Association of systemic lupus erythematosus disease activity index score with clinical and laboratory parameters in pediatric onset systemic lupus erythematosus

Bacterial infection in patients with juvenile systemic lupus erythematosus and fever

BACKGROUND

Juvenile Systemic Lupus Erythematosus (JSLE) is a chronic, systemic autoimmune disease characterized by an increased susceptibility to infections. Fever in these patients can result from infection, heightened lupus activity, or a combination of both. Various clinical factors and biomarkers have been proposed to differentiate between infection and disease activity, but the results remain inconclusive. The Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2 k) is used to assess lupus activity in the presence or absence of infection. This study aimed to identify factors associated with bacterial infections in JSLE patients presenting with fever.

METHODS

A case-control study, approved by the institutional ethics committee, was conducted.

RESULTS

Bacterial infection was identified in 17% of 116 patients. Factors evaluated included immunomodulator use, high-dose steroids, renal replacement therapy, erythrocyte sedimentation rate (ESR) > 20, C-reactive protein (CRP) > 60 and > 90 mg/L, ferritin > 500 ng/mL, neutrophil-to-lymphocyte ratio (NLR) > 6, platelet-to-lymphocyte ratio (PLR) > 133, procalcitonin (PCT) > 0.9 ng/mL, lymphocyte-to-C4 ratio (LC4R) > 66.7, and ESR/CRP ratio < 2. In the adjusted model, PCT > 0.9 ng/mL retained significance with p < 0.01. Nagelkerke's R2 was 0.65, and the Hosmer-Lemeshow test indicated good internal validity.

CONCLUSIONS

Bacterial infection was detected in 17% of JSLE patients with fever. Procalcitonin > 0.9 ng/mL is a critical marker for identifying bacterial infection. NLR, PLR, ESR/CRP ratio, LC4R, and ferritin require further investigation to establish definitive cut-off values for differentiating bacterial infections from other infections or disease activity. Individual patient evaluation remains the recommended approach for diagnosis.

Disease activity at the onset of diagnosis as a predictor of disease outcomes in a cohort of patients with systemic lupus erythematosus: A post hoc retrospective analysis of the COMOSLE-EGYPT study

INTRODUCTION

Systemic lupus erythematosus (SLE) has a non-uniform course directly reflected in changes in disease activity and anticipation of damage.

AIM

To determine the impact of disease activity at the onset of disease diagnosis, measured by the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) disease activity score, on different disease parameters and outcomes.

METHODS

This multicentre, retrospective cohort study included 823 SLE patients. Disease damage was measured by the Systemic Lupus International Collaborating Clinics Damage Index (SLICC), and comorbidities were measured by the Charlson Comorbidity Index (CCI). According to the mean SLEDAI at onset of disease diagnosis, patients were classified into two groups: I included patients with a mean SLEDAI ≤ 10 (non-severe disease activity), and II included patients with a mean SLEDAI > 10 (severe disease activity).

RESULTS

SLEDAI at onset of disease diagnosis was a predictor of damage and comorbidities.

CONCLUSION

A higher SLEDAI score at onset of disease diagnosis was associated with damage accrual. Patients who are younger at disease onset are more likely to have more severe disease. Severe disease activity at the onset of disease diagnosis was also associated with future comorbidity occurrences, but it was not significantly associated with mortality. SLEDAI at the onset of disease diagnosis could be a prognostic marker predicting the damage, which may help in the identification of patients who are at higher risk of adverse outcomes. Special care should be directed towards patients who are younger at disease onset as they may have a higher disease activity at diagnosis. Key Points • This is a unique study as it is the first to focus on the impact of SLE disease activity at the onset of disease diagnosis measured by SLEDAI disease activity score on different disease parameters and outcomes. • Previous studies, though these are scarce, have highlighted the impact of disease activity throughout the disease course and not specifically at the beginning of the SLE disease.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio Predicts the Disease Activity in Patients with Paediatric Systemic Lupus Erythematosus: An Observational Cross-Sectional Study

Background

To assess the association between Neutrophil-to-lymphocyte ratio (NLR) and Platelet-to-lymphocyte ratio (PLR) with a degree of activity of paediatric systemic lupus erythematosus (pSLE) in terms of Systemic Lupus Erythematosus Disease Activity Index (SLEDAI-2K) score.

