The Systemic Lupus Erythematosus Infection Predictive Index (LIPI): A Clinical-Immunological Tool to Predict Infections in Lupus Patients

SLESIS-R: an improved score for prediction of serious infection in patients with systemic lupus erythematosus based on the RELESSER prospective cohort

OBJECTIVE

To develop an improved score for prediction of severe infection in patients with systemic lupus erythematosus (SLE), namely, the SLE Severe Infection Score-Revised (SLESIS-R) and to validate it in a large multicentre lupus cohort.

METHODS

We used data from the prospective phase of RELESSER (RELESSER-PROS), the SLE register of the Spanish Society of Rheumatology. A multivariable logistic model was constructed taking into account the variables already forming the SLESIS score, plus all other potential predictors identified in a literature review. Performance was analysed using the C-statistic and the area under the receiver operating characteristic curve (AUROC). Internal validation was carried out using a 100-sample bootstrapping procedure. ORs were transformed into score items, and the AUROC was used to determine performance.

RESULTS

A total of 1459 patients who had completed 1 year of follow-up were included in the development cohort (mean age, 49±13 years; 90% women). Twenty-five (1.7%) had experienced ≥1 severe infection. According to the adjusted multivariate model, severe infection could be predicted from four variables: age (years) ≥60, previous SLE-related hospitalisation, previous serious infection and glucocorticoid dose. A score was built from the best model, taking values from 0 to 17. The AUROC was 0.861 (0.777-0.946). The cut-off chosen was ≥6, which exhibited an accuracy of 85.9% and a positive likelihood ratio of 5.48.

CONCLUSIONS

SLESIS-R is an accurate and feasible instrument for predicting infections in patients with SLE. SLESIS-R could help to make informed decisions on the use of immunosuppressants and the implementation of preventive measures.

Glucocorticoid treatment in SLE is associated with infections, comorbidities and mortality-a national cohort study

OBJECTIVES

Patients with SLE have an increased risk of comorbidities and impaired survival. We aimed to assess whether various thresholds of oral CS (OCS) can predict development of infections, comorbidities, malignancies and survival in SLE using data from national health registries in Sweden.

METHODS

All incident SLE cases, age >18 years, in Sweden (n = 5309) between 2005 and 2020 and matched population controls (n = 26 545) were included and followed until 2020, a total of 257 942 patient years. Data from national registers were retrieved including information from the National Prescribed Drug Register. Risk factors were analysed using time-dependent Cox regression models.

RESULTS

Compared with no OCS, >0 to <5.0 mg/day, 5.0-7.5 mg/day as well as >7.5 mg/day OCS predicted development of infections (pneumonia, influenza, herpes zoster and urinary tract infection), osteoporosis, osteonecrosis, gastroduodenal ulcers, cataracts, hypertension and mortality (all P < 0.05). OCS >0 to <5.0 mg/day was associated with lower hazard ratios for these comorbidities than higher doses of OCS. Fifteen years after diagnosis, 48% of patients were taking OCS at a median dose of 5.7 mg/day. A small reduction of OCS treatment 5 years after diagnosis in patients diagnosed with SLE 2006-10 compared with 2011-15 was observed, 49% vs 46% respectively (P = 0.039).

CONCLUSION

Results highlight the potential harm associated with even low OCS dose treatment in SLE and the need to judiciously use OCS at the lowest possible dose to maximize efficacy and minimize harm.

