Systemic lupus erythematosus in men: a retrospective analysis in a Veterans Administration Healthcare System population

Lupus Nephritis, Autoantibody Production and Kidney Outcomes in Males with Childhood-Onset Systemic Lupus Erythematosus

Childhood-onset systemic lupus erythematosus (cSLE) only represents 20% of all SLE patients, and males with SLE only represent 10%. To study this rare SLE subset, males diagnosed with cSLE over a 30-year period were identified. Organ involvement, autoantibody production, hypocomplementemia, and kidney biopsy findings were compared to cSLE females. Outcomes were assessed using SLE Disease Activity Index scores, Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, and Childhood Arthritis and Rheumatology Research Alliance definitions for nephritis responsiveness. Of 95 males and 545 females with cSLE, 62% and 57% developed nephritis, respectively. Median age of cSLE onset was 14 years in both genders. Among males, 80% of non-Hispanic whites, 64% of blacks, 59% of Hispanics, and 50% of Asians developed nephritis. The prevalence of pure and mixed class V membranous nephritis was 33%. Median follow-up was 3.2 years (range 0.1-18). Complete kidney responses were seen in 70% after a median 24 months; however, relapse rates were 46%. Kidney disease flares were 56% nephritic and 44% proteinuric. Males and females with cSLE present with comparable rates and nephritis class. While overall and kidney response rates are favorable, kidney disease relapses are common among males.

Health care utilization and costs of systemic lupus erythematosus in the United States: A systematic review

OBJECTIVES

To evaluate health care utilization and costs for patients with systemic lupus erythematosus (SLE) by disease severity.

METHODS

We searched PubMed and Embase from January 2000 to June 2020 for observational studies examining health care utilization and costs associated with SLE among adults in the United States. Two independent reviewers reviewed the selected full-text articles to determine the final set of included studies. Costs were converted to 2020 US $.

RESULTS

We screened 9224 articles, of which 51 were included. Mean emergency department visits were 0.3-3.5 per year, and mean hospitalizations were 0.1-2.4 per year (mean length of stay 0.4-13.0 days). Patients averaged 10-26 physician visits/year. Mean annual direct total costs were $17,258-$63,022 per patient and were greater for patients with moderate or severe disease ($19,099-$82,391) compared with mild disease ($12,242-$29,233). Mean annual direct costs were larger from commercial claims ($24,585-$63,022) than public payers (Medicare and Medicaid: $18,302-$27,142).

CONCLUSIONS

SLE remains a significant driver of health care utilization and costs. Patients with moderate to severe SLE use more health care services and incur greater direct and indirect costs than those with mild disease.

Racial and Ethnic Differences in the Prevalence and Time to Onset of Manifestations of Systemic Lupus Erythematosus: The California Lupus Surveillance Project

OBJECTIVE

The California Lupus Surveillance Project (CLSP) is a population-based registry of individuals with systemic lupus erythematosus (SLE) residing in San Francisco County, California from 2007 to 2009, with a special focus on Asian/Pacific Islander and Hispanic patients. We used retrospective CLSP data to analyze racial and ethnic differences in lupus manifestations and in the timing and risk of developing severe manifestations.

METHODS

A total of 724 patients with SLE were retrospectively identified. Prevalence ratios (PRs) of SLE manifestations were calculated using Poisson regression models stratified by race/ethnicity and adjusted for sex, age at SLE diagnosis, and disease duration. We studied onset of severe SLE manifestations after SLE diagnosis using Kaplan-Meier methods to examine time-to-event and Cox proportional hazards regression models to estimate hazard ratios (HRs). White patients were the referent group in all analyses.

RESULTS

African Americans, Asian/Pacific Islanders, and Hispanic patients had increased prevalence of renal manifestations (PR 1.74 [95% confidence interval (95% CI) 1.40-2.16], PR 1.68 [95% CI 1.38-2.05], and PR 1.35 [95% CI 1.05-1.74], respectively). Furthermore, African Americans had increased prevalence of neurologic manifestations (PR 1.49 [95% CI 1.12-1.98]), and both African Americans (PR 1.09 [95% CI 1.04-1.15]) and Asian/Pacific Islanders (PR 1.07 [95% CI 1.01-1.13]) had increased prevalence of hematologic manifestations. African Americans, Asian/Pacific Islanders, and Hispanic patients, respectively, had higher risk of developing lupus nephritis (HR 2.4 [95% CI 1.6-3.8], HR 4.3 [95% CI 2.9-6.4], and HR 2.3 [95% CI 1.4-3.8]) and thrombocytopenia (HR 2.3 [95% CI 1.1-4.4], HR 2.3 [95% CI 1.3-4.2], and HR 2.2 [95% CI 1.1-4.7]). Asian/Pacific Islander and Hispanic patients had higher risk of developing antiphospholipid syndrome (HR 2.5 [95% CI 1.4-4.4] and HR 2.6 [95% CI 1.3-5.1], respectively).