Methods

This observational cross-sectional study was conducted in Paediatric Rheumatology Clinic, Medical College Kolkata. Systemic lupus erythematosus was diagnosed in children based on the 2019 EULAR/ACR criteria and/or SLICC 2012 criteria. A total of 31 children were included in the study whereas patients with chronic illnesses were excluded.

Results

The mean age of presentation was 6.87 years among 31 children with pSLE. The most common presenting feature is prolonged fever and pallor followed by renal involvement. Most of the children presented with active disease 24 (77.42%). The mean NLR and PLR ratios were 4.29 ± 2.45 (0.9 - 10.57) and 112.26 ± 45.08 (47.7 - 203.9) respectively. The average SLEDAI-2K score was 15.9 (± 7.33). The NLR ratio in children with active disease (SLEDAI-2K score > 6) was 4.68 ± 2.44 (1.54 - 10.57) and inactive disease (SLEDAI-2K score <6) was 2.94 ± 2.10 (0.9 - 5.7) with p 0.0002. The PLR ratio in children with the active and inactive disease was 125.91 ± 41.29 (54.2 - 203.9) and 65.45 ± 18.0 (47.7 - 91.2) respectively (p 0.008).

Conclusion

The NLR and PLR ratio might be utilised as a trusted and cost-effective tool in the evaluation and prediction of pSLE disease activity.

Serum miRNA-21, miRNA-146a and plasma cell free DNA as novel biomarkers for assessing systemic lupus erythematosus activity

BACKGROUND

MicroRNA and cell-free DNA have shown significant correlations with several autoimmune disorders including systemic lupus erythematosus (SLE). SLE has been associated with challenges in determining its activity, so that the need for biomarkers contributing to assessing its activity is emerging. The current study investigated miRNA-21, miRNA-146a and plasma cf-DNA in determination of SLE activity, in addition their association with clinical data including complement factor 3 (C3), complement factor(C4), anti-dsDNA, and other disease activity indices.

METHODS AND RESULTS

Eighty subjects divided into; twenty active patients (with SLE-DAI2K score of 16-18) twenty inactive patients (with SLE-DAI2K score of 1-3), and forty healthy control participants) were included in this study. Serum miR-21, miR-146a, and plasma cf-DNA were quantified by real time PCR and their correlation with clinical data was statistically analyzed. The results demonstrated that active cases have significant upregulation of serum miRNA-21 and plasma cf-DNA. Moreover, miR-21 showed a negative, significant pertaining to C3, C4 and was positively related to Systemic Lupus Erythematosus Disease Activity Index 2 K score (SLE-DAI Index2K score) and Systemic-Lupus-Erythematosus-Disease Activity-Index 2 K activity (SLE-DAI 2 K activity). Also, Active group miRNA-146a was negatively, significantly correlated with C3, as well as a positive significant relationship with SLE-DAI2K score and SLEDAI 2 K activity, in addition to anti DNA Autoantibodies. Furthermore, miR-21 and cf-DNA demonstrated a differential value through Receiver Operating Characteristic (ROC) curve's study.

CONCLUSIONS

the present study illustrated miR-21, miR-146a, and cf-DNA relationship with SLE clinical data. In addition to their potential value in SLE diagnosis, and activity determination.

Prevalence of neuropsychiatric disorders in patients with systemic lupus erythematosus in Pakistan: A systematic review and meta-analysis

Introduction

By conducting a systematic review and meta-analysis, we investigated the prevalence of neuropsychiatric (NP) symptoms among systemic lupus erythematosus (SLE) patients in Pakistan.

Methods

In this review work, three electronic databases (Web of Science, MEDLINE, and Google Scholar) and local databases were screened for 20 years from 1 January 2002 to 30 September 2022, to identify the articles evaluating the prevalence of NP symptoms in SLE patients in Pakistan. We performed a random-effects meta-analysis to estimate the prevalence of NPSLE. Statistical heterogeneity was measured by the I2 index, and subgroup meta-analyses were used to access the statistical heterogeneity. Furthermore, meta-regression models were used to examine the associations between prevalence estimates and study characteristics of interest. Three independent authors reviewed existing studies, extracted data, and rated the qualities of selected studies. This review was registered on PROSPERO (Registration no. CRD42022361798).

