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Cornudella Lema J, Sánchez-González B, Carrión-Barberà I, Vázquez Montes de Oca S, García Pallarols F, Salman-Monte TC. Immune thrombocytopenia in systemic lupus erythematosus: Prevalence, risk factors, and a novel predictive model for risk assessment. Med Clin (Barc) 2024; 162:461-469. [PMID: 38383267 DOI: 10.1016/j.medcli.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/05/2023] [Accepted: 12/08/2023] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Immune thrombocytopenia (ITP) is a potentially severe manifestation of systemic lupus erythematosus (SLE) reported in 7-40% of SLE patients. ITP has been associated with a higher risk of organ damage and mortality. OBJECTIVES To describe which factors are associated with the presence of ITP in SLE patients. METHODS Retrospective case-control study. Cases were defined as SLE patients who had ever developed ITP and were sex- and age-matched with two controls. A predictive model was constructed to identify SLE patients who were at risk of developing ITP. RESULTS ITP prevalence in our SLE cohort was 8.35%. Cases had a higher frequency of hemolytic anemia, while controls had a higher prevalence of arthritis at SLE diagnosis. During SLE progression, cases tested positive for anticardiolipin, anti-β2-glycoprotein 1, and lupus anticoagulant antibodies more frequently. Cases received mycophenolic acid and azathioprine more often than controls and had a higher SLICC/ACR score. The model demonstrated a sensitivity of 87.53%, a positive predictive value of 81.92%, a specificity of 80.50%, area under the curve of 83.92%, a F1 of 83% and an overall accuracy of 83.68%. The variables that best explain the model were hemolytic anemia, arthritis, oral ulcers, Raynaud's phenomenon, low C4, low CH50, anticardiolipin and anti-β2GP1 antibodies. CONCLUSION SLE patients who develop ITP have a distinct phenotype characterized by more hemolytic anemia and less arthritis at SLE onset, and higher prevalence of antiphospholipid syndrome antibodies during SLE progression. This phenotype is associated with heightened organ damage and the need for more intensive therapies and stricter follow-up. Our predictive model has demonstrated an impressive ability to identify SLE patients at risk of developing ITP.
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Affiliation(s)
| | - Blanca Sánchez-González
- Department of Hematology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Research Institute, Barcelona, Spain; Hospital del Mar Autoimmune Diseases and Vasculitis Unit of Excellence Unit Disease, Spain
| | - Irene Carrión-Barberà
- Hospital del Mar Research Institute, Barcelona, Spain; Hospital del Mar Autoimmune Diseases and Vasculitis Unit of Excellence Unit Disease, Spain; Department of Rheumatology, Hospital del Mar, Barcelona, Spain.
| | | | - Francesc García Pallarols
- Department of Hematology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Research Institute, Barcelona, Spain
| | - Tarek Carlos Salman-Monte
- Hospital del Mar Research Institute, Barcelona, Spain; Hospital del Mar Autoimmune Diseases and Vasculitis Unit of Excellence Unit Disease, Spain; Department of Rheumatology, Hospital del Mar, Barcelona, Spain
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Lao C, White D, Rabindranath K, Dantzig PV, Foxall D, Lawrenson R. Mortality and causes of death in systemic lupus erythematosus in New Zealand: a population-based study. Rheumatology (Oxford) 2024; 63:1560-1567. [PMID: 37632770 PMCID: PMC11147544 DOI: 10.1093/rheumatology/kead427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/24/2023] [Accepted: 08/02/2023] [Indexed: 08/28/2023] Open
Abstract
OBJECTIVES This study aims to assess the mortality of systemic lupus erythematosus (SLE) patients and examine whether there are variations by subgroup. METHODS SLE patients from 2005 to 2021 were identified from the national administrative datasets. The underlying causes of death were examined. Standardized mortality ratio (SMR) was estimated to compare the relative rate of observed deaths in SLE patients with expected deaths in the general population. The hazard ratios (HR) and 95% confidence intervals (CI) of all-cause mortality and SLE specific mortality by ethnicity were estimated after adjustment for age using a Cox proportional hazards model. RESULTS Of the 2802 patients included for analysis, 699 (24.9%) died with 209 (29.9%) SLE deaths. The age-standardized mortality rate of SLE was 0.29 per 100 000 for women and 0.05 for men. The mean age at death was 65.3 (17.1) years. Younger patients were more likely to have SLE as the underlying cause of death, from 78.9% for those under 20 years old to 18.7% for those aged 70-79 years. Compared with the general population, SLE patients were four times more likely to die (SMR: 4.0; 95% CI: 3.7, 4.3). Young patients had higher SMRs than older patients. Māori had worse all-cause mortality (HR: 1.72; 95% CI: 1.10, 2.67) and SLE specific mortality (HR: 2.60; 95% CI: 1.29, 5.24) than others. CONCLUSIONS The outcomes of SLE in New Zealand were still very poor compared with the general population. Māori with SLE had worse survival than others. Further research is needed to identify the reasons for this disparity.
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Affiliation(s)
- Chunhuan Lao
- Medical Research Centre, The University of Waikato, Hamilton, New Zealand
| | - Douglas White
- Rheumatology Department, Waikato Hospital, Hamilton, New Zealand
| | | | | | - Donna Foxall
- Te Huataki Waiora—School of Health, The University of Waikato, Hamilton, New Zealand
| | - Ross Lawrenson
- Medical Research Centre, The University of Waikato, Hamilton, New Zealand
- Strategy and Funding, Waikato Hospital, Hamilton, New Zealand
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Ramnarain A, Liam C, Milea D, Morand E, Kent J, Kandane-Rathnayake R. Predictors of Organ Damage in Systemic Lupus Erythematosus in the Asia Pacific Region: A Systematic Review. Arthritis Care Res (Hoboken) 2024; 76:720-732. [PMID: 38191962 DOI: 10.1002/acr.25291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/21/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024]
Abstract
OBJECTIVE Irreversible organ damage is common in patients with systemic lupus erythematosus (SLE). Despite evidence of increased prevalence and severity of SLE in Asia Pacific, organ damage is less well studied in this region. This systematic review aims to identify predictors of organ damage in SLE in the Asia Pacific region. METHODS We searched Medline, PubMed, Embase, and Web of Science for observational studies on organ damage in adult patients with SLE in Asia Pacific from August 31, to September 5, 2022. Study selection and data extraction were completed by two independent reviewers using Covidence systematic review software. Risk of bias was assessed using the Newcastle-Ottawa Scale and Joanna Briggs Institute tool. Significant results from univariable and multivariable analyses were synthesized from included studies. RESULTS Thirty-eight eligible studies were selected from 1999 to 2022; 22 (58%) of these reported organ damage at study enrollment and 19 (50%) reported damage accrual, as measured by the Systemic Lupus International Collaborating Clinic/American College of Rheumatology Damage Index. Factors predictive of organ damage included older age, glucocorticoid use, longer disease duration, and disease activity. Lupus nephritis was a risk factor for renal and overall damage accrual. Hydroxychloroquine was protective against overall organ damage. CONCLUSION Predictors of organ damage in SLE in Asia Pacific are similar to other regions. Although glucocorticoid use is a modifiable risk factor for organ damage, the impact of immunosuppressives and biologic therapies needs further investigation. Effective strategies in early disease are needed to minimize initial organ damage as it predicts subsequent damage accrual.
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Affiliation(s)
- Arushi Ramnarain
- Monash University and Monash Health, Melbourne, Victoria, Australia
| | | | | | - Eric Morand
- Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Joanna Kent
- Monash Health, Melbourne, Victoria, Australia
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Li J, Peng L, Wu L, Ding Y, Duan X, Xu J, Wei W, Chen Z, Zhao C, Yang M, Jiang N, Zhang S, Wang Q, Tian X, Li M, Zeng X, Zhao Y, Zhao J. Antiphospholipid antibodies as potential predictors of disease severity and poor prognosis in systemic lupus erythematosus-associated thrombocytopenia: results from a real-world CSTAR cohort study. Arthritis Res Ther 2024; 26:67. [PMID: 38475924 DOI: 10.1186/s13075-024-03305-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/08/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND To investigate the role of antiphospholipid antibodies (aPLs) in the disease severity and prognosis of SLE-related thrombocytopenia (SLE-TP). METHODS This multicenter prospective study was conducted based on data from the CSTAR registry. TP was defined as a platelet count<100 × 109/L. Demographic characteristics, platelet count, clinical manifestations, disease activity, and autoantibody profiles were collected at baseline. Relapse was defined as the loss of remission. Bone marrow aspirate reports were also collected. RESULTS A total of 350 SLE-TP patients with complete follow-up data, 194 (55.4%) were aPLs positive. At baseline, SLE-TP patients with aPLs had lower baseline platelet counts (61.0 × 109/L vs. 76.5 × 109/L, P<0.001), and a higher proportion of moderate to severe cases (24.2% vs. 14.1% ; 18.0% vs. 8.3%, P<0.001). SLE-TP patients with aPLs also had lower platelet counts at their lowest point (37.0 × 109/L vs. 51.0 × 109/L, P = 0.002). In addition, thean increasing number of aPLs types was associated with a decrease in the baseline and minimum values of platelets ( P<0.001, P = 0.001). During follow-up, SLE-TP carrying aPLs had a higher relapse rate (58.2% vs. 44.2%, P = 0.009) and a lower complete response (CR) rate. As the types of aPLs increased, the relapse rate increased, and the CR rate decreased. Furthermore, there was no significant difference in the ratio of granulocytes to red blood cells (G/E), the total number of megakaryocyte and categories. CONCLUSION SLE-TP patients with positive aPLs had more severe disease a lower remission rate but a higher relapse rate.
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Affiliation(s)
- Jun Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Ministry of Education, Beijing, 100730, China
| | - Liying Peng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Ministry of Education, Beijing, 100730, China
| | - Lijun Wu
- Department of Rheumatology and Immunology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, 830001, China
| | - Yufang Ding
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Ministry of Education, Beijing, 100730, China
| | - Xinwang Duan
- Department of Rheumatology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Jian Xu
- Department of Rheumatology and Immunology, First Affiliated Hospital of Kunming Medical University, Kunming, 650032, China
| | - Wei Wei
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Zhen Chen
- Department of Rheumatology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, China
| | - Cheng Zhao
- Department of Rheumatology and Immunology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021, China
| | - Min Yang
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Nan Jiang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Ministry of Education, Beijing, 100730, China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Ministry of Education, Beijing, 100730, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Ministry of Education, Beijing, 100730, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Ministry of Education, Beijing, 100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Ministry of Education, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Ministry of Education, Beijing, 100730, China.
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Ministry of Education, Beijing, 100730, China.
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Ministry of Education, Beijing, 100730, China.
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Mohamed SS, Gamal SM, Mokbel A, Alkamary AK, Siam I, Soliman A, Elgengehy FT. Thrombocytopenia and disease outcomes in a cohort of patients with systemic lupus erythematosus. A post hoc analysis of the COMOSLE-EGYPT study. Int J Rheum Dis 2024; 27:e15016. [PMID: 38200649 DOI: 10.1111/1756-185x.15016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 11/09/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Thrombocytopenia ranges from 20% to 40% in patients with systemic lupus erythematosus (SLE). It is usually associated with severe disease manifestations and worse disease outcomes. AIM OF THE STUDY To identify the frequency of thrombocytopenia in a cohort of Egyptian patients with SLE and to examine the relationship of thrombocytopenia with various disease manifestations and disease outcomes. METHODS Data on 902 SLE patients were collected, including demographics, clinical, laboratory, immunological findings, and medications. SLE Disease Activity Index (SLEDAI) at baseline, last visit, and Systemic Lupus International Collaborating Clinics/ACR Damage Index (SLICC) were calculated. A comparison was done between patients with thrombocytopenia (group I) and patients without (group II) regarding different disease parameters. Regression analysis was done to examine if thrombocytopenia is a predictor of worse disease outcomes. RESULTS Thrombocytopenia was found in 33% of our cohort. Longer disease duration was observed in group I compared to group II (p value = .01). As regards clinical manifestations, significantly higher frequencies of constitutional manifestations, anemia, arterial thrombosis, pulmonary hypertension, cardiac manifestations, neurological manifestations, gastrointestinal tract (GIT), and hepatic manifestations were detected in group I compared to group II. The disease damage index was detected to be significantly higher in group I as compared to group II (p value < .001). Mortality was higher in group I (p value < .001). Although it was found that antiphospholipid antibodies (APL) were associated with thrombocytopenia and their presence resulted in higher damage (p value: .001), the presence of thrombocytopenia even in patients with negative APL antibodies was associated with higher damage and mortality. Apart from thrombocytopenia, the male gender was also found to be an independent risk factor for mortality. CONCLUSION Thrombocytopenia was associated with more organ damage and higher mortality in SLE patients with or without APL antibodies. SLE patients with thrombocytopenia have a 3.4 times higher risk of mortality than patients without thrombocytopenia. Apart from thrombocytopenia, the male gender was also found to be an independent risk factor for mortality.
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Affiliation(s)
| | | | - Abir Mokbel
- Rheumatology Department, Cairo University, Cairo, Egypt
| | | | - Ibrahem Siam
- Internal Medicine Department, National Research Center, Giza, Egypt
| | - Ahmed Soliman
- Dermatology Department, National Research Center, Giza, Egypt
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Robert M, Scherlinger M. Platelets are a major player and represent a therapeutic opportunity in systemic lupus erythematosus. Joint Bone Spine 2024; 91:105622. [PMID: 37495075 DOI: 10.1016/j.jbspin.2023.105622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 07/28/2023]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by immune dysregulation and organ injury with a premature mortality due to cardiovascular diseases. Platelets, that are primarily known for their role in hemostasis, have been shown to play an active role in the pathogenesis and in the progression of immune-mediated inflammatory diseases. Here we summarize the evidence of their roles in SLE pathogenesis which supports the development of targeted treatments. Platelets and their precursors, the megakaryocytes, are intrinsically different in SLE patients compared with healthy controls. Different triggers related to innate and adaptive immunity activate platelets which release extracellular vesicles, soluble factors and interact with immune cells, thereby perpetuating inflammation. Platelets are involved in organ damage in SLE, especially in lupus nephritis and participate in the heightened cardiovascular mortality. They also play a clear role in antiphospholipid syndrome which can be associated with both thrombocytopenia and thrombosis. To tackle platelet activation and their interactions with immune cells now constitute promising therapeutic strategies in SLE.
