Index of Erectile Function (IIEF).

RESULTS

Twelve observational studies were included after the selection process. The results generally suggested lower FSFI or IIEF scores in patients with asthma, allergic rhinitis, allergic rhinoconjunctivitis, and urticaria compared to the healthy control groups. The underlying factors of this relationship could be inflammation, psychological factors, hormonal changes, sleep disorders, sexual behavior-related allergic reactions, social economic status, and the use of medications.

CONCLUSION

SD and allergic disease are interrelated based on the extant literature. This scoping review provides insights into the clinical implications of both entities, while more research studies are warranted to further elucidate this complex relationship.

Estimated glomerular filtration rate and renal resistive index as possible predictive markers of mortality in systemic sclerosis

OBJECTIVE

Subclinical nephropathy is underestimated in systemic sclerosis (SSc). Study aim is to evaluate the role of renal resistance indices (RRI) and estimated glomerular filtration rate (eGFR) assessed by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) as predictive markers of mortality during 10 years of follow-up in SSc patients.

METHODS

181 SSc patients (60 years, 152 females) were enrolled. At baseline, the GFR was estimated in 181 SSc patients and RRI was measured in 122 SSc patients. During a follow-up of 10 years we recorded the main complications of disease, date and causes of death.

RESULTS

eGFR shows a linear negative correlation with RRI. RRI showed a correlation with systolic pulmonary artery pressure (sPAP). Overall survival is lower in SSc patients with eGFR<60 ml/min and RRI ≥0.70 than in SSc patients with eGFR≥60 ml/min (p<0.0001) and with RRI<0.70 (p<0.01) both for mortality due to SSc and all causes. In multivariate analysis, eGFR<60 ml/min [HR 6.429, 95%CI (1.006-41.08), p<0.05] and forced vital capacity (FVC) [HR 0.954, 95%CI (0.911-1), p<0.05] are predictive markers of mortality due to SSc, while eGFR [HR 3.617, 95%CI (1.370-9.554), p<0.01], RRI [HR 0.210, 95% CI (0.068-0.649), p<0.01], age [HR 1.062, 95%CI (1.023-1.103), p<0.01], FVC [HR 0.967, 95%CI (0.946-0.989), p<0.01] and disease activity index (DAI) [HR 1.663, 95%CI (1.262-2.191), p<0.0001] are predictive markers of mortality due to all causes.

CONCLUSION

We demonstrate that eGFR is a predictive marker of mortality due to SSc and to all causes, conversely RRI is predictive marker of mortality due to all causes.

Renal dysfunction in systemic sclerosis beyond scleroderma renal crisis

Research regarding renal involvement in SSc has almost exclusively focused on scleroderma renal crisis (SRC). There are relatively limited data regarding renal impairment in SSc beyond SRC. We performed an electronic search using the key words systemic sclerosis or scleroderma combined with each of the following: renal dysfunction, kidney, glomerular filtration rate (GFR), proteinuria and hematuria. We searched for reports relevant to renal dysfunction in SSc beyond SRC. In 796 SSc patients recruited in five studies. 251 (31.5%) had GFR < 90 ml/min whereas 155(19.5%) patients had GFR < 60 ml/min. Most data indicate that the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula should be considered as the most suitable tool for assessing renal function in SSc pts, since it provides similar results to measured GFR. These data indicate that renal dysfunction in SSc in not uncommon and therefore patients with SSc should have their renal function assessed by GFR estimation on a regular basis.

Clinical characteristics and outcomes of 566 Thais with systemic sclerosis: A cohort study

BACKGROUND

Most Thai patients with systemic sclerosis (SSc) have diffuse cutaneous SSc (dcSSc) unlike most Caucasians and some Asians. A longitudinal cohort study among Thai dcSSc is needed.

OBJECTIVES

We aimed to determine the overall clinical characteristics, define the clinical difference between limited cutaneous SSc (lcSSc) and dcSSc, and ascertain the mortality rate and the factors associated with mortality.

METHOD

We conducted a cohort study including 566 Thai adult SSc patients between January 2013 and June 2019. Clinical difference between lcSSc and dcSSc was investigated using generalized estimating equations (GEE).

RESULTS

Females presented more than males (356 vs 210 cases). The majority of cases were dcSSc (411; 72.6%). The median duration of disease at the time of pulmonary fibrosis (PF) detection was 2.5 years, pulmonary arterial hypertension 8.1 years, and renal crisis 4.1 years. By GEE analysis, dcSSc was significantly associated with salt-and-pepper skin, hand deformity, and every 1-point increase in modified Rodnan skin score (mRSS). A greater mortality risk was associated with age at onset >60 years (hazards ratio [HR] 5.5), a World Health Organization functional class (FC) III (HR 5.1), FC IV (HR 34.8), edematous skin (HR 11.4), early onset of PF (HR 1.7), each 5-point increase in the mRSS (HR 4.5), and ≥2 internal organ involvements (HR 10.1).