Results

Thirteen studies met the inclusion criteria out of the 322 studies with a total of 2,003 SLE patients for this systematic review and meta-analysis. The prevalence of NP disorders in SLE patients was estimated to be 30.42% (95% CI:18.26-44.11%), with cognitive dysfunction being the most common (31.51%; 95% CI:1.28-76.27%), followed by headache (10.22%; 95% CI: 0.00-33.43%), seizures (5.96%; 95% CI: 3.80-8.53%), psychosis (3.64%; 95% CI: 2.38-5.13%), and neuropathy is the least common (0.86%; 95% CI: 0.00-2.74%). The heterogeneity between studies was significant (p < 0.01). The pooled prevalence of NP disorders among SLE patients was found highest in Punjab (41.21%) and lowest in Sindh (17.60%).

Conclusion

Findings from this study revealed that SLE patients have a high prevalence of NP disorders. The most common symptoms were cognitive dysfunctions, headaches, seizures, psychosis, and neuropathy. Clinicians can manage these potentially deadly and disabling diseases more effectively if they understand the incidence of each NP symptom in SLE patients. NP symptoms among SLE patients are at their peak in Pakistan; policymakers should devise preventive strategies to curb the disease.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record. php?RecordID=361798, identifier CRD42022361798.

Clinical study on the use of advanced magnetic resonance imaging in lupus nephritis

OBJECTIVES

To investigate the correlation between the histopathology of the kidney and clinical indicators in patients with lupus nephritis (LN) using magnetic resonance imaging (MRI).

METHODS

A total 50 female participants were enrolled in the study. Thirty patients with LN were divided into types 2, 3, 4, and 5, according to their pathological features. The control group consisted of 20 healthy female volunteers. Serum creatinine, C3, C1q, and anti-ds-DNA were measured. Conventional MRI, DTI, DWI, and BOLD scanning was performed to obtain the FA, ADC, and R2* values for the kidney.

RESULTS

Compared with the control group, FA and the ADC were decreased in patients with LN, while the R2* value was increased (P < 0.05). The overall comparison of the SLEDAI (Activity index of systemic lupus erythematosus) score, total pathological score, AI, and serum creatinine C3 showed that these were significantly different between the two groups (P < 0.05). FA and the ADC were negatively correlated with urinary, blood ds-DNA, and serum creatinine and positively correlated with C1q (P < 0.05). The R2* value was positively correlated with urinary NGAL, blood ds-DNA, and serum creatinine (P < 0.05). FA and the ADC were negatively correlated with the SLEDAI score, total pathological score, AI, CI, nephridial tissue C3, and C1q. The R2* value was positively correlated with the SLEDAI score, total pathological score, AI, CI, nephridial tissue C3, and C1q (P < 0.05).

CONCLUSIONS

MRI examination in female patients with LN was correlated with pathologic test results, which may have clinical significance in determining the disease's severity, treatment, and outcome.

The Association of Complements, TGF-β, and IL-6 with Disease Activity, Renal Damage, and Hematological Activity in Patients with Naïve SLE

Several key player factors, such as cytokine and complement, play an important role in the pathogenesis of systemic lupus erythematosus (SLE). The purpose of this study was to reveal the association between complement 3 (C3), complement 4 (C4), interleukin-6 (IL-6), and transforming growth factor-β (TGF-β) with SLE disease activity, renal damage, and hematological activity in patients with naïve SLE. The Laboratory of Clinical Pathology Dr. Soetomo General Hospital in Surabaya performed all laboratory examinations on thirty women with naïve SLE. The SLE diagnosis is based on ACR criteria (1998 revised criteria) from Dr. Soetomo General Hospital Surabaya, Indonesia, and the systemic lupus activity measurement (SLAM) score is used to assess the disease activity. The correlation was statistically tested using the Spearman and Pearson tests. The differences in cytokine and complement levels are between SLE severity groups using the two-way Anova and Kruskal-Wallis. The unpaired T-test and Mann-Whitney test were used to determine the differences between the relatively normal and the more severe groups of organ damage and hematological activity. All tests were two-tailed, analyzed with GraphPad Prism 9 for windows, and a p value of less than 0.05 was considered statistically significant. This study found a significant decrease in C3 (20.2, 16.4-24.2 mg/dL) and C4 (7, 6-14.3 mg/dL) and an increase in IL-6 (35.60 ± 7.43 mg/dL) and TGF-β (311.1 ± 290.8 mg/dL) in the group of severe patients with SLAM scores >30. Although there is no significant relationship between SLAM and renal impairment or hematologic activity, patients with higher SLAM had a significant decrease in complement; this complement decrease was also significant in patients with higher leukocyte counts. An insignificant increase in cytokines was also observed in patients with higher SLAM. Patients with high serum creatinine levels had a significant increase in TGF-β, whereas those with a faster ESR had a significant increase in IL-6. In conjunction with complements evaluation, assessment of the cytokine profile may become a promising marker for reliable diagnosis and treatment of SLE in the future.