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Affiliation(s)
- Marie Robert
- Service de médecine interne et immunologie clinique, centre hospitalier universitaire Édouard-Herriot, hospices civils de Lyon, Lyon, France
| | - Marc Scherlinger
- Service de rhumatologie, centre hospitalier universitaire de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France; Laboratoire d'immuno-rhumatologie moléculaire, Institut national de la santé et de la recherche médicale (Inserm) UMR S 1109, Strasbourg, France; Centre national de référence des maladies auto-immunes et systémiques rares, Est/Sud-Ouest (RESO), France.
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Shobha V, Rajasekhar L, Bhat V, Mathew AJ, Kavadichanda C, Rathi M, Gupta R, Selvam S, Aggarwal A. Severe thrombocytopenia is associated with high mortality in systemic lupus erythematosus-analysis from Indian SLE Inception cohort for Research (INSPIRE). Clin Rheumatol 2023; 42:2279-2285. [PMID: 37270720 DOI: 10.1007/s10067-023-06641-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/18/2023] [Accepted: 05/20/2023] [Indexed: 06/05/2023]
Abstract
Thrombocytopenia in patients with systemic lupus erythematosus (SLE) is associated with higher morbidity and mortality. We report frequency, associations and short-term outcome of moderate-severe thrombocytopenia in a prospective inception cohort from India (INSPIRE). We evaluated consecutive SLE patients classified per SLICC2012 for the occurrence of thrombocytopenia and its associations. The outcomes assessed included bleeding manifestations, kinetics of thrombocytopenia recovery, mortality and recurrence of thrombocytopenia. Among a total of 2210 patients in the cohort, 230 (10.4%) had incident thrombocytopenia, of whom moderate (platelet count [PC] 20-50 × 109/L) and severe thrombocytopenia (PC < 20 × 109/L) were noted in 61 (26.5%) and 22 (9.5%), respectively. Bleeding manifestations were generally limited to the skin. Compared to controls, cases had a higher proportion of autoimmune haemolytic anaemia (p < 0.001), leukopenia (p < 0.001), lymphopenia (p < 0.001), low complement (p < 0.05), lupus anticoagulant (p < 0.001), higher median SLEDAI 2 K (p < 0.001) and lower proportion of anti-RNP antibody (p < 0.05). There was no significant difference in these variables between moderate and severe thrombocytopenia. There was a sharp rise in PC by 1 week that was sustained in the majority through the period of observation. There was three times higher mortality in the severe thrombocytopenia group as compared to moderate thrombocytopenia and controls. The thrombocytopenia relapse and lupus flare rates were similar across categories. We report a low occurrence of major bleeds and higher mortality in those with severe thrombocytopenia as compared to moderate thrombocytopenia and controls. Key Points • Severe thrombocytopenia occurs in 1% of patients with SLE; however, major bleeds are uncommon. • Thrombocytopenia has a strong association with other lineage cytopenias and lupus anticoagulants. • Response to initial glucocorticoids therapy is quick and is well sustained with additional immunosuppressants. • Severe thrombocytopenia increases mortality threefold in SLE.
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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 & Rheumatology, Nizam Institute of Medical Sciences, Hyderabad, India
| | - Vasudha Bhat
- Department of Clinical Immunology and Rheumatology, St. John's Medical College Hospital, Bengaluru, India
| | - Ashish J Mathew
- Department of Clinical Immunology & Rheumatology, Christian Medical College, Vellore, India
| | - Chengappa Kavadichanda
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ranjan Gupta
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India
| | - Sumithra Selvam
- Division of Epidemiology and Biostatistics, St. John's Research Institute, Bengaluru, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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Law AH, Chuah TY, Lee W, Teng GG, Lian TY, Saffari SE, Chew LC. Diffuse alveolar haemorrhage in systemic lupus erythematosus: A multicentre retrospective study in Singapore. Lupus 2023:9612033231180704. [PMID: 37268601 DOI: 10.1177/09612033231180704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Diffuse alveolar haemorrhage (DAH) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). We describe the clinical characteristics, treatment and survival outcomes of SLE patients with DAH in Singapore. METHODS We conducted a retrospective review of the medical records of SLE patients with DAH hospitalised in 3 tertiary hospitals between January 2007 and October 2017. Patient demographics, clinical characteristics, laboratory, radiologic and bronchoscopic findings, as well as the treatments, were compared between survivors and non-survivors. Survival rates were analysed between the various treatment groups. RESULTS A total of 35 patients with DAH were included in this study. Majority of them were female (71.4%) and of Chinese ethnicity (62.9%). Median age was 40.0 years (IQR: 25-54), with a median disease duration of 8.9 months (IQR: 0.13-102.4). Haemoptysis was the most common clinical presentation, and majority had concomitant cytopaenia and lupus nephritis. All patients received high dose glucocorticoids; 27 (77.1%), 16 (45.7%) and 23 (65.7%) received cyclophosphamide (CYP), rituximab (RTX), and plasmapheresis (PLEX), respectively. Twenty-two patients required mechanical ventilation with a median duration of 12 days. Overall mortality rate was 40%, with a median survival time of 162 days. Twenty-six patients (74.3%) achieved remission, with an overall median time to remission of 12 days (IQR: 6-46) after diagnosis of DAH. Patients on triple therapy (CYP, RTX and PLEX) had a median survival of 162 days as compared to 14 days in patients on PLEX alone (p = .0026). CONCLUSIONS The overall mortality of DAH in SLE patients remained high. There were no significant differences in patient demographics or clinical characteristics between the survivors and non-survivors. However, better survival appears to be associated with treatment with cyclophosphamide.
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Affiliation(s)
- Annie Hn Law
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tyng Yu Chuah
- Department of General Medicine (Rheumatology), Sengkang General Hospital, Singapore
| | - Weixian Lee
- Department of Medicine (Rheumatology), Ng Teng Fong General Hospital, Singapore
| | - Gim Gee Teng
- Department of Rheumatology, National University Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tsui Yee Lian
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Seyed Ehsan Saffari
- Centre for Quantitative Medicine, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Li-Ching Chew
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Chen H, Liang Y, Wang R, Wu Y, Zhang X, Huang H, Yu X, Hong M, Yang J, Liao K, Xu H, Liu M, Chen P, Chen Y. Metagenomic next-generation sequencing for the diagnosis of Pneumocystis jirovecii Pneumonia in critically pediatric patients. Ann Clin Microbiol Antimicrob 2023; 22:6. [PMID: 36647095 PMCID: PMC9841943 DOI: 10.1186/s12941-023-00555-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 01/05/2023] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the effectiveness of metagenomic next-generation sequencing (mNGS) for the diagnosis of Pneumocystis jirovecii Pneumonia (PCP) in critically pediatric patients. METHODS Seventeen critically pediatric patients with PCP and sixty patients diagnosed with non-PCP pneumonia who were admitted in pediatric intensive care unit between June 2018 and July 2021 were enrolled. Conventional methods and mNGS for detecting Pneumocystis jirovecii (P. jirovecii) were compared. The patients' demographics, comorbidities, laboratory test results, antibiotic treatment response and 30 day mortality were analyzed. RESULT The mNGS showed a satisfying diagnostic performance with a sensitivity of 100% in detecting P. jirovecii compared with Gomori methenamine silver staining (5.9%), serum (1,3)-β-D-glucan (86.7%) and and LDH (55.6%). The diagnostic specificity of mNGS for PCP was higher than that of serum BDG (56.7%) and LDH (71.4%). In PCP group, over one thirds' cases had mixed infections. Compared with survivors, non-survivors had higher stringently mapped read numbers (SMRNs) in bronchoalveolar lavage fluid (BALF) sample (P < 0.05), suggesting SMRNs were closely associated with the severity of response. The detection for P. jirovecii by mNGS both in BALF and blood samples reached a concordance rate of 100%, and the SMRNs in the BALF were remarkably higher than that in blood samples. Initial antimicrobial treatment was modified in 88.2% of PCP patients based on the mNGS results. CONCLUSION The mNGS is a potential and efficient technology in diagnosing PCP and shows a satisfying performance in the detection of co-pathogens. Both blood and BALF samples for mNGS are suggested for the presumptive diagnosis of PCP.
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Affiliation(s)
- Hengxin Chen
- grid.412615.50000 0004 1803 6239Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080 Guangdong China
| | - Yujian Liang
- grid.412615.50000 0004 1803 6239Department of Pediatric Intensive Care Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080 Guangdong China
| | - Ruizhi Wang
- grid.412615.50000 0004 1803 6239Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080 Guangdong China
| | - Yijie Wu
- grid.12981.330000 0001 2360 039XZhongshan School of Medicine, Sun Yat-Sen University, Guangdong, China
| | - Xiaoyun Zhang
- grid.12981.330000 0001 2360 039XZhongshan School of Medicine, Sun Yat-Sen University, Guangdong, China
| | - Hao Huang
- grid.412615.50000 0004 1803 6239Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080 Guangdong China
| | - Xuegao Yu
- grid.412615.50000 0004 1803 6239Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080 Guangdong China
| | - Mengzhi Hong
- grid.412615.50000 0004 1803 6239Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080 Guangdong China
| | - Juhua Yang
- grid.508230.cVision Medicals Co., Ltd, Guangzhou, China
| | - Kang Liao
- grid.412615.50000 0004 1803 6239Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080 Guangdong China
| | - Hongxu Xu
- grid.412615.50000 0004 1803 6239Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080 Guangdong China
| | - Min Liu
- grid.412615.50000 0004 1803 6239Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080 Guangdong China
| | - Peisong Chen
- grid.412615.50000 0004 1803 6239Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080 Guangdong China
| | - Yili Chen
- grid.412615.50000 0004 1803 6239Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080 Guangdong China
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10
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Aguirre A, Izadi Z, Trupin L, Barbour KE, Greenlund KJ, Katz P, Lanata C, Criswell L, Dall’Era M, Yazdany J. Race, Ethnicity, and Disparities in the Risk of End-Organ Lupus Manifestations Following a Systemic Lupus Erythematosus Diagnosis in a Multiethnic Cohort. Arthritis Care Res (Hoboken) 2023; 75:34-43. [PMID: 35452566 PMCID: PMC9587136 DOI: 10.1002/acr.24892] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/22/2022] [Accepted: 04/07/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Data on the onset of lupus manifestations across multiple organ domains and in diverse populations are limited. The objective was to analyze racial and ethnic differences in the risk of end-organ lupus manifestations following systemic lupus erythematosus (SLE) diagnosis in a multiethnic cohort. METHODS The California Lupus Epidemiology Study (CLUES) is a longitudinal study of SLE. Data on major end-organ lupus manifestations were collected and categorized by organ system: renal, hematologic, neurologic, cardiovascular, and pulmonary. Multiorgan disease was defined as manifestations in ≥2 of these distinct organ systems. Kaplan-Meier curves assessed end-organ disease-free survival, and Cox proportional hazards regression estimated the rate of end-organ disease following SLE diagnosis, adjusting for age at diagnosis, sex, and self-reported race and ethnicity (White, Hispanic, Black, and Asian). RESULTS Of 326 participants, 89% were female; the mean age was 45 years. Self-reported race and ethnicity were 30% White, 23% Hispanic, 11% Black, and 36% Asian. Multiorgan disease occurred in 29%. Compared to White participants, Hispanic and Asian participants had higher rates, respectively, of renal (hazard ratio [HR] 2.9 [95% confidence interval (95% CI) 1.8-4.7], HR 2.9 [95% CI 1.9-4.6]); hematologic (HR 2.7 [95% CI 1.3-5.7], HR 2.1 [95% CI 1.0-4.2]); and multiorgan disease (HR 3.3 [95% CI 1.8-5.9], HR 2.5 [95% CI 1.4-4.4]) following SLE diagnosis. CONCLUSION We found heightened risks of developing renal, hematologic, and multiorgan disease following SLE diagnosis among Hispanic and Asian patients with SLE, as well as a high burden of multiorgan disease among CLUES participants.
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Affiliation(s)
- Alfredo Aguirre
- University of California, San Francisco, Division of Rheumatology, Department of Medicine
| | - Zara Izadi
- University of California, San Francisco, Division of Rheumatology, Department of Medicine
| | - Laura Trupin
- University of California, San Francisco, Division of Rheumatology, Department of Medicine
| | | | | | - Patti Katz
- University of California, San Francisco, Division of Rheumatology, Department of Medicine
| | - Cristina Lanata
- National Human Genome Research Institute, National Institutes of Health
| | - Lindsey Criswell
- National Human Genome Research Institute, National Institutes of Health
| | - Maria Dall’Era
- University of California, San Francisco, Division of Rheumatology, Department of Medicine
| | - Jinoos Yazdany
- University of California, San Francisco, Division of Rheumatology, Department of Medicine
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11
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Ullah S, Haroon M, Hashmi F, Tayyab Z, Javed S. A Prospective Follow-Up Study on the Disease Course and Predictors of Poor Outcomes in a Random Population-Based Cohort of Newly Diagnosed Lupus Patients. Cureus 2022; 14:e27430. [PMID: 36051712 PMCID: PMC9420196 DOI: 10.7759/cureus.27430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 11/05/2022] Open
Abstract
Background and objective Systemic lupus erythematosus (SLE) is one of the most devastating systemic autoimmune connective tissue diseases. There is a paucity of prospective data on Pakistani SLE patients, and in this prospective study, we aimed to investigate the disease course, clinical outcomes, and the predictors of poor outcomes in a random population-based cohort of newly diagnosed SLE patients (diagnosed within the last one year). Methods This was a prospective observational study carried out in the rheumatology department of the Fatima Memorial Hospital, Lahore. Lupus patients are regularly reviewed in our dedicated lupus clinic every one to three months. For the purpose of this study, a focus group of newly diagnosed patients (diagnosed within the last one year) attending our lupus clinic was identified and prospectively followed up for 12 months. A wide range of demographical and clinical parameters was recorded. The association of clinical variables with the progressive disease was determined using univariate and multivariate logistic regressions. Results Prospective data of 89 newly diagnosed SLE patients regularly attending our dedicated lupus clinic were reviewed. During the study period, (January 2021 through January 2022), these patients had multiple visits overall - median: five, minimum: three, and maximum: nine visits [interquartile range (IQR) 4-7]. All 89 patients had completed one year of follow-up. Of note, 46% of the cohort was noted to have an ongoing active disease during the majority of visits in the study period. On multiple logistic regression analysis, there was a significant association between ongoing active disease ("progressors") and low education status [odds ratio (OR): 2.81, 95% confidence interval (CI): 1.01-7.76, p=0.046], stress at home (OR: 5.8, 95% CI: 2.13-15.8, p=0.001), and hematologic manifestations (OR: 3.0, 95% CI: 1.08-8.32, p=0.03). Conclusions Almost half of our cohort of lupus patients demonstrated active disease manifestations throughout the one-year prospective follow-up, and these were found to be associated with low education status, stress at home, and hematological manifestations.
