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Shobha V, Rajasekhar L, Manuel S, Nayana V, Kavadichanda C, Kounassegarane D, Mathew AJ, Gupta R, Rathi M, Ghosh P, Tripathy SR, Das B, Selvam S, Singh AK, Singh A, Jain A, Aggarwal A. Pattern of disease expression in SLE patients with antiphospholipid antibodies: data from Indian Systemic Lupus Erythematosus Inception cohort (INSPIRE). Rheumatol Int 2024; 44:819-829. [PMID: 38082159 DOI: 10.1007/s00296-023-05511-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/22/2023] [Indexed: 04/02/2024]
Abstract
Antiphospholipid antibodies (APLA) are present in one-third of systemic lupus erythematosus (SLE) patients, and they are associated with both criteria and non-criteria manifestations. We studied the prevalence, clinical associations, and impact on mortality of APLA in SLE patients from India. Among the Indian SLE inception cohort (INSPIRE), patients who had data on all five routinely performed APLAs [lupus anticoagulant (LA), IgG and IgM anticardiolipin antibody (aCL) and anti-β2-glycoprotein I(β2GPI)] at enrolment were selected. Patients were divided into four categories based on the presence/absence of APLA associated manifestations and presence/absence of the APLA viz SLE-APS, SLE-APLA, SLE: events but no APLA, and SLE: no events, no APLA (reference group). 1035 SLE patients at least 1 APLA antibody was detected in 372 (35.9%). LA was present in 206 (19.9%), aCL in 126 (12.2%) and β2-GPI in 178 (17.2%). There were 88 thrombotic events in 83 patients (8.0%); 73 (82.9%) being arterial; APLA positivity was present in 37 (44.6%) [AOR 1.70 (1.054, 2.76)]. SLE-APS patients were younger and had higher mortality [AOR 4.11 (1.51, 11.3)], neuropsychiatric and hematologic disease. SLE-APLA also had a higher mortality rate [AOR 2.94 (1.06, 8.22)] than the reference group. The mortality was highest in the subset of patients with thrombotic events in the presence of APLA [AOR 7.67 (1.25, 46.9)]. The mere presence of APLA also conferred higher mortality even in the absence of thrombotic events [AOR 3.51 (1.43, 8.63)]. Hematologic manifestations (36.1%) were the most common non-criteria-manifestation. One-third of SLE patients have APLA and its presence is associated with non-criteria hematologic manifestations, arterial thrombosis and higher mortality rate.
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Affiliation(s)
- Vineeta Shobha
- Department of Clinical Immunology and Rheumatology, St. John's Medical College Hospital, Bengaluru, India
| | - Liza Rajasekhar
- Department of Clinical Immunology and Rheumatology, Nizam Institute of Medical Sciences, Hyderabad, India
| | - Sandra Manuel
- Department of Clinical Immunology and Rheumatology, St. John's Medical College Hospital, Bengaluru, India
| | - V Nayana
- Department of Clinical Immunology and Rheumatology, St. John's Medical College Hospital, Bengaluru, India
| | - Chengappa Kavadichanda
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Deepika Kounassegarane
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Ashish J Mathew
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - Ranjan Gupta
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Parasar Ghosh
- Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education and Research, Kolkata, India
| | | | - Bidyut Das
- Department of Rheumatology, SCB Medical College, Cuttack, India
| | - Sumithra Selvam
- Division of Epidemiology and Biostatistics, St. John's Research Institute, St. John's Medical College Hospital, Bengaluru, India
| | - Abhishek Kumar Singh
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ankita Singh
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Avinash Jain
- Department of Clinical Immunology and Rheumatology, SMS Medical College & Hospital, Jaipur, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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Kavadichanda C, Ganapathy S, Kounassegarane D, Rajasekhar L, Dhundra B, Srivastava A, Manuel S, Shobha V, Swarna CB, Mathew AJ, Singh D, Rathi M, Tripathy SR, Das B, Akhtar MD, Gupta R, Jain A, Ghosh P, Negi VS, Aggarwal A. Clusters based on demography, disease phenotype, and autoantibody status predicts mortality in lupus: data from Indian lupus cohort (INSPIRE). Rheumatology (Oxford) 2023; 62:3899-3908. [PMID: 37018148 DOI: 10.1093/rheumatology/kead148] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/06/2023] [Accepted: 03/15/2023] [Indexed: 04/06/2023] Open
Abstract
OBJECTIVES SLE is associated with significant mortality, and data from South Asia is limited. Thus, we analysed the causes and predictors of mortality and hierarchical cluster-based survival in the Indian SLE Inception cohort for Research (INSPIRE). METHODS Data for patients with SLE was extracted from the INSPIRE database. Univariate analyses of associations between mortality and a number of disease variables were conducted. Agglomerative unsupervised hierarchical cluster analysis was undertaken using 25 variables defining the SLE phenotype. Survival rates across clusters were assessed using non-adjusted and adjusted Cox proportional-hazards models. RESULTS Among 2072 patients (with a median follow-up of 18 months), there were 170 deaths (49.2 deaths per 1000 patient-years) of which cause could be determined in 155 patients. 47.1% occurred in the first 6 months. Most of the mortality (n = 87) were due to SLE disease activity followed by coexisting disease activity and infection (n = 24), infections (n = 23), and 21 to other causes. Among the deaths in which infection played a role, 24 had pneumonia. Clustering identified four clusters, and the mean survival estimates were 39.26, 39.78, 37.69 and 35.86 months in clusters 1, 2, 3 and 4, respectively (P < 0.001). The adjusted hazard ratios (HRs) (95% CI) were significant for cluster 4 [2.19 (1.44, 3.31)], low socio-economic-status [1.69 (1.22, 2.35)], number of BILAG-A [1.5 (1.29, 1.73)] and BILAG-B [1.15 (1.01, 1.3)], and need for haemodialysis [4.63 (1.87,11.48)]. CONCLUSION SLE in India has high early mortality, and the majority of deaths occur outside the health-care setting. Clustering using the clinically relevant variables at baseline may help identify individuals at high risk of mortality in SLE, even after adjusting for high disease activity.