CONCLUSION

This is the first epidemiologic study comparing lupus manifestations among 4 major racial and ethnic groups. We found substantial differences in the prevalence of several clinical SLE manifestations among racial/ethnic groups and discovered that African Americans, Asian/Pacific Islanders, and Hispanic patients are at increased risk of developing several severe manifestations following a diagnosis of SLE.

Phenome-Wide Association Studies Uncover a Novel Association of Increased Atrial Fibrillation in Male Patients With Systemic Lupus Erythematosus

OBJECTIVE

Phenome-wide association studies (PheWAS) scan across billing codes in the electronic health record (EHR) and re-purpose clinical EHR data for research. In this study, we examined whether PheWAS could function as an EHR-based discovery tool for systemic lupus erythematosus (SLE) and identified novel clinical associations in male versus female patients with SLE.

METHODS

We used a de-identified version of the Vanderbilt University Medical Center EHR, which includes more than 2.8 million subjects. We performed EHR-based PheWAS to compare SLE patients with age-, sex-, and race-matched control subjects and to compare male SLE patients with female SLE patients, controlling for multiple testing using a false discovery rate (FDR) P value of 0.05.

RESULTS

We identified 1,097 patients with SLE and 5,735 matched control subjects. In a comparison of patients with SLE and matched controls, SLE patients were shown to be more likely to have International Classification of Diseases, Ninth Revision codes related to the SLE disease criteria. In the PheWAS of male versus female SLE patients, with adjustment for age and race, male patients were shown to be more likely to have atrial fibrillation (odds ratio 4.50, false discovery rate P = 3.23 × 10^-3 ). Chart review confirmed atrial fibrillation, with the majority of patients developing atrial fibrillation after the SLE diagnosis and having multiple risk factors for atrial fibrillation. After adjustment for age, sex, race, and coronary artery disease, SLE disease status was shown to be significantly associated with atrial fibrillation (P = 0.002).

CONCLUSION

Using PheWAS to compare male and female patients with SLE, we identified a novel association of an increased incidence of atrial fibrillation in male patients. SLE disease status was shown to be independently associated with atrial fibrillation, even after adjustment for age, sex, race, and coronary artery disease. These results demonstrate the utility of PheWAS as an EHR-based discovery tool for SLE.

Clinical characteristics of males with systemic lupus erythematosus (SLE) in an inception cohort of patients in Ghana

Background

Systemic Lupus Erythematosus (SLE) is said to be rare in Sub-Saharan Africa and even rarer in males worldwide. SLE is mostly considered a disease of women, though men may also be affected, and this may lead to a delay in diagnosis in men. The result is a greater burden of inflammation and subsequent organ damage over time.

Method

Data from the medical records of 13 male patients diagnosed with SLE at the Rheumatology Clinic of Korle- Bu Teaching Hospital between January 2014 and January 2017 was retrospectively analyzed.

Results

A total of 13 male patients out of a total of 134 SLE patients were included in our analysis. The mean age was 30.62 ± SD 8.47 years (range of 17 to 46 years). All of them (100%) presented with constitutional features. The most common ACR criteria observed was 61.5 % rash, 54.5 % oral ulcers, 92.3% arthritis, 61.5 % serositis and 38.5% renal involvement, 46.2 % CNS involvement. Looking at their serological profile, 91.7 % had a positive antinuclear antibody (ANA). 33.3 % had positive anti-dsDNA and 58.3 % extractable nuclear antigens. The mean duration from onset of symptoms to diagnosis was 21.31 months. Five patients were diagnosed with lupus nephritis, all at the time of diagnosis. There were no mortalities.