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12
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Santacruz JC, Mantilla MJ, Rueda I, Pulido S, Rodriguez-Salas G, Londono J. A Practical Perspective of the Hematologic Manifestations of Systemic Lupus Erythematosus. Cureus 2022; 14:e22938. [PMID: 35399432 PMCID: PMC8986464 DOI: 10.7759/cureus.22938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 12/15/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic inflammatory disease with an unknown etiology that can affect any organ or system of the human body. Hematological, renal, or central nervous system manifestations in these patients result in great morbidity because high doses of glucocorticoids, cytotoxic medications, or biological drugs are required to control these manifestations. It is noteworthy that hematological involvement predominates during the first years of the disease and tends to last over time, with the premise that it may be the initial manifestation of the disease. Clear examples of this are the cases of hemolytic anemia and immune thrombocytopenia that can be initially classified as idiopathic or primary to be later classified as secondary when associated with infections, medications, neoplasms, or autoimmune diseases. The spectrum of hematologic manifestations in SLE is very broad, including lymphopenia, anemia, thrombocytopenia, or pancytopenia. In some cases, lymphadenopathy and splenomegaly are also identified. The vast majority of these manifestations denote high disease activity. However, many of these alterations have a multifactorial cause that must be taken into account to adopt a more complete therapeutic approach. The objective of this review is to characterize in detail the hematological manifestations of SLE to offer clinicians a practical vision of its diagnosis and treatment.
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13
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Lee MH, Koh JWH, Ng CH, Lim SHH, Cho J, Lateef A, Mak A, Tay SH. A meta-analysis of clinical manifestations in asian systemic lupus erythematous: The effects of ancestry, ethnicity and gender. Semin Arthritis Rheum 2021; 52:151932. [PMID: 34996626 DOI: 10.1016/j.semarthrit.2021.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 11/17/2021] [Accepted: 12/06/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Systemic lupus erythematosus (SLE) in Asians is a unique patient group that has been thought to present with more severe organ involvement in comparison to their non-Asian counterparts. We set out to perform a meta-analysis to compare clinical manifestations between ancestries, with a focus on Southeast Asian ethnicities and gender. MATERIALS AND METHODS A cross-sectional study was performed in conjunction with a meta-analysis to identify differences in prevalences of SLE clinical manifestations. Searches were conducted on Medline for articles comparing between: (i) Asian and non-Asian ancestry; (ii) Southeast Asian ethnicities (Chinese, Malay and Indian); and (iii) male and female Asians. Using random effects model, effect sizes as odd ratios were pooled with DerSimonian and Laird's model. RESULTS A total of 13 articles were identified and pooled together with our study for this meta-analysis. Comparing among patients of Asian with Non-Asian/European ancestries, no significance difference was found in severe organ manifestations such as renal and neurological involvement [odds ratio (OR): 1.398, p= 0.320 and OR: 1.224, p= 0.526 respectively]. There was significantly greater proportion of Asian SLE patients with thrombocytopenia compared to non-Asian SLE. Chinese SLE patients were less likely to have oral ulcers compared to Indian SLE patients. Lastly, Asian male SLE patients had greater incidence of renal involvement and thrombocytopenia compared to Asian female SLE patients. CONCLUSIONS Severe SLE manifestations such as renal and neurological involvement were not significantly more frequent in Asian SLE compared to non-Asian/European SLE in this analysis.
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Affiliation(s)
- Ming Hui Lee
- Department of Biological Sciences, Faculty of Science, National University of Singapore, Singapore
| | - Jeffery Wei Heng Koh
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sandy H H Lim
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore
| | - Jiacai Cho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Rheumatology, Department of Medicine, National University Hospital, Singapore
| | - Aisha Lateef
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Rheumatology, Department of Medicine, National University Hospital, Singapore; Department of Medicine, Woodlands Health Campus, Singapore
| | - Anselm Mak
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Rheumatology, Department of Medicine, National University Hospital, Singapore
| | - Sen Hee Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Rheumatology, Department of Medicine, National University Hospital, Singapore.
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14
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Chen Y, Ai L, Zhou Y, Zhao Y, Huang J, Tang W, Liang Y. Rapid and precise diagnosis of pneumonia coinfected by Pneumocystis jirovecii and Aspergillus fumigatus assisted by next-generation sequencing in a patient with systemic lupus erythematosus: a case report. Ann Clin Microbiol Antimicrob 2021; 20:47. [PMID: 34174895 PMCID: PMC8235577 DOI: 10.1186/s12941-021-00448-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/24/2021] [Indexed: 11/26/2022] Open
Abstract
Background Pneumocystis jirovecii and Aspergillus fumigatus, are opportunistic pathogenic fungus that has a major impact on mortality in patients with systemic lupus erythematosus. With the potential to invade multiple organs, early and accurate diagnosis is essential to the survival of SLE patients, establishing an early diagnosis of the infection, especially coinfection by Pneumocystis jirovecii and Aspergillus fumigatus, still remains a great challenge. Case presentation In this case, we reported that the application of next -generation sequencing in diagnosing Pneumocystis jirovecii and Aspergillus fumigatus coinfection in a Chinese girl with systemic lupus erythematosus (SLE). Voriconazole was used to treat pulmonary aspergillosis, besides sulfamethoxazole and trimethoprim (SMZ-TMP), and caspofungin acetate to treat Pneumocystis jirovecii infection for 6 days. On Day 10 of admission, her chest radiograph displayed obvious absorption of bilateral lung inflammation though the circumstance of repeated fever had not improved. Unfortunately, the patient discharged from the hospital since the financial burden, and during the follow-up, it was documented the patient died within one week after discharge. Conclusions This successful application of the next generation sequencing assisting the rapid diagnosis of Pneumocystis jirovecii and Aspergillus fumigatus coinfection provides a new perspective in the clinical approach against the systematic fungi infections and highlights the potential of this technique in rapid etiological diagnosis.
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Affiliation(s)
- Yili Chen
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China
| | - Lu Ai
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China
| | - Yingqun Zhou
- Department of Laboratory Medicine, The First People's Hospital of Nanning, Nanning, 530022, Guangxi, China
| | - Yating Zhao
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China
| | - Jianyu Huang
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China
| | - Wen Tang
- Department of Pediatric Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China.
| | - Yujian Liang
- Department of Pediatric Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China.
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15
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Gheita TA, Noor RA, Abualfadl E, Abousehly OS, El-Gazzar II, El Shereef RR, Senara S, Abdalla AM, Khalil NM, ElSaman AM, Tharwat S, Nasef SI, Mohamed EF, Noshy N, El-Essawi DF, Moshrif AH, Fawzy RM, El-Najjar AR, Hammam N, Ismail F, ElKhalifa M, Samy N, Hassan E, Abaza NM, ElShebini E, Fathi HM, Salem MN, Abdel-Fattah YH, Saad E, Abd Elazim MI, Eesa NN, El-Bahnasawy AS, El-Hammady DH, El-Shanawany AT, Ibrahim SE, Said EA, El-Saadany HM, Selim ZI, Fawzy SM, Raafat HA. Adult systemic lupus erythematosus in Egypt: The nation-wide spectrum of 3661 patients and world-wide standpoint. Lupus 2021; 30:1526-1535. [PMID: 33951965 DOI: 10.1177/09612033211014253] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to present the epidemiology, clinical manifestations and treatment pattern of systemic lupus erythematosus (SLE) in Egyptian patients over the country and compare the findings to large cohorts worldwide. Objectives were extended to focus on the age at onset and gender driven influence on the disease characteristics. PATIENTS AND METHOD This population-based, multicenter, cross-sectional study included 3661 adult SLE patients from Egyptian rheumatology departments across the nation. Demographic, clinical, and therapeutic data were assessed for all patients. RESULTS The study included 3661 patients; 3296 females and 365 males (9.03:1) and the median age was 30 years (17-79 years), disease duration 4 years (0-75 years) while the median age at disease onset was 25 years (4-75 years). The overall estimated prevalence of adult SLE in Egypt was 6.1/100,000 population (1.2/100,000 males and 11.3/100,000 females).There were 316 (8.6%) juvenile-onset (Jo-SLE) and 3345 adult-onset (Ao-SLE). Age at onset was highest in South and lowest in Cairo (p < 0.0001). CONCLUSION SLE in Egypt had a wide variety of clinical and immunological manifestations, with some similarities with that in other nations and differences within the same country. The clinical characteristics, autoantibodies and comorbidities are comparable between Ao-SLE and Jo-SLE. The frequency of various clinical and immunological manifestations varied between gender. Additional studies are needed to determine the underlying factors contributing to gender and age of onset differences.
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Affiliation(s)
- Tamer A Gheita
- Rheumatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rasha Abdel Noor
- Internal Medicine Department, Rheumatology Unit, Tanta University, Gharbia, Egypt
| | - Esam Abualfadl
- Rheumatology Department, Faculty of Medicine, Sohag University, Sohag, Egypt.,Qena/Luxor Hospitals, Qena, Egypt
| | - Osama S Abousehly
- Rheumatology Department, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Iman I El-Gazzar
- Rheumatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rawhya R El Shereef
- Rheumatology Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Soha Senara
- Rheumatology Department, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Ahmed M Abdalla
- Rheumatology Department, Faculty of Medicine, Aswan University, Aswan, Egypt
| | - Noha M Khalil
- Internal Medicine Department, Rheumatology Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed M ElSaman
- Rheumatology Department, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Samar Tharwat
- Rheumatology Unit, Internal Medicine, Mansoura University, Dakahlia, Egypt
| | - Samah I Nasef
- Rheumatology Department, Faculty of Medicine, Suez-Canal University, Ismailia, Egypt
| | - Eman F Mohamed
- Internal Medicine Department, Rheumatology Unit, Faculty of Medicine (Girls), Al-Azhar University, Cairo, Egypt
| | - Nermeen Noshy
- Internal Medicine Department, Rheumatology Unit, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Dina F El-Essawi
- Internal Medicine Department, Rheumatology Unit, Egyptian Atomic Energy Authority (EAEA), Cairo, Egypt
| | - Abdel Hafeez Moshrif
- Rheumatology Department, Faculty of Medicine, Al-Azhar University, Assuit, Egypt
| | - Rasha M Fawzy
- Rheumatology Department, Faculty of Medicine, Benha University, Kalubia, Egypt
| | - Amany R El-Najjar
- Rheumatology Department, Faculty of Medicine, Zagazig University, Sharkia, Egypt
| | - Nevin Hammam
- Rheumatology Department, Faculty of Medicine, Assuit University, Assuit, Egypt.,Rheumatology Department, University of California San Francisco (UCSF), San Francisco, CA, USA
| | - Faten Ismail
- Rheumatology Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Marwa ElKhalifa
- Internal Medicine Department, Rheumatology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Nermeen Samy
- Internal Medicine Department, Rheumatology Unit, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Eman Hassan
- Internal Medicine Department, Rheumatology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Nouran M Abaza
- Rheumatology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Emad ElShebini
- Internal Medicine Department, Rheumatology Unit, Menoufiya University, Menoufiya, Egypt
| | - Hanan M Fathi
- Rheumatology Department, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Mohamed N Salem
- Internal Medicine Department, Rheumatology Unit, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Yousra H Abdel-Fattah
- Rheumatology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ehab Saad
- Rheumatology Department, Faculty of Medicine, South Valley University, Qena, Egypt
| | - Mervat I Abd Elazim
- Rheumatology Department, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Nahla N Eesa
- Rheumatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amany S El-Bahnasawy
- Rheumatology Department, Faculty of Medicine, Mansoura University, Dakahlia, Egypt
| | - Dina H El-Hammady
- Rheumatology Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Amira T El-Shanawany
- Rheumatology Department, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt
| | - Soha E Ibrahim
- Rheumatology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Emtethal A Said
- Rheumatology Department, Faculty of Medicine, Benha University, Kalubia, Egypt
| | - Hanan M El-Saadany
- Rheumatology Department, Faculty of Medicine, Tanta University, Gharbia, Egypt
| | - Zahraa I Selim
- Rheumatology Department, Faculty of Medicine, Assuit University, Assuit, Egypt
| | - Samar M Fawzy
- Rheumatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hala A Raafat
- Rheumatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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16
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Bultink IEM, de Vries F, van Vollenhoven RF, Lalmohamed A. Mortality, causes of death and influence of medication use in patients with systemic lupus erythematosus vs matched controls. Rheumatology (Oxford) 2021; 60:207-216. [PMID: 32653901 PMCID: PMC8312724 DOI: 10.1093/rheumatology/keaa267] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/31/2020] [Indexed: 01/26/2023] Open
Abstract
Objectives We wanted to estimate the magnitude of the risk from all-cause, cause-specific and
sex-specific mortality in patients with SLE and relative risks compared with matched
controls and to evaluate the influence of exposure to medication on risk of mortality in
SLE. Methods We conducted a population-based cohort study using the Clinical Practice Research
Datalink, Hospital Episode Statistics and national death certificates (from 1987 to
2012). Each SLE patient (n = 4343) was matched with up to six controls
(n = 21 780) by age and sex. Cox proportional hazards models were
used to estimate overall and cause-specific mortality rate ratios. Results Patients with SLE had a 1.8-fold increased mortality rate for all-cause mortality
compared with age- and sex-matched subjects [adjusted hazard ratio (HR) = 1.80, 95% CI:
1.57, 2.08]. The HR was highest in patients aged 18–39 years (adjusted HR = 4.87, 95%
CI: 1.93, 12.3). Mortality rates were not significantly different between male and
female patients. Cumulative glucocorticoid use raised the mortality rate, whereas the HR
was reduced by 45% with cumulative low-dose HCQ use. Patients with SLE had
increased cause-specific mortality rates for cardiovascular disease, infections,
non-infectious respiratory disease and for death attributable to accidents or suicide,
whereas the mortality rate for cancer was reduced in comparison to controls. Conclusion British patients with SLE had a 1.8-fold increased mortality rate compared with the
general population. Glucocorticoid use and being diagnosed at a younger age were
associated with an increased risk of mortality. HCQ use significantly reduced the
mortality rate, but this association was found only in the lowest cumulative dosage
exposure group.