The impact of the COVID-19 pandemic on SLE

Little is known about the association between coronavirus disease 2019 (COVID-19) and autoimmune diseases, especially in the case of systemic lupus erythematosus (SLE). SLE patients met with many questions during the pandemic in COVID-19, such as how to minimize risk of infection, the complex pathological features and cytokine profiles, diagnosis and treatment, rational choice of drugs and vaccine, good nursing, psychological supervision, and so on. In this study, we review and discuss the multifaceted effects of the COVID-19 pandemic on patients living with SLE using the available literature. Cross-talk in implicated inflammatory pathways/mechanisms exists between SLE and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and SARS-CoV-2 displays similar clinical characteristics and immuno-inflammatory responses to SLE. Current epidemiological data inadequately assess the risk and severity of COVID-19 infection in patients with SLE. More evidence has shown that hydroxychloroquine and chloroquine cannot prevent COVID-19. During the pandemic, patients with SLE had a higher rate of hospitalization. Vaccination helps to reduce the risk of infection. Several therapies for patients with SLE infected with COVID-19 are discussed. The cases in the study can provide meaningful information for clinical diagnosis and management. Our main aim is to help preventing infection and highlight treatment options for patients with SLE infected with COVID-19.

Disease activity is associated with changes in the innate immune function in patients with systemic lupus erythematosus

OBJECTIVE

To address the relationship between systemic lupus erythematosus (SLE) disease activity and the functional parameters of the innate immunity.

METHODS

We evaluated a cohort of 26 adult SLE patients and 10 sex and age-paired healthy donors. When the patients had a disease flare (baseline) and when they achieve clinical response (follow-up), we assessed the systemic lupus erythematosus disease activity index 2 K (SLEDAI 2 K) and the following parameters with flow cytometry and confocal microscopy: monocyte subsets, their expression of TLR2, phagocytic monocytes and neutrophils using the pHrodo Red E. coli BioParticles, the respiratory burst with 123-dihydrorhodamine in neutrophils, and the spontaneous and lipopolysaccharide (LPS)-induced production of neutrophil extracellular traps (NETs). We used the Wilcoxon test to compare the paired medians with interquartile range (IQR) and the Mann-Whitney U test for independent medians. To assess the effect of prednisone and SLEDAI 2 K on the mentioned parameters, we applied a generalized mixed linear model.

RESULTS

Twenty-three patients (88.4%) were women. The SLEDAI 2 K was higher at baseline 8 (6-14) in comparison to that at follow-up (6 (4-8), P = 0.028). At baseline, SLE patients had a decreased percentage of intermediate monocytes, a higher expression of TLR2 in total monocytes, increased phagocytosis in monocytes and neutrophils, a decreased respiratory burst intensity, and an increased production of NETs. In the mix model, the SLEDAI 2 K was the main factor influencing these functional innate immune parameters.

CONCLUSION

Disease activity regulates the innate immune function in SLE which may contribute to the clinical features and infection predisposition. Key points • This is the first cohort study addressing the effect of disease activity and prednisone use on the innate immune function of lupus patients. • Our results show that the disease activity is a key regulator of the respiratory burst, phagocytosis, and the production of neutrophil extracellular traps. • Also, we observed a differential proportion of monocyte subsets according to SLE disease activity. • We consider that our manuscript contributes to the evidence addressing the intrinsic immune abnormalities of patients with SLE regardless of the use of immunosuppressants and set the bases for new research work considering the disease activity as an element to decide the prescription and duration of antibiotic prophylaxis in SLE patients, which is of interest to all rheumatologists.

Characteristics and clustering analysis of peripheral blood lymphocyte subsets in children with systemic lupus erythematosus complicated with clinical infection

OBJECTIVES

Clinical infection is a common complication in children with systemic lupus erythematosus (SLE). However, few studies have investigated immune alterations in children with SLE complicated with clinical infection. We assessed lymphocyte subsets in children with SLE to explore the possibility of clinical infection.

METHODS

We retrospectively analyzed the proportion of peripheral lymphocyte subsets in 140 children with SLE. Children with SLE were classified into different clusters according to the proportion of peripheral blood lymphocyte subsets: (CD3 + /CD4 + T cell, CD3 + /CD8 + T cell, CD3 + /CD4 + /CD8 + T cell, CD3 + /CD4-/CD8- T cell, CD19 + B cell, and CD3-/CD16 + /CD56 + NK cell). Differences in the proportion of lymphoid subsets, infection rates, and systemic lupus erythematosus disease activity index (SLEDAI) scores were compared between clusters. In addition, we grouped the subjects according to the presence or absence of infection. Proportions of lymphoid subsets, demographic variables, clinical presentation, and other laboratory variables were compared between the infected and uninfected groups. Finally, the diagnostic ability of lymphocyte subset ratios to distinguish secondary infection in children with SLE was predicted using an ROC curve.