Correlation Between Quantitative Anti-dsDNA Levels with Severity of Proteinuria in Systemic Lupus Erythematosus Patients

OBJECTIVE

To evaluate the correlation of quantitative anti-dsDNA level with proteinuria levels in patients with lupus nephritis in a tertiary care hospital.

STUDY DESIGN

In this prospective cross-sectional study, 76 patients of newly diagnosed SLE coming to Fatima Memorial Hospital were included in the study period between January 2020 to June 2020. Demographic data such as age, gender, lupus manifestations such as serositis, arthritis, mucocutaneous disease, and neuropsychiatric manifestations were recorded. Quantitative anti-dsDNA was measured by enzyme-linked immunosorbent assay and proteinuria was estimated by 24h urinary protein collection. Data was analyzed by SPSS 23. Association between categorical variables was assessed using chi-square test. For comparison of categorical independent and continuous dependent variable t-test or Mann-Whitney U test was applied.

RESULTS

The median age of the cohort was 29 (with inter quartile range - IQR - of 13) years. The female gender comprised of 68 (89.4%) of the cohort population. The median anti-dsDNA level was 54.9 (183.6 IQR) IU, and baseline proteinuria of the cohort was 520mg/dL (1.49 IQR). There was a significant association of anti-dsDNA level with systemic features such as arthritis (p=<0.01), serositis (p=<0.01) and, Raynaud's phenomenon (p=<0.01). NPSLE and mucocutaneous features did not show statistically significant association (p=0.91 and 0.14 respectively). Baseline anti-dsDNA showed a statistically significant correlation with baseline proteinuria levels (p=<0.01).

CONCLUSION

Quantitative anti-dsDNA is directly correlated with nephritis measured as proteinuria, and can be detected even before organ involvement. Hence, it can determine disease course and guide early treatment.

Retrospective analysis of clinical and pathomorphological features of lupus nephritis in children

PURPOSE

The aim of the study was to evaluate the clinical course and pathomorphological correlations in Polish children with the diagnosis of lupus nephritis (LN).

METHODS

We retrospectively analyzed the medical records of 39 children hospitalized due to LN in 7 pediatric nephrology units in Poland between 2010 and 2019. Demographic data, clinical symptoms at the onset of LN and laboratory parameters were reviewed. We analyzed Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), histological LN findings with the activity (IA) and chronicity index (IC).

RESULTS

We examined 32 girls and 7 boys, median age at LN onset was 14.75 (IQR 13.0-16.0) years, SLEDAI of 22.0 (IQR 18.0-27.0) points; LN histological class: IV (59.4%), III (18.9%), III/V (10.8%), IV/V (8.1%), VI (2.7%); IA 8.0 (IQR 6.0-11.0) points, IC 1.05 (IQR 0-2.0) points. Children with nephrotic (n ​= ​22) and non-nephrotic (n ​= ​17) proteinuria differed in median Hb level (9.55, IQR 8.3-11.2 vs 10.9, IQR 10.1-11.6 ​g/L; P ​< ​0.05), albumin level (2.5, IQR 2.1-3.19 vs 3.6, IQR 3.4-4.1 ​g/dL; P ​< ​0.001), proteinuria (5.76, IQR 3.0-7.5 vs 1.08, IQR 0.53-1.50 ​g/day; P ​< ​0.0001), eGFR (53.9, IQR 27.0-68.8 vs 96.7, IQR 73.8-106.2 ​mL/min/1.73 ​m²; P ​< ​0.01) and occurrence of hypertension (77% vs 23%; P ​< ​0.01). In multivariate analysis Hb level (β ​= ​8.0; 95%CI, 1.90-14.11) was the significant predictor of eGFR<90 ​mL/min/1.73 ​m².

CONCLUSIONS

Proliferative forms of LN in children may have a varying clinical presentation. Children with LN with nephrotic range proteinuria have lower Hb level, lower eGFR and higher occurrence of hypertension. Hb level is the significant predictor of eGFR<90 ​mL/min/1.73 ​m² in children with LN.