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Affiliation(s)
- Irene E M Bultink
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, VU University Medical Center, Amsterdam
| | - Frank de Vries
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht.,Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht
| | - Ronald F van Vollenhoven
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, VU University Medical Center, Amsterdam
| | - Arief Lalmohamed
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
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17
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Michel M, Lega JC, Terriou L. [Secondary ITP in adults]. Rev Med Interne 2020; 42:50-57. [PMID: 33139079 DOI: 10.1016/j.revmed.2020.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 08/07/2020] [Indexed: 12/13/2022]
Abstract
Secondary forms of immune thrombocytopenia (ITP) represent approximately 20% of all ITP cases in adulthood and this rate increases with age. Since some causes may influence both the prognosis and outcome but also the management of ITP, a minimal workup must be performed at ITP diagnosis to look for an associated or underlying cause. Among adults, B-cell lymphomas and mainly chronic lymphocytic leukemia, systemic auto-immune diseases such as systemic lupus or primary immunodeficiencies mainly represented by common variable immunodeficiency are the most frequent causes of secondary ITP. Whereas first-line therapy used for secondary ITP is usually similar to the one commonly used in primary ITP and relies mostly on corticosteroids±intravenous immunoglobulin according to the severity of bleeding, second and third-line treatments must take into account the type and degree of activity of the underlying disease.
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Affiliation(s)
- M Michel
- Service de médecine interne, centre de référence pour les cytopénies auto-immunes de l'adulte, CHU Henri-Mondor, université Paris Est Créteil, Assistance publique-Hôpitaux de Paris, Créteil, France.
| | - J-C Lega
- Service de médecine interne et vasculaire, centre de compétences cytopénies auto-immunes, hôpital Lyon Sud, Lyon, France
| | - L Terriou
- Département de médecine interne et immunologie clinique, CHU de Lille, Lille, France
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Mao YM, Shi PL, Wu L, Hu YQ, He YS, Xiang K, Tao JH, Pan HF, Wu GC. Prevalence and influential factors of thrombocytopaenia in systemic lupus erythematosus patients: a retrospective analysis of 3140 cases in a Chinese population. Lupus 2020; 29:743-750. [DOI: 10.1177/0961203320922301] [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
Introduction The present study aimed to investigate the prevalence and influential factors of thrombocytopaenia in systemic lupus erythematosus (SLE) patients among the Chinese population in order to provide evidence for improving the treatment and nursing of SLE patients. Methods A retrospective analysis of 3140 SLE patients admitted to two large tertiary hospitals was conducted in Anhui, China, from 2011 to 2018. In addition, the influential factors related to SLE with thrombocytopaenia were analysed through univariate and multivariate analysis. Results A total of 804 SLE patients had thrombocytopaenia (25.6%). The top 5 clinical manifestations of SLE inpatients were proteinuria (51.0%), lupus nephritis (45.9%), new rash (38.4%), haematuria (36.7%) and pyuria (32.2%). The incidence of neurological manifestations, oral mucosal ulceration, pleurisy, pericarditis, hyperglycaemia, leucocytopaenia, urinary casts, haematuria, pyuria and high disease activity in the thrombocytopaenia group were higher than those in the non-thrombocytopaenia group ( p < 0.05). Multivariate analysis showed age (odds ratio (OR) = 1.009, p = 0.005), neurological manifestations (OR = 1.373, p = 0.048), pericarditis (OR = 1.394, p = 0.048), hyperglycaemia (OR = 1.717, p < 0.001), leucocytopaenia (OR = 2.551, p < 0.001), haematuria (OR = 1.582, p < 0.001), serum C3 level <0.85 g/L (OR = 1.525, p = 0.001), serum C4 concentration <0.10 g/L (OR = 1.287, p = 0.020), serum CRP concentration <8 ng/L (OR = 1.314, p = 0.005), prothrombin time >15.30 seconds (OR = 1.479, p = 0.032), activated partial thromboplatin time >45 seconds (OR = 1.924, p < 0.001) and thrombin time >21 seconds (OR = 1.629, p = 0.015) were associated with thrombocytopaenia. Conclusion Thrombocytopaenia has a high prevalence in SLE patients and is related to some baseline, clinical and laboratory characteristics, affecting multiple organs and systems.
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Affiliation(s)
- Yan-Mei Mao
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, PR China
| | - Pei-Li Shi
- School of Nursing, Anhui Medical University, Anhui, PR China
| | - Li Wu
- School of Nursing, Anhui Medical University, Anhui, PR China
| | - Yu-Qian Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, PR China
| | - Yi-Sheng He
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, PR China
| | - Kun Xiang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, PR China
| | - Jin-Hui Tao
- Department of Rheumatology and Immunology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, PR China
| | - Hai-Feng Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, PR China
| | - Guo-Cui Wu
- School of Nursing, Anhui Medical University, Anhui, PR China
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19
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Anver H, Dubey S, Fox J. Changing trends in mortality in systemic lupus erythematosus? An analysis of SLE inpatient mortality at University Hospital Coventry and Warwickshire NHS Trust from 2007 to 2016. Rheumatol Int 2019; 39:2069-2075. [PMID: 31570977 DOI: 10.1007/s00296-019-04450-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 09/19/2019] [Indexed: 01/08/2023]
Abstract
The aim of this study was to determine the causes of mortality in patients with systemic lupus erythematosus (SLE) at the University Hospital Coventry and Warwickshire (UHCW) NHS Trust over a 10 year period. This was a retrospective study of patients who had died in UHCW NHS Trust between 2007 and 2016, where SLE or lupus was mentioned on the death certificate. Ethics approval was obtained from the Research and Development. We identified 22 patients out of 1979 admissions with SLE who had died during the period between 2007 and 2016, 7 of these patients were under 50 years of age. The leading cause of death was infection with pneumococcus being associated with two deaths. Active disease was associated with younger age at death. Median age at death was 58.5 years, with median duration of disease of 14.5 years. Constitutional and mucocutaneous features were the most common items scoring on disease activity, seen in 68.2% and 45.45%, respectively. We identified three patients with biopsy proven lupus nephritis and one patient with CNS lupus. Surprisingly, none of the patients died because of vascular problems. The study suggests a changing trend in SLE mortality with none of the deaths in this cohort being due to cardiovascular or cerebrovascular disease. Infection continues to be the biggest reason for mortality in this cohort and greater emphasis is needed on vaccination for preventable infections like pneumococcus.
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Affiliation(s)
- Himashi Anver
- Dept of Rheumatology, Portsmouth Hospitals Trust, Cosham, Portsmouth, PO6 3LY, UK
| | - Shirish Dubey
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK.
| | - James Fox
- , 9, Druid's Cross Road, Liverpool, L18 3EA, UK
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20
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Artım-Esen B, Çene E, Şahinkaya Y, Erdugan M, Oğuz E, Gül A, Öcal L, İnanç M. Autoimmune haemolytic anaemia and thrombocytopaenia in a single-centre cohort of patients with systemic lupus erythematosus from Turkey: clinical associations and effect on disease damage and survival. Lupus 2019; 28:1480-1487. [DOI: 10.1177/0961203319877245] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction Thrombocytopaenia and autoimmune haemolytic anaemia (AIHA) have considerable impact on prognosis in systemic lupus erythematosus (SLE). We investigated the frequencies of these haemocytopaenias, along with their associations and effect on outcome in a single-centre cohort of patients with SLE. Methods Demographic characteristics, clinical features, autoantibody profiles, damage and mortality data were compared between patients with and without each haematological abnormality. Variables displaying significant differences between the groups were entered into logistic regression. Results Ninety-three patients had AIHA and 215 had thrombocytopaenia. Both were associated with neuropsychiatric (NP) involvement, with each other, leucopaenia, antiphospholipid syndrome (APS) and antiphospholipid antibodies. More patients in both groups had organ damage, and their damage scores were higher. Association to NP damage was discernible. In addition, cardiovascular and renal damage and diabetes were more pronounced in patients with thrombocytopaenia. At logistic regression analysis, younger age, anticardiolipin antibody IgM positivity, leucopaenia and thrombocytopaenia were associated with AIHA whilst lupus anticoagulant activity, AIHA, leucopaenia, APS and NP involvement were associated with thrombocytopaenia. Among damage items, peripheral vascular damage, diabetes, NP damage, renal and ocular damage displayed significant associations with thrombocytopaenia, whereas none of the items did with AIHA. Patients with AIHA had significantly reduced survival rates at 10 and 20 years. Conclusions We observed that AIHA and thrombocytopaenia were associated with severe lupus, affecting major organs and causing end organ damage. Thus, they may be considered as prognostic markers. Furthermore, AIHA and especially thrombocytopaenia may also be a marker for a subgroup of lupus patients who have or may develop APS.
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Affiliation(s)
- B Artım-Esen
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - E Çene
- Department of Statistics, Faculty of Arts and Sciences, Yıldız Technical University, Istanbul, Turkey
| | - Y Şahinkaya
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - M Erdugan
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - E Oğuz
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - A Gül
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - L Öcal
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - M İnanç
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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21
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Wang J, Niu R, Jiang L, Wang Y, Shao X, Wu M, Ma Y. The diagnostic values of C-reactive protein and procalcitonin in identifying systemic lupus erythematosus infection and disease activity. Medicine (Baltimore) 2019; 98:e16798. [PMID: 31415387 PMCID: PMC6831178 DOI: 10.1097/md.0000000000016798] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
To explore the values of C-reactive protein (CRP) and procalcitonin (PCT) in identifying infection and disease activity in systemic lupus erythematosus (SLE) patients.Patients with SLE and infection from April 2015 to January 2018 were included in this study. We compared the clinical characteristics and biomarkers between different groups and calculated the receiver operating characteristic curve, sensitivity, and specificity of the corresponding biomarkers. Logistic regression analysis was performed on the variables exhibiting significant differences in univariate analysis.A total of 177 SLE patients were retrospectively analyzed. The patients were divided into noninfected-inactive group, noninfected-active group, infected-inactive group, and infected-active group. CRP level of infected-inactive group was significantly higher than noninfected-inactive group (P < .05), but not significantly in infected-active group than noninfected-active group (P > .05). Multivariate analysis showed that CRP (>24.0 mg/L) was the only independent risk factor for SLE infection (odds ratio, OR = 2.896, P = .032). PCT level of infected-active group was significantly higher than infected-inactive group (P < .05), but not significantly in noninfected-active group than noninfected-inactive group (P > .05). SLE active group had shorter disease course, lower infection rate, higher PCT level, and lower platelet count (PLT). Multivariate logistic analysis showed that PCT (>0.048 ng/mL) and PLT (<150 × 10/L) were independent risk factors for SLE activity (OR = 3.498 and 4.391, P = .011 and 0.009), and disease course (>96 months) was independent protective factor (OR = 0.169, P < .001). The area under the curve of the logistic model was significantly larger than any single variable (all P < .05).CRP is the only effective marker for diagnosing infection in SLE patients. Moreover, PCT helps predict SLE activity.
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Affiliation(s)
| | | | | | | | | | - Min Wu
- Department of Rheumatology and Immunology, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yingchun Ma
- Department of Rheumatology and Immunology, the Third Affiliated Hospital of Soochow University, Changzhou, China
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22
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Chen Z, Zhong H, Dong G. Thrombocytopenia as a Prognostic Marker for Systemic Lupus Erythematosus: A Systematic Review and Meta-analysis. Am J Med Sci 2019; 357:461-467. [PMID: 30987767 DOI: 10.1016/j.amjms.2019.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 02/22/2019] [Accepted: 03/05/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) patients often exhibit hematological abnormalities, but the role of thrombocytopenia on the prognosis of SLE shows inconsistent results. The purpose of this meta-analysis was to confirm the impact of thrombocytopenia on mortality and end organ damage in patients with SLE. MATERIALS AND METHODS Three electronic databases, PubMed, Embase and Cochrane library were systematically searched to identify the eligible studies from inception to November 2017 in order to evaluate the impact of thrombocytopenia on the prognosis of patients with SLE. The summary odds ratios (ORs) and 95% confidence intervals (CIs) were used to measure the impact of thrombocytopenia on mortality and end organ damage based on the random-effects model. RESULTS A total of 8 studies that reported data on 2,158 patients with SLE were included. The summary OR indicated that SLE subjects with thrombocytopenia were significantly associated with an increased risk of mortality (OR: 4.57; 95% CI: 2.28-9.17; P < 0.001) and end-organ damage (OR: 3.31; 95% CI: 1.11-9.86; P = 0.031). Furthermore, the sensitivity analysis indicated stable mortality, while the result for end organ damage was variable. In addition, the patients with thrombocytopenia with disease duration <60 months presented a greater risk for mortality than those with disease duration ≥60.0 months (P = 0.002). CONCLUSIONS Patients with SLE and thrombocytopenia were found to be associated with an increased risk of mortality and end organ damage.