Conclusion

Male SLE patients in Ghana are comparable to other populations, with arthritis and constitutional features being predominant early features and lupus nephritis being the main early indicator of organ damage. This should warrant aggressive management in male patients.

Funding

None declared

A Rare Case of Malignant Mesothelioma Presenting with Systemic Lupus Erythematosus Seropositivity: A Case Report and Review of Literature

While malignant mesothelioma may initially present in a variety of ways, it is uncommon to present with systemic lupus erythematosus (SLE) seropositivity and thus obscuring its diagnosis. Our case involves a 75-year-old Caucasian male with a past medical history of essential hypertension, remote prostate cancer status post prostatectomy, and lifetime nontobacco use presenting with progressive shortness of breath over one month. After a negative cardiac assessment, a postcardiac catheterization chest X-ray (CXR) revealed a right-sided moderate-to-large pleural effusion that, on further workup, was found to be exudative. Effusion studies were negative for malignancy and bacterial growth. Recurrent accumulation of fluid after a thoracentesis one week prior prompted an autoimmune work up. Positive markers included antinuclear antibodies, anti-double stranded DNA antibodies, and anti-histone antibodies, while anti-Smith antibodies were negative. Although SLE was initially suspected based on serologies, no clinical signs or symptoms were present to fulfill the diagnosis criteria. A trial of oral prednisone resulted in decreased pleural effusion size with no further recurrence. Additional studies included a CT scan of the chest that showed pleural masses confirmed with biopsy to be epithelioid mesothelioma. Given the patient’s age and new diagnosis of malignant mesothelioma, we hypothesized that the presence of autoantibodies was likely false positives due to acquired autoantibodies with age, hyperactivity of the immune system from malignancy, and possible prior asbestos exposure.

Systemic lupus erythematosus among male patients in Malaysia: how are we different from other geographical regions?

BACKGROUND

Systemic lupus erythematosus (SLE) is an autoimmune disease which predominantly affects females. The disease characteristics in male SLE patients are reported to be distinct and may vary across ethnicities and geographical regions.

OBJECTIVE

To determine and compare the clinical phenotype and organ damage between male and female patients with SLE in Malaysia.

METHODOLOGY

This was a cross-sectional study involving SLE patients from Universiti Kebangsaan Malaysia Medical Centre from June 2016 until June 2017. Information on their socio-demographics and disease characteristics were obtained from the clinical records. Disease damage was assessed using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index (SDI) scores. The disease characteristics, autoantibody profiles and organ damage were compared between male and female patients, and multivariable analysis using male sex as dependent variable was then performed.

RESULTS

A total of 418 patients were recruited and a total of 59 (14.1%) patients were male. Male patients presented with lower SLE ACR criteria at initial presentation but a significantly higher number of them had renal involvement (lupus nephritis) (78.0% versus 63.8%, p = 0.04). Male patients had less musculoskeletal involvement (45.8% versus 63.0%, p = 0.02) and tended to have lesser mucocutaneous involvement. Immunologic profile revealed that a lower number of male patients had positive anti-Ro antibody (22.7% versus 44.7%, p = 0.04) and they tended to have positive lupus anticoagulant antibody (27.6% versus 14.3%, p = 0.06). Presence of organ damage (SDI score ≥ 1) was significantly higher among males (55.9% versus 39.6%, p = 0.02) with higher renal damage (25.4% versus 9.2%, p = 0.004) and cardiovascular event of ischaemic heart disease or stroke (20.3% versus 7.0%, p = 0.004). They were also inclined to develop damage much earlier as compared to female patients, 3 (interquartile range (IQR) 7.5) versus 5 (IQR 7) years, p = 0.08. The occurrence of disease damage was independently associated with male gender with odds ratio of 1.9 (95% confidence interval 1.1-3.5), p = 0.02.

CONCLUSION

Male patients with SLE have more severe disease with renal damage and cardiovascular event.