CONCLUSION

dcSSc is a common SSc subset among Thais. PF was an early complication in SSc and earlier PF detection was associated with a poorer prognosis. Elderly onset, high FC, severe skin tightness, and multiple organ involvements were associated with a greater mortality risk.

Risk factors and outcome of Thai patients with scleroderma renal crisis: a disease duration-matched case control study

INTRODUCTION

Data regarding the prevalence, risk factors and outcome of scleroderma renal crisis (SRC) in Asian patients with systemic sclerosis (SSc) are limited.

OBJECTIVE

To determine the prevalence, risk factors and outcomes of SRC in Thai SSc patients.

METHOD

Medical records of all SSc patients seen at the Division of Rheumatology, Chiang Mai University, Thailand, from January 1990 to December 2015 were retrospectively reviewed. For each SRC case, a disease duration (±1 year) matched control (four SSc patient without SRC for each SRC patient) was identified.

RESULT

Of 608 SSc patients seen during the study period, 19 SRC cases were identified, resulting in an SRC prevalence of 3.13%, with 76 matched controls. Of the 19 cases, mean ± SD age and median (interquartile range 1-3) disease duration was 56.2 ± 13.8 years and 5 (3-22) months, respectively. Seventeen patients (89.5%) had diffuse cutaneous SSc. Twelve patients (63.2%) had hypertensive renal crisis and seven (36.8%) had normotensive renal crisis. Multivariate conditional logistic regression analyses showed that digital gangrene (adjusted odd ratio [AOR] 31.41, 95% CI = 1.16-852.23, P = 0.041), current prednisolone dose ≥ 15 mg/day (AOR 31.22, 95% CI = 1.59-613.85, P = 0.024), serum albumin < 3 mg/dL (AOR 7.97, 95% CI = 1.49-42.56, P = 0.015), and cardiac involvement (AOR = 6.62, 95% CI = 1.08-40.63, P = 0.041) were independent risk factors for SRC. Fifteen SRC patients (78.9%) required dialysis and 10 (52.6%) died.

CONCLUSION

SRC was an uncommon complication in Thai patients with SSc, but is associated with high mortality. Digital gangrene, current prednisolone dose ≥ 15 mg/day, serum albumin < 3 mg/dL and cardiac involvement were independent risk factors for SRC.

The Frequency of Scleroderma Renal Crisis over Time: A Metaanalysis

Objective.

Systemic sclerosis (SSc) leads to a high mortality from internal organ involvement. Scleroderma renal crisis (SRC) usually occurs in the diffuse cutaneous SSc (dcSSc) subset early in the disease, often with acute severe hypertension and renal failure. Prevalence of SRC since its classification in the early 1970s was determined in publications to assess whether the prevalence of SRC has changed over time because the proportion with the dcSSc subset is smaller in contemporary cohorts.

Methods.

A review of the literature was conducted up to May 2015 using the PubMed, EMBASE, CINAHL, and Cochrane Library databases. Articles were included if they mentioned the prevalence of SRC and were cohort or cross-sectional studies with 50 or more patients with SSc. Articles were excluded if they were not in English or were a case series of SRC or case-control studies.

Results.

Of the 5317 citations identified, 22 qualified. Years of publication were from 1983 to 2011, and cohort size varied from 68 to 8554 patients with SSc totaling 21,908 patients (9248 with dcSSc, 42%). There was no statistical reduction in the temporal prevalence of SRC noticed in the overall patients (4%), patients with dcSSc (7%–9%), or patients with limited cutaneous SSc (lcSSc; 0.5%–0.6%) based on either the start date of the cohort or publication date.

Conclusion.

It appears that SRC remains uncommon in lcSSc and the rate in the dcSSc group may be stable over time. However, increasing awareness of SRC could lead to higher rates in more recent years and/or better survival from SRC, but this was not observed.

Rheumatological diseases and kidneys: a nephrologist's perspective

Renal involvement is a common occurrence in subjects with rheumatological diseases and can develop either due to the disease itself or secondary to drugs used in the treatment. The prevalence of renal involvement and its severity depends on the underlying disease as well as aggressiveness of the therapy. For most rheumatological diseases, renal involvement heralds a poor prognosis and warrants aggressive immunosuppressive treatment. Thus, it is important to diagnose and manage them at an early stage. On the other hand, patients with primary kidney disease can also develop rheumatological manifestations which need to be differentiated from the former. This article provides the nephrologist's perspective upon various rheumatological disorders and associated renal involvement with the aim of sensitizing the rheumatological community about them, resulting in better management of these subjects.

Tc-99m diethylenetriamine pentaacetic acid (DTPA) renal function reserve estimation: is it a reliable predictive tool for assessment of preclinical renal involvement in scleroderma patients?