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Affiliation(s)
- Zhixian Chen
- Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China; Department of Rheumatism, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Han Zhong
- Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Guangfu Dong
- Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
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23
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Zhang W, Wang F, Wang H, Hua B, Feng X, Sun L. Severe thrombocytopenia in connective tissue diseases: a single-center review of 131 cases. Clin Rheumatol 2018; 37:3337-3344. [DOI: 10.1007/s10067-018-4312-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 09/09/2018] [Accepted: 09/23/2018] [Indexed: 01/23/2023]
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24
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Wang XM, Tu JC. TNFSF15 is likely a susceptibility gene for systemic lupus erythematosus. Gene 2018; 670:106-113. [PMID: 29803925 DOI: 10.1016/j.gene.2018.05.098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 04/27/2018] [Accepted: 05/23/2018] [Indexed: 10/16/2022]
Abstract
We aim to explore the correlation of TNFSF15 genetic polymorphisms with susceptibility to systemic lupus erythematosus (SLE). This study enrolled SLE patients and healthy individuals to detect three single nucleotide polymorphisms (SNPs) of TNFSF15 (rs3810936, rs6478108 and rs4979462) through using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) to analyze the possible association of these three SNPs with the risk of SLE and the mRNA level of TNFSF15 was quantified by real-time PCR. The rs3810936 T allele carrier greatly decreased risk of SLE (OR = 0.620, 95% CI = 0.454-0.849, P = 0.003), while the risk of SLE for rs4979462 T allele carrier was significantly increased (OR = 1.66, 95% CI = 1.243-2.218, P < 0.001). The mRNA level of TNFSF15 was obviously higher in SLE patients, and specifically, the patients who carried the CC genotype of TNFSF15 rs3810936 had a higher TNFSF15 mRNA, but the rs4979462 CC genotype carriers appeared to be associated with the decreased TNFSF15 mRNA (all P < 0.05). Besides, the genotypes of rs3810936 and rs4979462 of TNFSF15 were significantly associated with butterfly rash, arthritis, serositis, renal nephritis, hematological disorder, immunological disorder and positive antinuclear antibody (ANA) of SLE patients (all P < 0.05). CCT and CTT haplotypes were risk factors of SLE, but CCC and TTT were protective factors of SLE (all P < 0.05). Logistic regression analysis showed that rs3810936 and rs4979462 of TNFSF15, histories of chilblain and wet living environment were independently associated with the risk of SLE (all P < 0.05).The current results suggested that TNFSF15 (rs3810936 and rs4979462) SNPs may confer susceptibility to SLE risk, which were significantly associated with the clinical phenotypes of SLE.
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Affiliation(s)
- Xian-Mo Wang
- Department of Clinical Laboratory, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, PR China; The First People's Hospital of Jingzhou, The First Affiliated Hospital of Yangtze University, Jingzhou 434000, Hubei, PR China
| | - Jian-Cheng Tu
- Department of Clinical Laboratory, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, PR China; The First People's Hospital of Jingzhou, The First Affiliated Hospital of Yangtze University, Jingzhou 434000, Hubei, PR China.
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25
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Scherlinger M, Sisirak V, Richez C, Lazaro E, Duffau P, Blanco P. New Insights on Platelets and Platelet-Derived Microparticles in Systemic Lupus Erythematosus. Curr Rheumatol Rep 2018; 19:48. [PMID: 28718063 DOI: 10.1007/s11926-017-0678-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Current knowledge on the role of platelets and platelet-derived microparticles (PMPs) on the immune system has been fast-growing. Systemic lupus erythematosus (SLE) is a systemic auto-immune disorder characterized by a loss of tolerance toward nuclear auto-antigens. Although recent studies allowed a better understanding of SLE pathogenesis, there is an urgent need for the development of new treatments and the identification of new biomarkers to assess the disease activity. We describe here the state-of-the-art knowledge linking platelets and PMPs to SLE. RECENT FINDINGS Platelet system activation is a key event in the pathogenesis of SLE. Circulating immune complexes, anti-phospholipid antibodies, and infectious agents such as virus are the main activators of platelets in SLE. Platelet activation can be monitored through different ways such as P-selectin expression, mean platelet volume, or circulating PMP levels, suggesting their potential use as biomarkers. Upon activation, platelets promote type I interferon production, NETosis, dendritic cell activation, and T and B lymphocyte activation, all essential events contributing to the development of SLE. Of interest, platelets also play a fundamental role in SLE organ disease such as the development of cardiovascular, thrombotic, and renal diseases. Finally, we review current knowledge on drugs targeting platelet activation and their potential impact on SLE pathogenesis. Platelets play a major role in SLE pathogenesis and organ disease and represent a great potential for novel biomarkers and drug development.
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Affiliation(s)
- Marc Scherlinger
- Service de Rhumatologie, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, place Amélie Raba Léon, 33076, Bordeaux, France.,Université de Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France.,CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Vanja Sisirak
- Université de Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France.,CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Christophe Richez
- Service de Rhumatologie, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, place Amélie Raba Léon, 33076, Bordeaux, France.,Université de Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France.,CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Estibaliz Lazaro
- Université de Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France.,CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France.,Laboratoire d'Immunologie et Immunogénétique, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, place Amélie Raba Léon, 33076, Bordeaux, France
| | - Pierre Duffau
- Université de Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France.,CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France.,Service de médecine interne, FHU ACRONIM, Hôpital Saint André, Centre Hospitalier Universitaire, 1 rue Jean Burguet, 33076, Bordeaux, France
| | - Patrick Blanco
- Université de Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France. .,CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France. .,Laboratoire d'Immunologie et Immunogénétique, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, place Amélie Raba Léon, 33076, Bordeaux, France.
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26
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Scherlinger M, Guillotin V, Truchetet ME, Contin-Bordes C, Sisirak V, Duffau P, Lazaro E, Richez C, Blanco P. Systemic lupus erythematosus and systemic sclerosis: All roads lead to platelets. Autoimmun Rev 2018; 17:625-635. [PMID: 29635077 DOI: 10.1016/j.autrev.2018.01.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 01/18/2018] [Indexed: 01/13/2023]
Abstract
Systemic lupus erythematosus (SLE) and systemic sclerosis (SSc) are two phenotypically distincts inflammatory systemic diseases. However, SLE and SSc share pathogenic features such as interferon signature, loss of tolerance against self-nuclear antigens and increased tissue damage such as fibrosis. Recently, platelets have emerged as a major actor in immunity including auto-immune diseases. Both SLE and SSc are characterized by strong platelet system activation, which is likely to be both the witness and culprit in their pathogenesis. Platelet activation pathways are multiple and sometimes redundant. They include immune complexes, Toll-like receptors activation, antiphospholipid antibodies and ischemia-reperfusion associated with Raynaud phenomenon. Once activated, platelet promote immune dysregulation by priming interferon production by immune cells, providing CD40L supporting B lymphocyte functions and providing a source of autoantigens. Platelets are actively implicated in SLE and SSc end-organ damage such as cardiovascular and renal disease and in the promotion of tissue fibrosis. Finally, after understanding the main pathogenic implications of platelet activation in both diseases, we discuss potential therapeutics targeting platelets.
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Affiliation(s)
- Marc Scherlinger
- Service de Rhumatologie, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, Place Amélie Raba Léon, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Vivien Guillotin
- Service de médecine interne, FHU ACRONIM, Hôpital Saint André, Centre Hospitalier Universitaire, 1 rue Jean Burguet, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Marie-Elise Truchetet
- Service de Rhumatologie, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, Place Amélie Raba Léon, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Cécile Contin-Bordes
- Laboratoire d'Immunologie et Immunogénétique, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, Place Amélie Raba Léon, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Vanja Sisirak
- Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Pierre Duffau
- Service de médecine interne, FHU ACRONIM, Hôpital Saint André, Centre Hospitalier Universitaire, 1 rue Jean Burguet, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Estibaliz Lazaro
- Laboratoire d'Immunologie et Immunogénétique, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, Place Amélie Raba Léon, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Christophe Richez
- Service de Rhumatologie, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, Place Amélie Raba Léon, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Patrick Blanco
- Laboratoire d'Immunologie et Immunogénétique, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, Place Amélie Raba Léon, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France.
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27
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Cieslinski JZ, Skare TL, Nisihara R, De Messias-Reason IJ, Utiyama SRR. Mannose-binding lectin serum levels in patients with systemic lupus erythematosus: association with thrombocytopaenia and seizure. Lupus 2017; 27:372-379. [PMID: 28786770 DOI: 10.1177/0961203317722846] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The complement system contributes to the pathogenesis of systemic lupus erythematosus (SLE). Mannose-binding lectin (MBL) is a key molecule of the lectin pathway of complement and seems to be related to the clinical manifestations of this disease. We evaluated the serum levels of MBL and its relationship with disease onset and clinical findings in SLE patients. Serum samples were analysed in 195 patients and 145 healthy controls from southern Brazil. Patients with high MBL levels (above 2000 ng/ml) showed a significant increase in the frequency of thrombocytopaenia ( p = 0.007; OR = 2.71; 95% CI = 1.32-5.55); and seizures ( p = 0.034; OR = 2.61; 95% CI = 1.07-6.37). A positive correlation between disease activity and MBL levels (>2000 ng/ml; p = 0.031, rho = 0.279) as well as of MBL concentration with accumulated organ damage ( p = 0.021; rho = 0.232) was observed. Our results suggest a role for MBL in the development of clinical manifestations such as thrombocytopaenia and seizures in SLE patients. These findings corroborate the participation of the lectin pathway of complement in the pathophysiologic mechanisms underlying clinical manifestations of SLE.
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Affiliation(s)
- J Z Cieslinski
- 1 Laboratory of Immunopathology, Clinical Hospital, Federal University of Paraná, Curitiba, Brazil
| | - T L Skare
- 2 Rheumatology Clinic, Evangelical University Hospital of Curitiba, Curitiba, Brazil
| | - R Nisihara
- 1 Laboratory of Immunopathology, Clinical Hospital, Federal University of Paraná, Curitiba, Brazil.,3 Department of Medicine, Positivo University, Curitiba, Brazil
| | - I J De Messias-Reason
- 1 Laboratory of Immunopathology, Clinical Hospital, Federal University of Paraná, Curitiba, Brazil
| | - S R R Utiyama
- 1 Laboratory of Immunopathology, Clinical Hospital, Federal University of Paraná, Curitiba, Brazil.,4 Department of Clinical Analysis, Federal University of Paraná, Curitiba, Brazil
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Ye JB, Sul YH, Go SJ, Choi JH, Kim JS. The Management of Lupus Thrombocytopenia in Poly Trauma Patient. JOURNAL OF TRAUMA AND INJURY 2017. [DOI: 10.20408/jti.2017.30.2.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jin Bong Ye
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Young Hoon Sul
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Seung Je Go
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Jung Hee Choi
- Department of Anesthesiology and Pain Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Joong Suck Kim
- Department of Trauma Surgery, Cheju Halla General Hospital, Jeju, Korea
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Li Y, Feng X. Efficacy and safety of tacrolimus in systemic lupus erythematosus patients with refractory thrombocytopenia: a retrospective study. Lupus 2017; 27:60-65. [PMID: 28566017 DOI: 10.1177/0961203317711011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective We evaluated the efficacy and safety of tacrolimus in systemic lupus erythematosus patients with refractory thrombocytopenia. Methods We retrospectively reviewed the data for 20 systemic lupus erythematosus patients with refractory thrombocytopenia and treated with tacrolimus during the period January 2013 to January 2015. In addition to glucocorticoids, all patients were treated with tacrolimus, 1 mg taken twice daily. The clinical effect of tacrolimus treatment in patients was evaluated by analysis of platelet counts at baseline and after one, three and six months of tacrolimus treatment. Levels of anti-double-stranded DNA antibodies and complement C3, C4 were determined individually. Results After one month of tacrolimus treatment, three patients (15%) did not respond, three patients (15%) achieved a complete response and the other 14 patients (75%) achieved a partial response. After three months of tacrolimus treatment, the platelet counts of all patients were significantly improved. A partial response was seen in 14 patients (75%) and the complete response rate increased to 25% (five patients). After six months, all patients attained partial response or complete response without relapse, and the rate of complete response increased to 75%. Compared to pretreatment, anti-double-stranded DNA antibody levels and the disease activity index score were markedly decreased after tacrolimus treatment. The levels of serum C3 and C4 were increased significantly ( P < 0.05). Conclusions Our survey revealed that a six-month course of tacrolimus is a safe and effective treatment for systemic lupus erythematosus patients with refractory thrombocytopenia.
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Affiliation(s)
- Y Li
- Department of Physiology, Jinzhou Medical University, Jinzhou, P.R. China
| | - X Feng
- Department of Rheumatology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, P.R. China
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Abstract
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.
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Affiliation(s)
- Guillermo J Pons-Estel
- a Department of Autoimmune Diseases , Institut Clinic de Medicina I Dermatologia, Hospital Clinic , Barcelona , Catalonia , Spain.,b Division of Rheumatology and Autoimmune Diseases , Sanatorio Parque, Grupo Oroño , Rosario , Argentina
| | - Manuel F Ugarte-Gil
- c Servicio de Reumatología , Hospital Nacional Guillermo Almenara Irigoyen, EsSalud , Lima , Perú.,d School of Medicine , Universidad Científica del Sur , Lima , Perú
| | - Graciela S Alarcón
- e Division of Clinical Immunology and Rheumatology, School of Medicine , The University of Alabama at Birmingham , Birmingham , AL , USA.,f Department of Medicine, School of Medicine , Universidad Peruana Cayetano Heredia , Lima , Perú
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Galanopoulos N, Christoforidou A, Bezirgiannidou Z. Lupus thrombocytopenia: pathogenesis and therapeutic implications. Mediterr J Rheumatol 2017; 28:20-26. [PMID: 32185250 PMCID: PMC7045921 DOI: 10.31138/mjr.28.1.20] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/01/2017] [Accepted: 03/14/2017] [Indexed: 12/12/2022] Open
Abstract
Systemic Lupus Erythematosus (SLE) is frequently complicated by cytopenias. Thrombocytopenia is usually non severe and its frequency ranges from 20% to 40%. It is mostly an autoimmune process caused by autoantibodies against platelet surface glycoproteins and it is associated with worse prognosis in SLE. It can also be a result of SLE treatment with azathioprine, methotrexate and rarely hydroxychloroquine or thrombotic microangiopathy or macrophage activation syndrome. If thrombocytopenia is mild (>50×109/L) and there is no other evidence of disease there is no need of therapy. Severe thrombocytopenia is less frequent and needs therapeutic management. Corticosteroids are the cornerstone of therapy. Continuous high dose oral prednisolone or pulse high dose methylprednisolone (MP) with or without intravenous immune globulin are used in the acute phase. Second line agents (hydroxychloroquine, danazol, azathioprine, cyclosporine, mycophenolate mofetil, cyclophosphamide, rituximab) are usually needed. Splenectomy is indicated for recurrent or resistant cases. There are no evidence-based guidelines to facilitate selection of one drug over another but certainly the co-existence of other systemic SLE manifestations must be taken into account. Newer therapies are emerging although there is no consensus on the treatment of refractory lupus thrombocytopenia due to the absence of controlled randomized trials.