The Importance of Sex Stratification in Autoimmune Disease Biomarker Research: A Systematic Review

The immune system is highly dynamic and regulated by many baseline characteristic factors. As such, significant variability may exist among different patient groups suffering from the same autoimmune disease (AD). However, contemporary research practices tend to take the reductionist aggregate approach: they do not segment AD patients before embarking on biomarker discovery. This approach has been productive: many novel AD biomarkers have recently been discovered. Yet, subsequent validation studies of these biomarkers tend to suffer from a lack of specificity, sensitivity, and reproducibility which hamper their translation for clinical use. To enhance reproducibility in validation studies, an optimal discovery-phase study design is paramount: one which takes into account different parameters affecting the immune system biology. In this systematic review, we highlight need for stratification in one such parameter, i.e., sex stratification. We will first explore sex differences in immune system biology and AD prevalence, followed by reported sex-bias in the clinical phenotypes of two ADs—one which more commonly affects females: systemic lupus erythematosus, and one which more commonly affects males: ankylosing spondylitis. The practice of sex stratification in biomarker research may not only advance the discovery of sex-specific AD biomarkers but more importantly, promote reproducibility in subsequent validation studies, thus easing the translation of these novel biomarkers from bench to bedside to improve AD diagnosis. In addition, such practice will also promote deeper understanding for differential AD pathophysiology in males and females, which will be useful for the development of more effective interventions for each sex type.

Diseases and Aging: Gender Matters

At first glance, biological differences between male and female sex seem obvious, but, in fact, they affect a vast number of deeper levels apart from reproductive function and related physiological features. Such differences affect all organizational levels including features of cell physiology and even functioning of separate organelles, which, among other things, account for such global processes as resistance to diseases and aging. Understanding of mechanisms underlying resistance of one of the sexes to pathological processes and aging will allow taking into consideration gender differences while developing drugs and therapeutic approaches, and it will provide an opportunity to reproduce and enhance such resistance in the more vulnerable gender. Here we review physiological as well as cellular and biological features of disease course including aging that are affected by gender and discuss potential mechanisms behind these processes. Such mechanisms include features of oxidative metabolism and mitochondrial functioning.

Early Life Factors Associated with Adult-Onset Systemic Lupus Erythematosus in Women

Background

Exposure early in life can influence adult disease and immunity, but the role of early life exposures in risk of systemic lupus erythematosus (SLE) is not established.

Methods

Women in a national cohort (ages 35–74) provided data on perinatal, maternal, and sociodemographic factors, longest residence to age 14, and residential farm history of at least 12 months to age 18. Cases (N = 124) reported SLE diagnosed age 16 years or older with use of disease modifying antirheumatic drugs. Non-cases (N = 50,465) did not report lupus. Odds ratios (OR) and 95% confidence intervals (CI) were estimated by logistic regression adjusting for age and race/ethnicity.

Results

SLE was associated with low birthweight (data on 84 cases and 36,477 non-cases; <2,500 versus 3,000 to <3,500 g OR = 2.2; 95%CI 1.2, 3.9) and preterm birth (57 cases and 22,784 non-cases; ≥1 month early versus full-term OR = 3.4; 95%CI 1.6, 7.4). Considering longest childhood residence to age 14, SLE was associated with more frequent pesticide use (e.g., at least monthly OR = 2.3; 95%CI 1.3, 4.1). SLE was associated with having an early and extended childhood farm residence (i.e., prenatal/maternal farm exposure and longest childhood farm residence OR = 1.8; 95%CI 1.1, 3.0 versus neither). In those with a childhood-only farm residence of 12+ months, agricultural pesticide use was associated with SLE, with the strongest associations for direct personal exposures.

Conclusion

The association of SLE with preterm birth is consistent with studies in other populations and with an observed association with low birthweight. The associations of SLE with childhood exposure to residential and agricultural pesticides warrant further study.

Outcome of adult onset systemic lupus erythematosus in Iran

AIM

The aim of this study was to determine systemic lupus erythematosus (SLE) survival in adult patients and its predictors in Iran.

METHODS

The adult patients diagnosed with SLE and admitted to our referral general hospital from 1992 to 2011 were studied. Demographic, clinical and laboratory data at the time of diagnosis were obtained retrospectively and analyzed. Survival rates were calculated by the Kaplan-Meier method. Predictors of mortality were assessed by Cox regression analysis.

RESULTS

In total, 417 were enrolled in the study; 23 were lost to follow-up. Mean (SD) age of SLE onset was 30 (9.7) years. During the study period 35 patients (8.9%) died. The most common causes of death were active SLE (43%), infections (28.6%) and circulatory diseases (20%). Overall survival rates after 5, 10, 15 and 20 years were 93%, 90%, 90% and 80%, respectively. Poor survival predictors in univariate analysis were pericarditis, seizure and hematuria. With multivariate Cox regression analysis, no pericarditis (p = 0.007, HR = 0.22, 95%CI: 0.075-0.657) and no seizure (p = 0.019, HR = 0.35, 95%CI: 0.149-0.846) at the time of SLE diagnosis were found as protective factors in patients' survival.