RESULTS

Cluster C2 had a higher proportion of B cells than Cluster C1, while Cluster C1 had a lower proportion of NK cells, CD3 + T cells, CD3 + /CD4 + T cells, CD3 + /CD8 + T cells, and CD3 + /CD4-/CD8- T cells. Infection rates and SLEDAI scores were higher in Cluster C2 than in Cluster C1. The infected children had a higher proportion of B cells and a lower proportion of CD3 + T cells, CD3 + /CD4 + T cells, CD3 + /CD8 + T cells, and CD3 + /CD4-/CD8- T cells. There were no significant differences in lymphoid subsets between children in Cluster C2 and the infected groups. The area under the ROC curve of B lymphocytes in predicting SLE children with infection was 0.842. The area under the ROC curve was 0.855 when a combination of B cells, NK cells, CD4 + T cells, and CD8 + T cells was used to predict the outcome of coinfection.

CONCLUSIONS

A high percentage of B cells and a low percentage of CD3 + T cells, CD3 + /CD4 + T cells, CD3 + /CD8 + T cells, CD3 + /CD4 + /CD8 + T cells, and CD3 + /CD4-/CD8- T cells may be associated with infection in children with SLE. B cells was used to predict the outcome of coinfection in children with SLE. Key Points • A high percentage of B cells and a low percentage of CD3 + T cells, CD3 + /CD4 + T cells, CD3 + /CD8 + T cells, CD3 + /CD4 + /CD8 + T cells, and CD3 + /CD4-/CD8- T cells may be associated with infection in children with SLE • B cells was used to predict the outcome of coinfection in children with SLE.

Multisystem inflammatory syndrome in systemic lupus erythematosus patient with COVID-19: Case report and review

Multisystem inflammatory syndrome in adults (MIS-A) is considered a rare and serious complication of coronavirus disease 2019, which more frequently occurs in young, male, and either non-Hispanic black or Hispanic persons. Here we present a Chinese woman aged 50 years with systemic lupus erythematosus diagnosed with MIS-A. She experienced unexpected sudden cardiac and liver injuries and hemodynamic collapse, and her platelet count dropped sharply on hospital day 2. Unfortunately, the patient's condition gradually deteriorated despite maximum support and she died on day 3. We present this rare case to emphasize that MIS-A in autoimmune diseases may be more severe and its management may be more difficult.

Major Infections of Newly Diagnosed Childhood-Onset Systemic Lupus Erythematosus

Objective

To evaluate the risk of major infections in children with newly diagnosed childhood-onset systemic lupus erythematosus (cSLE).

Methods

Predictors of major infections were identified by the multivariable logistic regression. Major infection free was defined as no major infection events within 6 months after the diagnosis of cSLE. The Kaplan-Meier survival plot was performed. A prediction model for major infection events was established and examined by receiver operating characteristic (ROC) curve analysis.

Results

A total of 98 eligible patients were recorded in the medical charts. Sixty-three documented events of major infections were found in 60 (61.2%) cSLE patients. Furthermore, 90.5% (57/63) of infection events occurred within the first 6 months after the diagnosis of cSLE. The high SLEDAI (SLEDAI >10), lupus nephritis and lymphocyte count <0.8×109/L were predictors for major infections. The CALL score (Children with high disease activity [SLEDAI >10], lymphopenia, and LN) was defined by the number of predictors. Patients were then categorized into two groups: low-risk (score 0-1) and high-risk (score 2-3). Patients in the high-risk group had higher rates of the major infection occurrence than those in the low-risk group during the 6 months after the diagnosis of the cSLE (P<0.001) (HR:14.10, 95% CI 8.43 to 23.59). The ROC curve analysis indicated that the CALL score was effective both in the whole cSLE cohort [area under the curve (AUC) = 0.89, 95% CI: 0.81-0.97] and in the subgroup of lung infections (n = 35) (AUC = 0.79, 95% CI: 0.57-0.99).