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Affiliation(s)
- Nikolaos Galanopoulos
- Outpatient Department of Rheumatology, University General Hospital of Evros (Alexandroupolis), Thrace, Greece
| | - Anna Christoforidou
- Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Zoe Bezirgiannidou
- Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece
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Rúa-Figueroa Í, López-Longo J, Galindo-Izquierdo M, Calvo-Alén J, Del Campo V, Olivé-Marqués A, Pérez-Vicente S, Fernández-Nebro A, Andrés M, Erausquin C, Tomero E, Horcada L, Uriarte E, Freire M, Montilla C, Sánchez-Atrio A, Santos G, Boteanu A, Díez-Álvarez E, Narváez J, Martínez-Taboada V, Silva-Fernández L, Ruiz-Lucea E, Andreu JL, Hernández-Beriain JÁ, Gantes M, Hernández-Cruz B, Pérez-Venegas J, Pecondón-Español Á, Marras C, Ibáñez-Barceló M, Bonilla G, Torrente V, Castellví I, Alegre JJ, Calvet J, Marenco JL, Raya E, Vázquez T, Quevedo V, Muñoz-Fernández S, Rodríguez-Gómez M, Ibáñez J, Pego-Reigosa JM. Incidence, associated factors and clinical impact of severe infections in a large, multicentric cohort of patients with systemic lupus erythematosus. Semin Arthritis Rheum 2017; 47:38-45. [PMID: 28259425 DOI: 10.1016/j.semarthrit.2017.01.010] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 01/16/2017] [Accepted: 01/23/2017] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To estimate the incidence of severe infection and investigate the associated factors and clinical impact in a large systemic lupus erythematosus (SLE) retrospective cohort. METHODS All patients in the Spanish Rheumatology Society Lupus Registry (RELESSER) who meet ≥4 ACR-97 SLE criteria were retrospectively investigated for severe infections. Patients with and without infections were compared in terms of SLE severity, damage, comorbidities, and demographic characteristics. A multivariable Cox regression model was built to calculate hazard ratios (HRs) for the first infection. RESULTS A total of 3658 SLE patients were included: 90% female, median age 32.9 years (DQ 9.7), and mean follow-up (months) 120.2 (±87.6). A total of 705 (19.3%) patients suffered ≥1 severe infection. Total severe infections recorded in these patients numbered 1227. The incidence rate was 29.2 (95% CI: 27.6-30.9) infections per 1000 patient years. Time from first infection to second infection was significantly shorter than time from diagnosis to first infection (p < 0.000). Although respiratory infections were the most common (35.5%), bloodstream infections were the most frequent cause of mortality by infection (42.0%). In the Cox regression analysis, the following were all associated with infection: age at diagnosis (HR = 1.016, 95% CI: 1.009-1.023), Latin-American (Amerindian-Mestizo) ethnicity (HR = 2.151, 95% CI: 1.539-3.005), corticosteroids (≥10mg/day) (HR = 1.271, 95% CI: 1.034-1.561), immunosuppressors (HR = 1.348, 95% CI: 1.079-1.684), hospitalization by SLE (HR = 2.567, 95% CI: 1.905-3.459), Katz severity index (HR = 1.160, 95% CI: 1.105-1.217), SLICC/ACR damage index (HR = 1.069, 95% CI: 1.031-1.108), and smoking (HR = 1.332, 95% CI: 1.121-1.583). Duration of antimalarial use (months) proved protective (HR = 0.998, 95% CI: 0.997-0.999). CONCLUSIONS Severe infection constitutes a predictor of poor prognosis in SLE patients, is more common in Latin-Americans and is associated with age, previous infection, and smoking. Antimalarials exerted a protective effect.
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Affiliation(s)
- Íñigo Rúa-Figueroa
- Rheumatology Department, Doctor Negrín University Hospital Las Palmas de Gran Canaria, Bco. de la Ballena s/n, 35020 Las Palmas, Spain.
| | - Javier López-Longo
- Rheumatology Department, Gregorio Marañón University Hospital, Madrid, Spain
| | | | - Jaime Calvo-Alén
- Rheumatology Department, Sierrallana Hospital, Torrelavega, Spain
| | - Víctor Del Campo
- Preventive Medicine Service, Biomedical Research Institute of Vigo (IBIV), University Hospital Complex of Vigo, Vigo, Spain
| | | | - Sabina Pérez-Vicente
- Statistical Department, Research Unit, Spanish Society of Rheumatology (SER), Madrid, Spain
| | | | - Mariano Andrés
- Rheumatology Department, Hospital of Alicante, Alicante, Spain
| | - Celia Erausquin
- Rheumatology Department, Doctor Negrín University Hospital Las Palmas de Gran Canaria, Bco. de la Ballena s/n, 35020 Las Palmas, Spain
| | - Eva Tomero
- Rheumatology Department, La Princesa University Hospital, Madrid, Spain
| | - Loreto Horcada
- Rheumatology Department, Hospital of Navarra, Pamplona, Spain
| | - Esther Uriarte
- Rheumatology Department, Donostia Hospital, Donostia, Guipuzcoa, Spain
| | - Mercedes Freire
- Rheumatology Department, University Hospital Complex of A Coruña, A Coruña, Spain
| | - Carlos Montilla
- Rheumatology Department, Salamanca University Hospital, Salamanca, Spain
| | - Ana Sánchez-Atrio
- System Diseases and Oncology Service, Príncipe de Asturias University Hospital Alcalá de Henares, Madrid, Spain
| | - Gregorio Santos
- Rheumatology Department, Marina Baixa Hospital, Alicante, Spain
| | - Alina Boteanu
- Rheumatology Department, Ramon y Cajal University Hospital, Madrid, Spain
| | | | - Javier Narváez
- Rheumatology Department, Bellvitge Hospital, Barcelona, Spain
| | | | | | | | - José Luis Andreu
- Rheumatology Department, Puerta de Hierro-Majadahonda Hospital, Madrid, Spain
| | | | - Marian Gantes
- Rheumatology Department, University Hospital of Canarias, Tenerife, Spain
| | | | - José Pérez-Venegas
- Rheumatology Department, Jerez de la Frontera University Hospital, Cádiz, Spain
| | | | - Carlos Marras
- Rheumatology Department, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | | | - Gema Bonilla
- Rheumatology Department, La Paz University Hospital, Madrid, Spain
| | - Vicente Torrente
- Rheumatology Department, Hospital of Hospitalet-Moisés Broggi CSI, Barcelona, Spain
| | - Iván Castellví
- Rheumatology Unit, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Joan Calvet
- Rheumatology Department, Parc Taulí Hospital, Barcelona, Spain
| | - Jose Luis Marenco
- Rheumatology Department, Virgen de Valme University Hospital, Sevilla, Spain
| | - Enrique Raya
- Rheumatology Department, San Cecilio Hospital, Granada, Spain
| | - Tomás Vázquez
- Rheumatology Department, Lucus Augusti Hospital, Lugo, Spain
| | | | | | | | - Jesús Ibáñez
- Rheumatology Unit, POVISA Medical Center, Vigo, Spain
| | - José M Pego-Reigosa
- Rheumatology Department, Biomedical Research Institute of Vigo (IBIV), University Hospital Complex of Vigo, Vigo, Spain
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Liu Y, Chen S, Sun Y, Lin Q, Liao X, Zhang J, Luo J, Qian H, Duan L, Shi G. Clinical characteristics of immune thrombocytopenia associated with autoimmune disease: A retrospective study. Medicine (Baltimore) 2016; 95:e5565. [PMID: 27977588 PMCID: PMC5268034 DOI: 10.1097/md.0000000000005565] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To clarify clinical characteristics of immune thrombocytopenia (ITP) subsets associated with autoimmune diseases (AIDs).Five thousand five hundred twenty patients were reviewed retrospectively. One hundred four ITP patients were included for analysis. Clinical manifestations at first thrombocytopenic episode were recorded.Systemic lupus erythematosus (SLE) and primary Sjogren syndrome (pSS) accounted for a large part in AIDs associated with secondary ITP. SLE-ITP, pSS-ITP, and primary ITP (pITP) patients were different in several aspects in clinical and immunological characteristics. A subgroup of patients in pITP patients with some obvious autoimmune features (defined as AIF-ITP) such as positive ANA but failing to meet the diagnosis criteria now used for a specific kind of connective tissue diseases were also different with other pITP patients in some immunological features, indicating the difference in the pathogenesis mechanism of those autoimmune featured ITP patients.ITP patients were heterogeneous in clinical characteristics. Further study about the different pathogenesis of ITP subsets especially those AIF-ITP patients who only presented with thrombocytopenia will help us have a better understanding of pathogenesis of ITP and a better management of ITP patients.
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MESH Headings
- Adult
- Antibodies, Antinuclear/immunology
- China/epidemiology
- Cohort Studies
- Comorbidity
- Databases, Factual
- Female
- Humans
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/epidemiology
- Lupus Erythematosus, Systemic/therapy
- Male
- Middle Aged
- Prevalence
- Prognosis
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/epidemiology
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Retrospective Studies
- Risk Assessment
- Severity of Illness Index
- Sjogren's Syndrome/diagnosis
- Sjogren's Syndrome/epidemiology
- Young Adult
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Affiliation(s)
- Yuan Liu
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital of Xiamen University
| | - Shiju Chen
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital of Xiamen University
| | - Yuechi Sun
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital of Xiamen University
| | - Qingyan Lin
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital of Xiamen University
| | - Xining Liao
- Medical College, Xiamen University, Xiamen, Fujian, China
| | - Junhui Zhang
- Medical College, Xiamen University, Xiamen, Fujian, China
| | - Jiao Luo
- Medical College, Xiamen University, Xiamen, Fujian, China
| | - Hongyan Qian
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital of Xiamen University
| | - Lihua Duan
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital of Xiamen University
| | - Guixiu Shi
- Department of Rheumatology and Clinical Immunology, The First Affiliated Hospital of Xiamen University
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34
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Velo-García A, Castro SG, Isenberg DA. The diagnosis and management of the haematologic manifestations of lupus. J Autoimmun 2016; 74:139-160. [DOI: 10.1016/j.jaut.2016.07.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 12/21/2022]
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35
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Gao J, Zhang L, Zhang X, Zhao SL, Liu SY, Xing LH. Levels of serum procalcitonin and C-reactive protein for evaluating pulmonary bacterial infection in patients with lupus erythematosus. ACTA ACUST UNITED AC 2016; 36:653-658. [DOI: 10.1007/s11596-016-1641-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/08/2016] [Indexed: 11/30/2022]
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36
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Abdel Galil SM, Edrees AM, Ajeeb AK, Aldoobi GS, El-Boshy M, Hussain W. Prognostic significance of platelet count in SLE patients. Platelets 2016; 28:203-207. [PMID: 27590999 DOI: 10.1080/09537104.2016.1214253] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Hematological abnormalities, especially thrombocytopenia (TCP), are highly prevalent among patients with systemic lupus erythematosus (SLE) and at the same time it has been reported as a significant prognostic factor of SLE course. We further investigate the correlation between platelet count and the clinical manifestations and disease activity of SLE, in a cohort of Saudi Arabian female patients. A retrospective analysis was done for the medical records of 100 SLE female patients, selected from all patients diagnosed and treated for SLE at the Rheumatology outpatient clinics in Hera'a General Hospital, Holly Makkah, Saudi Arabia. The data collected from every patient's file included laboratory investigations (complete blood count, platelet parameters, ESR, anti-double-stranded DNA antibody, ANA), clinical manifestations, as well as SLE disease activity index (SLEDAI-2k) scores throughout a period of six sequential follow-up visits. Patients were divided into three groups according to the SLEDAI-2k: mild, moderate, and high-activity group. We found that, out of 100 patients, TCP was the most prevalent hematological abnormality evident in 15%, more than leucopenia (14%) and anemia (2%). TCP was acute in onset and associated with arthritis, neurologic manifestations, and nephritis. Platelet count showed a significant negative correlation with disease activity, in all of the three groups of patients. We concluded that platelet count has a negative correlation with disease activity in SLE patients, whatever the associated manifestations, and it should be considered as a prognostic factor, identifying patients with aggressive disease course.