CONCLUSION

Our study revealed that the survival rate of SLE is comparable with the acceptable worldwide trend. Presenting with pericarditis and seizure at the time of SLE diagnosis prominently decreased the survival rate. Prospective and multicenter studies are needed to better identify the behavior of SLE in Iran.

Clinical and immunological pattern of systemic lupus erythematosus in men in a cohort of 2355 patients

AIM

To investigate the impact of gender on expression of systemic lupus erythematosus (SLE) in a cohort of 2355 SLE patients as one of the largest series of cases among the present reports.

METHOD

In this retrospective study we used medical records of all patients (239 male and 2116 female) of the SLE registry of Rheumatology Research Center (RRC), Tehran University of Medical science (TUMS), Iran. Both clinical and paraclinical manifestations of SLE patients have been registered in this database since 1976 and updated during their follow-up. Chi-square test was used to compare the clinical and paraclinical manifestations in men and women at disease onset and during the disease course. We used logistic regression to compute odds ratios with 95% confidence intervals. A P-value < 0.05 was considered as statistically significant.

RESULTS

Mean age at disease onset was 25 ± 11.8 and 24.5 ± 10.3 years in men and women, respectively (P = 0.48). Comparison of clinical and immunological manifestations showed that male patients had a higher prevalence of mucocutaneous (43.5% vs. 33.7%, P = 0.005) and a lower prevalence of musculoskeletal symptoms (44% vs. 54.7%, P = 0.003) as the initial manifestation. During the disease course, discoid rash (25.9% vs. 13%, P = 0.000) and type IV lupus nephritis (23.4% vs. 18.1%, P = 0.03) were significantly more common, whereas arthritis (61.1% vs. 71.7%, P = 0.01) and leukopenia (28.5% vs. 35.8%, P = 0.024) were significantly less common in men.

CONCLUSION

This study reveals gender influence on some manifestations of SLE. Considering sex differences is recommended in diagnostic and therapeutic features of the disease.

Burden of systemic lupus erythematosus in Taiwan: a population-based survey

This population-based study aimed to determine the trend of incidence, prevalence, and mortality of systemic lupus erythematosus (SLE) in a 6-year period in Taiwan. Patients with international classification of diseases ninth revision (ICD-9) code 710.0 were retrieved from the Taiwanese National Health Insurance Research Database (NHIRD), which covered more than 96 % of the entire population, and from the Ministry of Interior between 2003 and 2008 in Taiwan. Patients with SLE registered as catastrophic illness were enrolled for analysis. The incidence rate, prevalence ratio, and mortality rate stratified by sex and age were analyzed. There were a total of 6,675 SLE patients (5,836 females and 839 in males) during the study period. The average annual incidence rate was 4.87 per 100,000 population, and the average female-to-male incidence ratio was 7.15. The ratio increased with age and peaked at the age of 40-49 years, then decreased thereafter. The incidence rate decreased by 4.2 % per year. The highest incidence rate was noted in the 20-29-year-old age group in females and the 70-79-year-old age group in males. The average prevalence and mortality rates were 97.5 and 1.2 per 100,000 population, respectively. Mortality was 3.2 % in patients diagnosed within 1 year and is more prevalent in young patients with average age of 15.6 years. Incidence rate of SLE has been declining in recent years but the prevalence rate has remained steady. The highest mortality rate is among younger patients diagnosed with SLE within 1 year.

Differences between male and female systemic lupus erythematosus in a multiethnic population

OBJECTIVE

Male patients with systemic lupus erythematosus (SLE) are thought to be similar to female patients with SLE, but key clinical characteristics may differ. Comparisons were made between male and female patients with SLE in the Hopkins Lupus Cohort.

METHODS

A total of 1979 patients in the Hopkins Lupus Cohort were included in the analysis.