Conclusion

High disease activity, LN and lymphopenia were predictors for major infections in newly diagnosed cSLE patients. Specific predictors help identify the cSLE patients with the high risk of major infections. The CALL score could be a useful tool to stratify cSLE patients in practice.

Associations of lymphocyte subpopulations with clinical phenotypes and long-term outcomes in juvenile-onset systemic lupus erythematosus

OBJECTIVE

Juvenile-onset systemic lupus erythematosus (JSLE) is a complex and heterogeneous immune-mediated disease. Cellular components have crucial roles in disease phenotypes and outcomes. We aimed to determine the associations of lymphocyte subsets with clinical manifestations and long-term outcomes in JSLE patients.

METHODS

A cohort of 60 JSLE patients provided blood samples during active disease, of whom 34 provided further samples during inactive disease. In a longitudinal study, blood samples were obtained from 49 of the JSLE patients at 0, 3, and 6 months. The healthy control (HC) group consisted of 42 age-matched children. Lymphocyte subsets were analyzed by flow cytometry.

RESULTS

The percentages of CD4+ T, γδ T, and NK cells were significantly decreased in JSLE patients compared with HC, while the percentages of CD8+ T, NKT, and CD19+ B cells were significantly increased. The percentage of regulatory T cells (Tregs) was significantly lower in JSLE patients with lupus nephritis (LN) than in non-LN JSLE patients and HC. The patients were stratified into high and low groups by the median frequency of each lymphocyte subset. The γδ T cells high group and NK cells high group were significantly related to mucosal ulcer. The CD4+ T cells high group was significantly associated with arthritis, and the NKT cells high group was substantially linked with autoimmune hemolytic anemia. The CD8+ T cells low group was mainly related to vasculitis, and the Tregs low group was significantly associated with LN. The percentage of Tregs was significantly increased at 6 months of follow-up, and the LN JSLE group had a lower Treg percentage than the non-LN JSLE group. Predictors of remission on therapy were high Tregs, high absolute lymphocyte count, direct Coombs test positivity, and LN absence at enrollment.

CONCLUSION

JSLE patients exhibited altered lymphocyte subsets, which were strongly associated with clinical phenotypes and long-term outcomes.

Predictors of admission to intensive care unit among systemic lupus erythematosus patients: prospective study

Background

Through the disease course, different prognostic factors have been addressed in patients with SLE admitted to intensive care unit. For instance, higher disease activity on admission, recent immunosuppressive therapy, infections, renal disease, and central nervous system involvement, all had negative effects on the outcome of the disease. It is still a clinical challenge for the physicians to manage this disease which has many aspects regarding its pathogenesis, clinical presentation, and its outcome remains to be explained.

The aim of our study was determining the course, outcome, and determinants of admission to intensive care unit in patients with systemic lupus erythematosus.

Results

Patients with systemic lupus erythematosus admitted to the intensive care unit in the study sample was 21.4%, and the death rate among them is 18.2%. In our study, the main causes of intensive care admission were cardiovascular causes followed by renal failure then infections. Holding the other covariates constant, a higher value of CRP, SLEDAI, and damage index value is associated with intensive care admission among lupus patients.

Conclusion

Our study showed that systemic lupus erythematosus patients with a higher value of CRP, SLEDAI, and damage index value were liable for intensive care unit admission. Good control of disease activity of SLE which in turn reduces damage of different body systems is mandatory. Periodic screening for functions of renal and cardiac systems is of great value. Proper screening and prophylaxis is recommended against variable causes of infections. Rheumatologists should be careful in controlling SLE active disease and to balance the doses of immunosuppressive especially in the presence of infection. They should focus the research on finding more accurate infection predictive index parameters to early predict the onset of infection.