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Affiliation(s)
- Sahar Mahfouz Abdel Galil
- a Medicine Department, Faculty of Medicine , Umm Alqura University , Makkah , Kingdom of Saudi Arabia.,b Rheumatology and Rehabilitation Department , Faculty of Medicine, Zagazig university , Egypt
| | - Azzahra Mohammed Edrees
- a Medicine Department, Faculty of Medicine , Umm Alqura University , Makkah , Kingdom of Saudi Arabia
| | - Afnan Khaled Ajeeb
- a Medicine Department, Faculty of Medicine , Umm Alqura University , Makkah , Kingdom of Saudi Arabia
| | - Ghadeer Sameer Aldoobi
- a Medicine Department, Faculty of Medicine , Umm Alqura University , Makkah , Kingdom of Saudi Arabia
| | - Mohamed El-Boshy
- c Department of Laboratory Medicine, Faculty of Applied Medical Science , Umm Al-Qura University , Makkah , Kingdom of Saudi Arabia
| | - Waleed Hussain
- d Head of Rheumatology Unit , Hera'a General Hospital , Makkah , Kingdom of Saudi Arabia
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Ruiz-Irastorza G, Egurbide MV, Martinez-Berriotxoa A, Ugalde J, Aguirre C. Antiphospholipid antibodies predict early damage in patients with systemic lupus erythematosus. Lupus 2016; 13:900-5. [PMID: 15645743 DOI: 10.1191/0961203304lu2030oa] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to determine whether the different autoantibodies predict early damage in patients with systemic lupus erythematosus (SLE). The patients comprised a prospective inception cohort of 205 patients with SLE, 154 on follow-up for at least five years after diagnosis. Eight patients who died before the fifth year of disease course were included in analyses comprising survival. Organ damage was measured using the Systemic Lupus International Collaborating Clinics - American College of Rheumatology damage index (SDI). Endpoints were the development of some (SDI ≥1) or severe (SDI > 2) damage at five years after diagnosis or the combined outcome ‘SDI ≥1 or death at five years’. Autoantibodies [anti-DNA, anti-Ro, anti-La, anti-Sm, anti-U1 RNP, any anti-ENA and antiphospholipid (aPL)] were included in univariate and multivariate analysis. ‘Age at diagnosis’ was also included as an independent variable in multivariant analyses. Sapporo criteria were used to define aPL positivity. Eighty-four patients (54.5%) had accrued damage at five years, 17 patients (11.0%) having severe damage. Patients with aPL had damage in a higher proportion (63.2% any damage, 17.6% severe damage). Only aPL were related to damage in univariate analysis ( P = 0.03). In logistic regression models, aPL were the only independent predictors of damage at five years (OR 1.94, 95% CI 1.01-3.73), severe damage at five years (OR 3.34, 95% CI 1.11-10.03) and increasing damage since diagnosis (OR 2.46, 95% CI 1.24-4.87). No autoantibody was a predictor of the outcome ‘SDI ≥1 or death at five years’. The conclusion was that aPL predict early damage in patients with SLE.
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Affiliation(s)
- G Ruiz-Irastorza
- Service and Department of Internal Medicine, Hospital de Cruces, Universidad del Pais Vasco/ Euskal Herriko Unibertsitatea, Bizkaia, The Basque Country, Spain.
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Parker BJ, Bruce IN. High dose methylprednisolone therapy for the treatment of severe systemic lupus erythematosus. Lupus 2016; 16:387-93. [PMID: 17664228 DOI: 10.1177/0961203307079502] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The pharmacological armamentarium for the treatment of SLE is expanding and a number of novel therapies are currently under investigation. In spite of this, steroid therapy remains the cornerstone of treatment and intravenous methylprednisolone (IVMP) is still widely used in clinical practice. There is however surprisingly little evidence on which to define its precise role. The objective of this review was to consider the published evidence relating to the use of IVMP in SLE patients and also to identify open questions that still need to be answered with regard to its use.In acute flares, IVMP induces rapid suppression of acute inflammation. There is not however a strong evidence base to support the use of high doses compared to low IVMP doses or oral prednisolone. In maintenance regimes, secondary analyses suggest that IVMP may confer additional long-term renal survival over oral steroids as part of a cyclophosphamide regime. Therefore, in addition to the evaluation of novel therapies for SLE, better evidence to define the precise role of IVMP in SLE is still required. ( Lupus (2007) 16, 387—393)
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Affiliation(s)
- B J Parker
- The Kellgren Centre for Rheumatology, Central Manchester and Manchester Children's NHS Trust, Manchester Royal Infirmary
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Abstract
Mycophenolate mofetil (MMF) has been increasingly used in patients with systemic lupus erythematosus (SLE). While most information concentrates on lupus nephritis, its efficacy in nonrenal manifestations of SLE has not been systematically studied. We describe the successful use of MMF in a patient with SLE-related hemolytic anemia that was refractory to cyclophosphamide, pulse methylprednisolone, intravenous immunoglobulin and cyclosporine. The mechanisms of action of MMF are briefly reviewed.
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MESH Headings
- Adult
- Anemia, Hemolytic/drug therapy
- Anemia, Hemolytic/etiology
- Anemia, Hemolytic/pathology
- Anemia, Refractory/drug therapy
- Anemia, Refractory/etiology
- Anemia, Refractory/pathology
- Dose-Response Relationship, Drug
- Female
- Glucocorticoids/therapeutic use
- Humans
- Immunosuppressive Agents/therapeutic use
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/drug therapy
- Lupus Erythematosus, Systemic/pathology
- Mycophenolic Acid/analogs & derivatives
- Mycophenolic Acid/therapeutic use
- Treatment Outcome
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Affiliation(s)
- A Mak
- Department of Medicine, Tuen Mun Hospital, New Territories, Hong Kong SAR, China.
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40
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Zhao L, Xu D, Qiao L, Zhang X. Bone Marrow Megakaryocytes May Predict Therapeutic Response of Severe Thrombocytopenia in Patients with Systemic Lupus Erythematosus. J Rheumatol 2016; 43:1038-44. [DOI: 10.3899/jrheum.150829] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2016] [Indexed: 12/25/2022]
Abstract
Objective.To analyze the predictive value of megakaryocyte counts in bone marrow (BM-MK) for determining the therapeutic response of severe thrombocytopenia (TP) in patients with systemic lupus erythematosus (SLE).Methods.Thirty-five patients with SLE with severe TP (platelet count ≤ 50 × 109/l) from the Peking Union Medical College Hospital admitted between 2007 and 2014 with appreciable bone marrow aspiration results were analyzed retrospectively. The associations between therapeutic response and clinical manifestations, laboratory findings including BM-MK counts, were evaluated.Results.Seventeen (49%) and 8 (23%) patients achieved a complete response (CR) and a partial response (PR), respectively, and 10 had no response (NR). The BM-MK counts in each group were 102 ± 25 (0–322), 136 ± 48 (2–419), and 28 ± 12 (0–105) per slide, respectively. Significant differences were observed in the counts of BM-MK between patients who achieved a clinical response (CR + PR) and those who did not (NR; p = 0.007). Patients in the NR group exhibited fewer BM-MK compared with those in the CR and PR groups (p = 0.017 and p = 0.006, respectively). A receiver-operation characteristic analysis identified that a cutoff value of BM-MK counts at 20 performed pretty well in discriminating patients with differential responses to immunotherapy, with sensitivity and specificity and area under the curve of 88%, 70%, and 0.798, respectively.Conclusion.BM-MK count may serve as a good predicting factor for immunotherapeutic response in patients with SLE with severe TP. Patients with BM-MK counts < 20 per slide tend to exhibit poor clinical response.
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Hammad M, Eissa M, Fathi S. Possible risk factors associated with greater damage in systemic lupus erythematosus patients: an Egyptian multicenter study. Lupus 2016; 25:1019-27. [PMID: 26957352 DOI: 10.1177/0961203316636465] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 01/28/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Systemic lupus erythematosus (SLE) is a prototypic multisystem autoimmune disorder. The total damage in a patient with SLE may result from SLE itself or from any other pathologic process. The aim of this study was to assess risk factors of greater damage in a sample of Egyptian SLE patients. METHODS This Egyptian multicenter retrospective study included 100 SLE patients: 64 patients from Cairo University Hospitals and 36 patients from Zagazig University Hospitals. The Systemic Lupus International Collaborative Clinics (SLICC)/American College of Rheumatology (ACR) Damage Index (ACR-DI) was used to document the damage in each patient. RESULTS The total SLICC/ACR-DI score ranged from 0 to 8. A higher DI score was found in hypertensive patients, compared to normotensive patients; and among those with positive anti-phospholipid antibodies, compared to those with negative anti-phospholipid antibodies. This difference was statistically significant (p < 0.01). Also, a higher DI score was found in cyclophosphamide users, compared to non-users; and in those with proteinuria and seizures, compared to those without; and the difference was statistically significant (p < 0.05). There was a significant positive correlation between the DI and patient age (p < 0.05). CONCLUSIONS Damage in SLE cannot be prevented completely, as SLE disease is considered an aggressive disease treated by aggressive medications, but rheumatologists should try to minimize damage as much as possible to maintain the patients' health, functioning and general wellbeing.
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Affiliation(s)
- M Hammad
- Faculty of medicine, Zagazig University, Zagazig, Egypt.
| | - M Eissa
- Faculty of medicine, Cairo University, Cairo, Egypt
| | - S Fathi
- Faculty of medicine, Zagazig University, Zagazig, Egypt
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ANA Negative Systemic Lupus Erythematosus Leading to CTEPH, TTP-Like Thrombocytopenia, and Skin Ulcers. Case Rep Rheumatol 2016; 2016:4507247. [PMID: 27006850 PMCID: PMC4783548 DOI: 10.1155/2016/4507247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 02/07/2016] [Accepted: 02/11/2016] [Indexed: 11/23/2022] Open
Abstract
SLE affects almost every organ system, with differing degrees of severity. During its clinical course periods of flares may alternate with periods of remission culminating in disease and therapy related damage. We describe a case of ANA negative SLE with severe thrombocytopenia, cutaneous vasculitis, antiphospholipid antibody syndrome, and pulmonary artery hypertension. As there is no definitive cure for SLE the treatment lies in caring for the individual organ systems involved and simultaneously taking care of the patient as a whole.
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González-Naranjo LA, Betancur OM, Alarcón GS, Ugarte-Gil MF, Jaramillo-Arroyave D, Wojdyla D, Pons-Estel GJ, Rondón-Herrera F, Vásquez-Duque GM, Quintana-López G, Da Silva NA, Tavares Brenol JC, Reyes-Llerena G, Pascual-Ramos V, Amigo MC, Massardo L, Alfaro-Lozano J, Segami MI, Esteva-Spinetti MH, Iglesias-Gamarra A, Pons-Estel BA. Features associated with hematologic abnormalities and their impact in patients with systemic lupus erythematosus: Data from a multiethnic Latin American cohort. Semin Arthritis Rheum 2015; 45:675-83. [PMID: 26698222 DOI: 10.1016/j.semarthrit.2015.11.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/03/2015] [Accepted: 11/06/2015] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To examine hematological manifestations' correlates and their impact on damage accrual and mortality in SLE patients from the multiethnic, Latin American, GLADEL cohort. METHODS In patients with recent SLE diagnosis (≤2 years), the association between follow-up hematological manifestations (per ACR criteria) and socio-demographic and clinical variables was examined by univariable and multivariable logistic regressions; their impact on damage accrual and mortality was examined by Poisson and Cox proportional-hazards regression analyses, respectively. RESULTS Of 1437 patients, 948 (66.0%) developed ≥1 hematological manifestation [5.5% hemolytic anemia (AHA), 16.3% thrombocytopenia, and 56.4% lymphopenia] over 4.3 (3.3) follow-up years. Younger age, Mestizo ethnicity, hematologic disorder (at/or before SLE diagnosis), and first damage recorded were associated with hematological manifestations while antimalarials were negatively associated. AHA (at/or before SLE diagnosis), anti-Sm, and anti-RNP antibodies were associated with subsequent AHA occurrence while musculoskeletal involvement was negatively associated. Thrombocytopenia (at/or before SLE diagnosis), AHA, anti-phospholipid antibodies (aPLs), anti-SSA/Ro, anti-SSB/La antibodies, and first damage recorded were associated with later thrombocytopenia occurrence. Lymphopenia (at/or before SLE diagnosis), younger age at diagnosis, Mestizo ethnicity, having medical insurance, and first damage recorded were associated with subsequent lymphopenia occurrence while antimalarials and azathioprine treatment were negatively associated. AHA was associated with damage accrual and mortality after adjusting for variables known to affect these outcomes. CONCLUSIONS Mestizo ethnicity and early hematological manifestations are risk factors for their subsequent occurrence while antimalarials have a protective effect. The associations between AHA and aPLs and thrombocytopenia were corroborated. AHA contributes independently to damage accrual and diminished survival.
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Affiliation(s)
- Luis A González-Naranjo
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Calle 70 No. 52-21, Medellin, Antioquia 229, Colombia.
| | | | - Graciela S Alarcón
- Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Manuel F Ugarte-Gil
- Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru; Universidad Científica del Sur, Lima, Peru
| | - Daniel Jaramillo-Arroyave
- Rheumatology Unit, Department of Internal Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Daniel Wojdyla
- Escuela de Estadística, Universidad Nacional de Rosario, Rosario, Argentina
| | - Guillermo J Pons-Estel
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Barcelona, Spain
| | - Federico Rondón-Herrera
- Rheumatology Unit, Department of Internal Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Gloria M Vásquez-Duque
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Calle 70 No. 52-21, Medellin, Antioquia 229, Colombia
| | - Gerardo Quintana-López
- Rheumatology Unit, Department of Internal Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Nilzio A Da Silva
- Rheumatology Unit, Faculdade de Medicina da Universidade Federal de Goias, Goiania, Brazil
| | - João C Tavares Brenol
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil; Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Gil Reyes-Llerena
- Servicio Nacional de Reumatología, Centro de Investigaciones Médico Quirúrgicas (CIMEQ), La Habana, Cuba
| | - Virginia Pascual-Ramos
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - Mary C Amigo
- Reumatología, Centro Médico ABC, Ciudad de México, Mexico
| | - Loreto Massardo
- Department of Clinical Immunology and Rheumatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - José Alfaro-Lozano
- Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - María I Segami
- Hospital Nacional "Edgardo Rebagliatti Martins", Essalud, Lima, Peru
| | - María H Esteva-Spinetti
- Servicio de Reumatología, Departamento de Medicina, Hospital Central de San Cristóbal, San Cristóbal, Venezuela
| | - Antonio Iglesias-Gamarra
- Rheumatology Unit, Department of Internal Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
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Kazzaz NM, Coit P, Lewis EE, McCune WJ, Sawalha AH, Knight JS. Systemic lupus erythematosus complicated by diffuse alveolar haemorrhage: risk factors, therapy and survival. Lupus Sci Med 2015; 2:e000117. [PMID: 26430514 PMCID: PMC4586940 DOI: 10.1136/lupus-2015-000117] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 08/14/2015] [Accepted: 08/28/2015] [Indexed: 01/09/2023]
Abstract
Objectives While diffuse alveolar haemorrhage (DAH) is recognised as a life-threatening complication of systemic lupus erythematosus (SLE), little is known about its risk factors and response to treatment. We describe 22 cases of DAH in a US lupus cohort of approximately 1000 patients, and compare them to 66 controls from the same outpatient cohort. Methods We captured variables pertaining to diagnoses of SLE and secondary antiphospholipid syndrome (APS), and analysed them by univariate testing. Those variables with p values <0.05 were then further considered in a multivariate model. Kaplan-Meier curves were constructed for each group, and survival was analysed by Log-rank test. Results Of the 22 patients with DAH, 59% were diagnosed with DAH within 5 years of lupus diagnosis. By univariate testing, several manifestations of SLE and APS were more common in patients with DAH, including history of thrombocytopenia, cardiac valve disease, low C3, leucopenia, neuropsychiatric features, haemolysis, arterial thrombosis, lupus anticoagulant, secondary APS and low C4. On multivariate analysis, history of thrombocytopenia and low C3 were maintained as independent risk factors. Importantly, only two patients had platelet counts <50 000/µL at the time of the DAH episode, arguing that DAH was not simply a haemorrhagic complication of thrombocytopenia. All patients were treated with increased immunosuppression, including various combinations of corticosteroids, plasmapheresis, cyclophosphamide, rituximab and mycophenolate mofetil. Notably, all patients in the cohort survived their initial episode of DAH. While the patients with DAH did well in the short-term, their long-term survival was significantly worse than controls. Several of the deaths were attributable to thrombotic complications after recovering from DAH. Conclusions To the best of our knowledge, this is the largest case–control study of lupus DAH to date. History of thrombocytopenia was strongly predictive of DAH (OR ∼40). A number of APS manifestations correlated with DAH by univariate analysis, and deserve further consideration in larger studies.