RESULTS

The cohort consisted of 157 men (66.2% white, 33.8% African American) and 1822 women (59.8% white, 40.2% African American). The mean followup was 6.02 years (range 0-23.73). Men were more likely than women to have disability, hypertension, thrombosis, and renal, hematological, and serological manifestations. Men were more likely to be diagnosed at an older age and to have a lower education level. Women were more likely to have malar rash, photosensitivity, oral ulcers, alopecia, Raynaud's phenomenon, or arthralgia. Men were more likely than women to have experienced end organ damage including neuropsychiatric, renal, cardiovascular, peripheral vascular disease, and myocardial infarction, and to have died. In general, differences between males and females were more numerous and striking in whites, especially with respect to lupus nephritis, abnormal serologies, and thrombosis.

CONCLUSION

Our study suggests that there are major clinical differences between male and female patients with SLE. Differences between male and female patients also depend on ethnicity. Future SLE studies will need to consider both ethnicity and gender to understand these differences.

Outcomes and organ dysfunctions of critically ill patients with systemic lupus erythematosus and other systemic rheumatic diseases

Our objective was to compare the pattern of organ dysfunctions and outcomes of critically ill patients with systemic lupus erythematosus (SLE) with patients with other systemic rheumatic diseases (SRD). We studied 116 critically ill SRD patients, 59 SLE and 57 other-SRD patients. The SLE group was younger and included more women. Respiratory failure (61%) and shock (39%) were the most common causes of ICU admission for other-SRD and SLE groups, respectively. ICU length-of-stay was similar for the two groups. The 60-day survival adjusted for the groups' baseline imbalances was not different (P = 0.792). Total SOFA scores were equal for the two groups at admission and during ICU stay, although respiratory function was worse in the other-SRD group at admission and renal and hematological functions were worse in the SLE group at admission. The incidence of severe respiratory dysfunction (respiratory SOFA >2) at admission was higher in the other-SRD group, whereas severe hematological dysfunction (hematological SOFA >2) during ICU stay was higher in the SLE group. SLE patients were younger and displayed a decreased incidence of respiratory failure compared to patients with other-SRDs. However, the incidences of renal and hematological failure and the presence of shock at admission were higher in the SLE group. The 60-day survival rates were similar.

Male systemic lupus erythematosus, an overlooked diagnosis

Lupus erythematosus is a chronic autoimmune inflammatory disease of unknown cause that involves multiple systems. Autoimmune diseases that are prevalent in men usually manifest themselves clinically before the age of 50 years old and are characterized by an acute inflammation, whereas autoimmune diseases with predominance among women appear clinically in later stages of life, when chronic diseases, fibrosis and increased number of autoantibodies are present. Lupus erythematosus is more prevalent among women during the reproductive period, but the cause of this predilection is not fully established and little is known about the disease among men. We report a case of systemic lupus erythematosus (SLE) in a male patient whose diagnosis was delayed due to the systemic manifestations and because SLE is considered an uncommon disease in men.

Review: Male systemic lupus erythematosus: a review of sex disparities in this disease

Although males with systemic lupus erythematosus (SLE) represent 4-22% of all SLE patients, it may not be appropriate that these cases should be subordinated to females with SLE in terms of most health-related issues. Over the past few decades, some distinctive features of male lupus have been observed with regard to genetic and environmental aspects of sex differences, clinical features, and outcome. In addition, recent insights into sex disparities in this disease have brought forth a few plausible and novel pathogenetic hypotheses. This review discusses these findings and sex disparities in SLE that appear to be especially noteworthy and pertinent to our understanding of male SLE.

Can morbidity and mortality of SLE be improved?

Systemic lupus erythematosus (SLE) is the second most common autoimmune disorder (after thyroid disease) in women of childbearing age. Lupus is increasingly being recognized throughout the world's population. The incidence and prevalence of SLE varies among racial and ethnic groups. Lupus patient survival has significantly improved over the past five decades, but a three- to fivefold increased risk of death remains compared with the general population. As lupus patients survive longer, these individuals face a range of complications from the disease itself or consequent to its treatment. Emerging data from epidemiological studies underscore the importance of incorporating race and ethnicity in understanding the risk factors leading to the significant burden of mortality and morbidity associated with this disease. This chapter describes the epidemiology of lupus with a focus on racial and ethnic differences, reviews the mortality associated with the disease, discusses selected complications associated with morbidity related to the disease and highlights areas where we can improve mortality and morbidity.