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Affiliation(s)
- Chengappa Kavadichanda
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sachit Ganapathy
- Department of Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Deepika Kounassegarane
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Liza Rajasekhar
- Department of Rheumatology, Nizam Institute of Medical Sciences, Hyderabad, India
| | - Bhavani Dhundra
- Department of Rheumatology, Nizam Institute of Medical Sciences, Hyderabad, India
| | - Akansha Srivastava
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sandra Manuel
- Department of Clinical Immunology and Rheumatology, St John's Medical College Hospital, Bengaluru, India
| | - Vineeta Shobha
- Department of Clinical Immunology and Rheumatology, St John's Medical College Hospital, Bengaluru, India
| | - C Brilly Swarna
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - Ashish J Mathew
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - Dalbir Singh
- Department of Nephrology, PGIMER, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, PGIMER, Chandigarh, India
| | | | - Bidyut Das
- Department of Medicine, SCB Medical College, Cuttack, India
| | - Md Dilshad Akhtar
- Department of Rheumatology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Ranjan Gupta
- Department of Rheumatology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Avinash Jain
- Division of Clinical Immunology and Rheumatology, SMS Medical College & Hospital, Jaipur, India
| | - Parasar Ghosh
- Department of Clinical Immunology and Rheumatology, IPGMER, Kolkata, India
| | - Vir Singh Negi
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Amita Aggarwal
- Department of Rheumatology, Nizam Institute of Medical Sciences, Hyderabad, India
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Kavadichanda C, Singh P, Maurya S, Tota S, Kiroubagarin A, Kounassegarane D, Anand S, Negi VS, Aggarwal A. Clinical and serological association of plasma 25-hydroxyvitamin D (25(OH)D) levels in lupus and the short-term effects of oral vitamin D supplementation. Arthritis Res Ther 2023; 25:2. [PMID: 36597127 PMCID: PMC9807987 DOI: 10.1186/s13075-022-02976-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 12/12/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Data on the association of vitamin D levels and clinical phenotype and disease activity in systemic lupus erythematosus (SLE) is controversial. Further, the optimal dose of oral vitamin D supplementation in SLE is not clear. Thus, the present study was designed to determine the association of plasma vitamin D levels with clinical phenotype, disease variables and serology in a large, cohort of SLE from South Asia and to evaluate the short-term effect of two different dosage regimens of oral vitamin D supplementation on disease flares and plasma vitamin D levels. METHODS This is a two-phase study. Phase I was a cross-sectional analytical study of patients from north (26.85° N) and south India (11.94° N). Plasma 25-hydroxyvitamin-D(25(OH)D) was measured, and its association with demography, serology, disease activity, Galectin-9 and CXCL-10 was analysed. In phase II, patients with SLEDAI-2KG < 10 and on stable immunosuppression were randomised to receive either high dose (weekly 60,000 U*5, followed by 60,000 U monthly) or routine dose (30,000 U monthly) oral vitamin D. Outcomes were assessed at 6 months RESULTS: Phase I included 702 patients with a mean age of 29.46 + 10.7 years. The median plasma vitamin D was 22.83 (13.8-31.8) ng/ml. Deficiency (< 20 ng/ml) was seen in 41.5% of patients. Patients from South India had higher vitamin D levels (27.06 ± 20.21 ng/dl) as compared to North India (17.15 ± 16.07 ng/ml) (p < 0.01). Univariate analyses demonstrated weak negative correlation of vitamin D with SLEDAI2K and positive correlation with age. Galactin-9 had modest correlation with SLEDAI2K but not with vitamin D levels. On multiple linear regression, centre of recruitment (β = 4.37) and age (β = 0.18) predicted (p < 0.05) plasma vitamin D levels. In the phase II, 91 randomised to 2 groups completed 6 months. Median change in plasma vitamin D levels was more in high dose (9.5 versus 2.6 ng/ml; p = 0.04). There were 14 SLE flares and six minor adverse events which were equal across both groups. CONCLUSION Vitamin D deficiency is common in SLE. Geographical location of residence is the major determinant rather than the disease activity. The IFN regulated proteins reflect disease activity independent of vitamin D levels. High-dose oral vitamin D supplementation seems safe and more effective in improving vitamin D levels in SLE. TRIAL REGISTRATION The second phase of this study was a registered randomised controlled trial CTRI/2019/06/019658 [registered on: 14/06/2019].
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Affiliation(s)
- Chengappa Kavadichanda
- grid.414953.e0000000417678301Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Pratibha Singh
- grid.263138.d0000 0000 9346 7267Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Supriya Maurya
- grid.263138.d0000 0000 9346 7267Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sneha Tota
- grid.263138.d0000 0000 9346 7267Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Aberaame Kiroubagarin
- grid.414953.e0000000417678301Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Deepika Kounassegarane
- grid.414953.e0000000417678301Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Swathi Anand
- grid.414953.e0000000417678301Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Vir Singh Negi
- grid.414953.e0000000417678301Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India ,grid.413618.90000 0004 1767 6103All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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