COVID-19 in patients with systemic lupus erythematosus: lessons learned from the inflammatory disease

As the world navigates the coronavirus disease 2019 (COVID-19) pandemic, there is a growing need to assess its impact in patients with autoimmune rheumatic diseases, such as systemic lupus erythematosus (SLE). Patients with SLE are a unique population when considering the risk of contracting COVID-19 and infection outcomes. The use of systemic glucocorticoids and immunosuppressants, and underlying organ damage from SLE are potential susceptibility factors. Most patients with SLE have evidence of high type I interferon activity, which may theoretically act as an antiviral line of defense or contribute to the development of a deleterious hyperinflammatory response in COVID-19. Other immunopathogenic mechanisms of SLE may overlap with those described in COVID-19, thus, studies in SLE could provide some insight into immune responses occurring in severe cases of the viral infection. We reviewed the literature to date on COVID-19 in patients with SLE and provide an in-depth review of current research in the area, including immune pathway activation, epidemiology, clinical features, outcomes, and the psychosocial impact of the pandemic in those with autoimmune disease.

Predictive models of infection in patients with systemic lupus erythematosus: A systematic literature review

INTRODUCTION

Having reliable predictive models of prognosis/the risk of infection in systemic lupus erythematosus (SLE) patients would allow this problem to be addressed on an individual basis to study and implement possible preventive or therapeutic interventions.

OBJECTIVE

To identify and analyze all predictive models of prognosis/the risk of infection in patients with SLE that exist in medical literature.

METHODS

A structured search in PubMed, Embase, and LILACS databases was carried out until May 9, 2020. In addition, a search for abstracts in the American Congress of Rheumatology (ACR) and European League Against Rheumatism (EULAR) annual meetings' archives published over the past eight years was also conducted. Studies on developing, validating or updating predictive prognostic models carried out in patients with SLE, in which the outcome to be predicted is some type of infection, that were generated in any clinical context and with any time horizon were included. There were no restrictions on language, date, or status of the publication. To carry out the systematic review, the CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies) guideline recommendations were followed. The PROBAST tool (A Tool to Assess the Risk of Bias and Applicability of Prediction Model Studies) was used to assess the risk of bias and the applicability of each model.

RESULTS

We identified four models of infection prognosis in patients with SLE. Mostly, there were very few events per candidate predictor. In addition, to construct the models, an initial selection was made based on univariate analyses with no contraction of the estimated coefficients being carried out. This suggests that the proposed models have a high probability of overfitting and being optimistic.

CONCLUSIONS

To date, very few prognostic models have been published on the infection of SLE patients. These models are very heterogeneous and are rated as having a high risk of bias and methodological weaknesses. Despite the widespread recognition of the frequency and severity of infections in SLE patients, there is no reliable predictive prognostic model that facilitates the study and implementation of personalized preventive or therapeutic measures.Protocol registration number: PROSPERO CRD42020171638.

Lymphocyte subset clustering analysis in treatment-naive patients with systemic lupus erythematosus

OBJECTIVES

The aim of the study is to identify clusters of lymphocyte subsets within treatment-naive systemic lupus erythematosus (SLE) patients and evaluate the potential association of these clusters with disease activities.

METHODS

We conducted a cross-sectional study of consecutive 143 treatment-naive SLE patients in the Affiliated Hospital of Nantong University, China. We used hierarchical cluster analysis to classify individuals into clusters based on circulating lymphocyte subset proportions (CD3⁺CD4⁺T cell, CD3⁺CD8⁺T cell, CD19⁺B cell, and CD3-CD16 + CD56 NK cell) via R software. Demographic variables, clinical manifestations, laboratory variables, and disease activities were compared among clusters.