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Affiliation(s)
- Nayef M Kazzaz
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Patrick Coit
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Emily E Lewis
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - W Joseph McCune
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Amr H Sawalha
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Jason S Knight
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
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Jiang B, Li T, Guo L, Shen H, Ye S, Chen S. Efficacy and Safety of Rituximab in Systemic Lupus Erythematosus and Sjögren Syndrome Patients With Refractory Thrombocytopenia: A Retrospective Study of 21 Cases. J Clin Rheumatol 2015; 21:244-50. [PMID: 26203828 PMCID: PMC4539196 DOI: 10.1097/rhu.0000000000000273] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Recent studies suggested a potential of rituximab (RTX) in treating autoimmune thrombocytopenia (AITP) secondary to autoimmune diseases. In this study, we retrospectively evaluated the efficacy and safety of RTX therapy in patients with refractory AITP secondary to systemic lupus erythematosus (SLE) and Sjögren syndrome (SS). METHODS Twenty-one SLE and/or SS patients with treatment-resistant AITP were treated once or repeatedly with RTX at the Rheumatology Clinic Renji Hospital, during the period March 2012 to June 2014. Clinical and laboratory variables recorded at every follow-up visit were analyzed. RESULTS The median age of all patients was 37.05 ± 3.15 years (range, 13-67 years; 20 female and 1 male). The median AITP duration before RTX treatment was 5.46 years. Previous treatments of 21 patients included immunosuppressive agents such as corticosteroids (n = 19), cyclosporine (n = 9), mycophenolate mofetil (n = 2), methotrexate (n = 3), cyclophosphamide (n = 2), vincristine (n = 3), and hydroxychloroquine (n = 15), and 7 patients received concomitantly intravenous immunoglobulin therapy. Two patients had undergone splenectomy without improvement. Seventeen patients (80.95%) were treated repeatedly with RTX during the follow-up period. The overall response rate to RTX treatment (including complete response, 52.38%; partial response, 28.57%) was 80.95%. A significant increase (P < 0.05) of platelet counts was seen after 1 month (median, 32.24 × 10/mL vs 66.53 × 10/mL). Relapses occurred mostly during the first 9 months, and maintaining duration of response was 10.27 months (range, 2-17 months) on average after the first RTX infusion. Antiplatelet antibodies, especially IgG isotype, decreased significantly (P < 0.05) after RTX treatment. No adverse effects were observed among 15 patients (71.4%); however, 2 cases died of severe pneumonia, and another developed lymphoma. CONCLUSIONS Rituximab is an additional potent therapeutic treatment option for SLE and SS patients with AITP refractory to conventional immunosuppressive treatments. For most patients, RTX was safe and well tolerated.
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Affiliation(s)
- Bin Jiang
- From the *Shanghai Institute of Immunology and †Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; ‡Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ting Li
- From the *Shanghai Institute of Immunology and †Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; ‡Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Li Guo
- From the *Shanghai Institute of Immunology and †Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; ‡Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Hao Shen
- From the *Shanghai Institute of Immunology and †Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; ‡Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Shuang Ye
- From the *Shanghai Institute of Immunology and †Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; ‡Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sheng Chen
- From the *Shanghai Institute of Immunology and †Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; ‡Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Agarwal N, Yasui NY, Kumar V. Lupus: Vocational aspects and the best rehabilitation practices. JOURNAL OF VOCATIONAL REHABILITATION 2015. [DOI: 10.3233/jvr-150757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Neelam Agarwal
- Center for Accommodations and Support Services (CASS), University of Texas at El Paso, El Paso, TX, USA
| | - Naoko Yura Yasui
- Department of Rehabilitation Studies, Alabama State University, Montgomery, AL, USA
| | - Vinod Kumar
- Department of Mechanical Engineering, University of Texas at El Paso, El Paso, TX, USA
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Gómez-Puerta JA, Barbhaiya M, Guan H, Feldman CH, Alarcón GS, Costenbader KH. Racial/Ethnic variation in all-cause mortality among United States medicaid recipients with systemic lupus erythematosus: a Hispanic and asian paradox. Arthritis Rheumatol 2015; 67:752-60. [PMID: 25590668 DOI: 10.1002/art.38981] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 11/25/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The incidence of systemic lupus erythematosus (SLE) is disproportionately high in nonwhite patients compared with white patients. However, variation in mortality according to race/ethnicity has not been well studied. The aim of this study was to examine all-cause mortality according to race/ethnicity among SLE patients enrolled in Medicaid. METHODS We used Medicaid Analytic eXtract data, with billing claims from 47 US states and Washington, DC, to identify individuals ages 18-65 years who were enrolled in Medicaid for ≥3 months in 2000-2006. Individuals were classified as having SLE if they had ≥3 visits ≥30 days apart with an International Classification of Diseases, Ninth Revision (ICD-9) code for SLE (710.0). Among the individuals with SLE, those with lupus nephritis (LN) were identified by the presence of ≥2 ICD-9 claims for glomerulonephritis, proteinuria, or renal failure. We calculated mortality rates per 1,000 person-years, with 95% confidence intervals (95% CIs), according to race/ethnicity. Multivariable Cox proportional hazards regression models were used to estimate mortality risks, adjusting for age, sex, demographics, and comorbidities. RESULTS Among 42,221 prevalent cases of SLE, 8,191 prevalent cases of LN were identified. Blacks represented 40.1%, whites 38.4%, and Hispanics 15.3%. Overall SLE mortality rates per 1,000 person-years were highest among Native American (27.52), white (20.17), and black (24.13) patients and were lower among Hispanic (7.12) or Asian (5.18) patients. After multivariable adjustment, Hispanic and Asian patients had lower mortality risks (hazard ratio [HR] 0.48 [95% CI 0.40-0.59] and 0.59 [95% CI 0.40-0.86], respectively) compared with whites. Conversely, the risk of death was significantly higher among Native American (HR 1.40 [95% CI 1.04-1.90]) and black (HR 1.21 [95% CI 1.10-1.33]) patients compared with white patients. Among patients with LN, mortality risks were lower in Hispanic and Asian patients compared with white patients. CONCLUSION After accounting for demographic and clinical factors, mortality among Asian and Hispanic Medicaid patients with SLE was lower than that among black, white, or Native American patients.
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Affiliation(s)
- Alberta Hoi
- Lupus Clinic, Monash Medical Centre, Autoimmune Clinic Austin Hospital, and Monash University; Melbourne Vic. Australia
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Al Sawah S, Zhang X, Zhu B, Magder LS, Foster SA, Iikuni N, Petri M. Effect of corticosteroid use by dose on the risk of developing organ damage over time in systemic lupus erythematosus-the Hopkins Lupus Cohort. Lupus Sci Med 2015; 2:e000066. [PMID: 25861455 PMCID: PMC4378372 DOI: 10.1136/lupus-2014-000066] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 02/16/2015] [Accepted: 02/18/2015] [Indexed: 12/02/2022]
Abstract
Objectives The impact of corticosteroids on the risk of organ damage in the context of clinical end points endorsed in some systemic lupus erythematosus (SLE) clinical trials is underexplored. Methods We analysed data from the Hopkins Lupus Cohort using Cox proportional hazards models to understand the impact of exposure to different corticosteroid doses on the risk of developing any new organ damage or any new organ damage at the individual organ systems over time. Results Mean prior prednisone dose, recent disease activity and immunosuppressant use during follow-up, as well as organ damage score at cohort entry, were significant independent predictors of the risk of developing any new organ damage. Even after adjustment for recent disease activity, there was a dose-response relationship across the different levels of exposure to prednisone during follow-up and the risk of developing any new organ damage. The risk more than doubled in patients exposed to a mean prior prednisone dose of ≥20 mg/day versus <7.5 mg/day (HR=2.514, p<0.001). It was estimated that a 1 mg/day increase in prior prednisone dose during follow-up was associated with a 2.8% increase in the risk of developing new organ damage. For individual organ systems, exposure to a mean prior prednisone dose of ≥7.5 mg/day versus <7.5 mg/day significantly increased the risk of developing cataracts (HR=2.41, p<0.001), osteoporotic fractures (HR=2.16, p<0.001) and cardiovascular damage (HR=1.54, p=0.041), but showed no significant difference for renal damage (HR=1.44, p=0.163) or for other individual organ systems. Conclusions Organ damage in SLE is multifactorial; corticosteroid treatment and disease activity play a role.
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Affiliation(s)
| | - Xiang Zhang
- Eli Lilly and Company , Indianapolis, Indiana , USA
| | - Baojin Zhu
- Eli Lilly and Company , Indianapolis, Indiana , USA
| | - Laurence S Magder
- University of Maryland School of Medicine , Baltimore, Maryland , USA
| | | | | | - Michelle Petri
- The Johns Hopkins University School of Medicine , Baltimore, Maryland , USA
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Fayyaz A, Igoe A, Kurien BT, Danda D, James JA, Stafford HA, Scofield RH. Haematological manifestations of lupus. Lupus Sci Med 2015; 2:e000078. [PMID: 25861458 PMCID: PMC4378375 DOI: 10.1136/lupus-2014-000078] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/12/2015] [Accepted: 01/18/2015] [Indexed: 12/14/2022]
Abstract
Our purpose was to compile information on the haematological manifestations of systemic lupus erythematosus (SLE), namely leucopenia, lymphopenia, thrombocytopenia, autoimmune haemolytic anaemia (AIHA), thrombotic thrombocytopenic purpura (TTP) and myelofibrosis. During our search of the English-language MEDLINE sources, we did not place a date-of-publication constraint. Hence, we have reviewed previous as well as most recent studies with the subject heading SLE in combination with each manifestation. Neutropenia can lead to morbidity and mortality from increased susceptibility to infection. Severe neutropenia can be successfully treated with granulocyte colony-stimulating factor. While related to disease activity, there is no specific therapy for lymphopenia. Severe lymphopenia may require the use of prophylactic therapy to prevent select opportunistic infections. Isolated idiopathic thrombocytopenic purpura maybe the first manifestation of SLE by months or even years. Some manifestations of lupus occur more frequently in association with low platelet count in these patients, for example, neuropsychiatric manifestation, haemolytic anaemia, the antiphospholipid syndrome and renal disease. Thrombocytopenia can be regarded as an important prognostic indicator of survival in patients with SLE. Medical, surgical and biological treatment modalities are reviewed for this manifestation. First-line therapy remains glucocorticoids. Through our review, we conclude glucocorticoids do produce a response in majority of patients initially, but sustained response to therapy is unlikely. Glucocorticoids are used as first-line therapy in patients with SLE with AIHA, but there is no conclusive evidence to guide second-line therapy. Rituximab is promising in refractory and non-responding AIHA. TTP is not recognised as a criteria for classification of SLE, but there is a considerable overlap between the presenting features of TTP and SLE, and a few patients with SLE have concurrent TTP. Myelofibrosis is an uncommon yet well-documented manifestation of SLE. We have compiled the cases that were reported in MEDLINE sources.
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Affiliation(s)
- Anum Fayyaz
- Arthritis & Clinical Immunology Program , Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA ; Department of Medicine , University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma , USA ; Medical Service, Department of Veterans Affairs Medical Center, Oklahoma City, Oklahoma , USA
| | - Ann Igoe
- Arthritis & Clinical Immunology Program , Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA ; Department of Medicine , University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma , USA ; Departments of Medicine and Pediatrics , Metro Health System , Cleveland, Ohio , USA
| | - Biji T Kurien
- Arthritis & Clinical Immunology Program , Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA ; Department of Medicine , University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma , USA ; Medical Service, Department of Veterans Affairs Medical Center, Oklahoma City, Oklahoma , USA
| | - Debashish Danda
- Arthritis & Clinical Immunology Program , Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA ; Department of Rheumatology , Christian Medical Center , Vellore , India
| | - Judith A James
- Arthritis & Clinical Immunology Program , Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA ; Department of Medicine , University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma , USA ; Medical Service, Department of Veterans Affairs Medical Center, Oklahoma City, Oklahoma , USA
| | - Haraldine A Stafford
- Depertment of Medicine , Roy J. and Lucille A. Carver College of Medicine, University of Iowa , Iowa City, Iowa , USA
| | - R Hal Scofield
- Arthritis & Clinical Immunology Program , Oklahoma Medical Research Foundation , Oklahoma City, Oklahoma , USA ; Department of Medicine , University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma , USA ; Medical Service, Department of Veterans Affairs Medical Center, Oklahoma City, Oklahoma , USA
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