Prognosis of systemic sclerosis (SSc) depends on internal organ involvement. We assessed the value of renal function reserve (RFR) for the detection of preclinical nephropathy in scleroderma. Thirty SSc patients with normal serum creatinine and 30 healthy controls were included. Medsger disease severity score, glomerular filtration rate (GFR), and microalbuminuria were measured. Tc-99m DTPA was utilized for GFR measurement at baseline and after oral protein overload (stimulated GFR). RFR was calculated as the percentile increase of stimulated GFR. SSc patients had lower means of baseline GFR (P=0.001), stimulated GFR (P=0.004), RFR (P=0.046), and higher microalbuminuria (P=0.009) than controls. According to baseline GFR, SSc patients showed three categories-normal baseline GFR (n=12), hyperfiltration GFR (n=3), and reduced baseline GFR (n=15). In the former category, RFR was normal in 6/12 patients and abnormal in the remainders (50%). Hyperfiltration patients and those with reduced baseline GFR showed abnormal RFR. A statistically significant negative association was found between microalbuminuria versus stimulated GFR and RFR (r= -0.5, P=0.007 and r= -0.45, P=0.013, respectively). The majority of SSc patients with abnormal RFR had disease duration of ≥48 months (60% vs. 20%, P=0.008). All SSc patients with pulmonary hypertension had abnormal RFR, while reduced baseline GFR was noted in only 60%. A significant negative correlation was found between reduced baseline GFR and cumulative dose of corticosteroids in SSc patients (r= -0.4, P=0.022). RFR estimation could be a useful predictive marker for preclinical renal involvement in SSc patients so that early prophylactic measures and therapy modifications could be considered.

Renal disease in systemic sclerosis with normal serum creatinine

Prognosis of systemic sclerosis largely depends on involvement of internal organs. The aim was to evaluate renal impairment in patients with systemic sclerosis by measuring the Glomerular filteration rate (GFR) and then calculating the GFR using the Cockgroft and Gault formula and the Modification of Diet in Renal Disease Equation (MDRD) formula. Thirty one scleroderma patients were recruited from the Rheumatology and Rehabilitation Department, Cairo University Hospitals, mean age 43.25 +/- 11.28 years, 31 healthy controls were included. Disease severity was done using Medsger score. GFR was measured using classical Gates method TC99mDTPA. The modified Cockcroft and Gault formula and equation 7 from the MDRD were used for calculation of GFR. All patients had within normal serum creatinine levels. A normal GFR (>89ml/min) was found in 45.1%. Gates method showed reduced GFR was reported in 54.9%. Stage II chronic kidney disease (60-89 ml/min) found 32.3%, and stage III (30-59 ml/min) in 22.6%. The formulae used showed reduction of GFR in 35.29% of those affected by the Cockcroft-Gault and in 41.17% of those affected using the MDRD. No correlation to patients' age, disease duration, or severity. A positive correlation was also reported between the presence of renal involvement and pulmonary vascular involvement p = 0.04. Gates method showed reduction of the GFR in 54.9% of the systemic sclerosis patients. The formulae used were not as precise as the measured GFR in diagnosing all cases with subclinical renal involvement. Patients with systemic sclerosis should be screened for renal involvement irrespective of disease severity or duration.

Antiphospholipid antibodies and kidney involvement in patients with systemic sclerosis

Antiphospholipid (aPL) antibodies are often detected in systemic autoimmune diseases. The aim of the study was to examine the correlation between the presence of aPL and certain markers of renal function in systemic sclerosis (SSc). Fifty patients (pts) with SSc were examined for the presence of antibodies to cardiolipin (aCL) and to anti-beta 2 glycoprotein I (a-B2GPI) in immunoglobulin M (IgM) and IgG class. Moreover, serum levels of creatinine, cystatin C, and glomerular filtration rate (GFR) were determined in all patients. In all studied pts together, three multiple-regression analyses were performed with one set cystatin C as a dependent variable, in the second GFR according to the Cockcroft-Gault formula and in the third creatinine clearance by Modification of Diet in Renal Disease (MDRD) formula. As independent variables, aPL of either type were inserted in addition to disease duration and age. IgG aCL was significantly positively associated with serum cystatin C (p = 0.002), significantly negatively associated with creatinine clearance according to the Cockcroft-Gault and MDRD formula (p = 0.01 and 0.02, respectively). IgG a-B2GPI was significantly negatively associated with creatinine clearance according to the Cockcroft-Gault (p = 0.03) and MDRD (p = 0.01) formula. IgM aCL and IgM a-B2GPI were not associated with any markers of the renal function. Our study suggests the relationship between kidney involvement and the positivity for some aPL in patients with SSc. Positivity for IgG aCL and IgG a-B2GPI in patients with SSc without secondary antiphospholipid syndrome seems to be connected with decrease of glomerular filtration.