RESULTS

The SLE patients (median age 35 (26-48) years, 90.9% female) were divided into four clusters. The clustering features were as follows: cluster 1 (B high), cluster 2 (CD4 high), cluster 3 (CD8 high), and cluster 4 (NK high). SLE patients in cluster 1 showed the highest incidence of arthritis (70.6%, 34.2%, 48.3%, and 42.9% in clusters 1, 2, 3, and 4, respectively; P = 0.046), and patients in cluster 3 and cluster 4 showed significantly a higher incidence of nephritis (35.3%, 25.0%, 48.3%, and 61.9% in in clusters 1, 2, 3, and 4, respectively; P = 0.008). Patients in cluster 2 suffered from lower SLE Disease Activity Index (SLEDAI) score (12.1 ± 5.0, 10.3 ± 5.6, 12.2 ± 4.6, and 14.4 ± 7.3 in clusters 1, 2, 3, and 4, respectively; P = 0.046). Regression analysis indicated that, compared with patients in cluster 2, patients in cluster 1 exhibited higher rate of arthritis (OR 4.53, 95% CI 1.38-14.86, P = 0.013), while patients in cluster 3 (OR 2.85, 95%CI 1.15-7.08, P = 0.024) and cluster 4 (OR 4.93, 95%CI 1.76-13.85, P = 0.002) exhibited higher rate of nephritis.

CONCLUSION

This study supports the existence of lymphocyte subset clusters with different clinical features in treatment-naive SLE patients, which could help to differentiate between various subsets of SLE. Key Points • Lymphocyte subsets may occur in a pattern of cluster in treatment-naive SLE patients.

Selective DNA Demethylation Accompanies T Cell Homeostatic Proliferation and Gene Regulation in Lupus-Prone lpr Mice

Systemic lupus erythematosus (SLE) is characterized by increased DNA demethylation in T cells, although it is unclear whether this occurs primarily in a subset of SLE T cells. The process driving the DNA demethylation and the consequences on overall gene expression are also poorly understood and whether this represents a secondary consequence of SLE or a primary contributing factor. Lupus-prone lpr mice accumulate large numbers of T cells with age because of a mutation in Fas (CD95). The accumulating T cells include an unusual population of CD4-CD8-TCR-αβ+ (DN) T cells that arise from CD8+ precursors and are also found in human SLE. We have previously observed that T cell accumulation in lpr mice is due to dysregulation of T cell homeostatic proliferation, which parallels an increased expression of numerous genes in the DN subset, including several proinflammatory molecules and checkpoint blockers. We thus determined the DNA methylome in lpr DN T cells compared with their CD8+ precursors. Our findings show that DN T cells manifest discrete sites of extensive demethylation throughout the genome, and these sites correspond to the location of a large proportion of the upregulated genes. Thus, dysregulated homeostatic proliferation in lpr mice and consequent epigenetic alterations may be a contributing factor to lupus pathogenesis.

Syk Inhibitor Attenuates Polymicrobial Sepsis in FcgRIIb-Deficient Lupus Mouse Model, the Impact of Lupus Characteristics in Sepsis

The impact of spleen tyrosine kinase (Syk) signaling might be prominent in lupus because (i) Syk is a shared downstream signaling molecule among circulating immune complex, LPS, and (1→3)-β-D-glucan (BG), and (ii) all of these factors are detectable in the serum of Fc gamma receptor IIb-deficient (FcgRIIb-/-) mice with sepsis. As a proof of concept study, we activated macrophages with BG combined with LPS (BG + LPS). We found that BG + LPS predominantly upregulated Syk expression and proinflammatory cytokines in FcgRIIb-/- macrophages compared with wild-type (WT) macrophages. Syk inhibition downregulated several inflammatory pathways in FcgRIIb-/- macrophages activated with BG + LPS, as determined by RNA sequencing analysis, suggesting the potential anti-inflammatory impact of Syk inhibitors in lupus. Indeed, administration of a Syk inhibitor prior to cecal ligation and puncture (CLP) sepsis in FcgRIIb-/- mice reduced baseline lupus-induced proinflammatory cytokines and attenuated sepsis severity as evaluated by mortality, organ injury, serum LPS, and post-sepsis serum cytokines. In conclusion, it was easier to induce Syk expression in FcgRIIb-/- macrophages than in WT macrophages. This might be because of the loss of inhibitory signaling, which might be responsible for prominent Syk abundance in the spleens of 40-week-old FcgRIIb-/- mice and the potent effect of Syk inhibitor in lupus mice compared with WT.

Immunosuppressive Agents and Infectious Risk in Transplantation: Managing the "Net State of Immunosuppression"

Successful solid organ transplantation reflects meticulous attention to the details of immunosuppression, balancing risks for graft rejection against risks for infection. The 'net state of immune suppression' is a conceptual framework of all factors contributing to infectious risk. Assays which measure immune function in the immunosuppressed transplant recipient relative to infectious risk and allograft function are lacking. The best measures of integrated immune function may be quantitative viral loads to assess the individual's ability to control latent viral infections. Few studies address adjustment of immunosuppression during active infections. Thus, confronted with infection in solid organ recipients, the management of immunosuppression is based largely on clinical experience. This review examines known measures of immune function and the immunologic effects of common immunosuppressive drugs and available studies reporting modification of drug regimens for specific infections. These data provide a conceptual framework for the management of immunosuppression during infection in organ recipients.

Clinical characteristics and risk factors of infection in patients with systemic lupus erythematosus: A systematic review and meta-analysis of observational studies

OBJECTIVE

Infection is one of the major causes of morbidity and mortality in systemic lupus erythematosus (SLE) patients. We conducted a systematic review and meta-analysis to investigate the clinical characteristics and risk factors of infection in SLE by comparing demographic factors, laboratory data, clinical features, and therapeutic factors between infection and non-infection SLE patients.

METHODS

PubMed, Embase, and Cochrane databases were searched systematically without restricting the language or year (up to September 2019) by using MeSH terms and keywords pertaining to SLE and infection. Three independent reviewers selected all observational studies based on the established inclusion criteria. Odds ratio (OR) and standardized mean difference (SMD) along with 95% confidence intervals (CI) were used and the analyses were carried out by using a random/fixed-effects model. When necessary, different subgroup and sensitivity analyses were conducted. Study quality was assessed by the modified version (nine-star scoring system) of the Newcastle-Ottawa Scale (NOS) and publication bias was evaluated by funnel plots, and Egger's and Begg's tests.

RESULTS

In total, we included 39 studies (3709 infection SLE patients and 10526 non-infection SLE patients) based on the inclusion criteria. Compared with the SLE patients without infection, we found that infected SLE patients had a significantly higher incidence rate of the following: 1) lymphopenia (OR = 2.738 95%CI (1.017-7.376), P = 0.046, I² = 81.4%), 2) thrombocytopenia (OR = 1.61 95%CI (1.4-1.85), P<0.001, I² = 0%), 3) anemia (OR = 2.294 95%CI (1.402-3.755), P = 0.001, I² = 83.0%), 4) hypoproteinemia (OR = 2.336 95%CI (1.408-3.876), P = 0.001, I² = 84.2%), 5) C3 consumed (OR = 1.890 95%CI (1.190-3.002), P = 0.007, I² = 77.4%), 6) diabetes mellitus (OR = 3.890 95%CI (2.450-6.160), P < 0.001, I² = 0%), 7) elevated creatinine (OR = 1.954 95%CI (1.646-2.320), P < 0.001, I² = 0.0%), 8) renal involvement (OR = 2.692 95%CI (2.000-3.623), P < 0.001, I² = 76.0%), 9) serositis (OR = 3.877 95%CI (0.995-15.110), P = 0.051, I² = 79.1%), and 10) use of steroid immunosuppressants (OR = 3.116 95%CI (1.959-4.957), P < 0.001, I² = 77.9%). Furthermore, infected SLE patients had a significantly higher mean dose of prednisone (SMD = 2.088 95%CI (1.196-2.981), P < 0.001, I² = 97.8%). In addition, SLE patients with infection showed a significantly lower incidence of antimalarial drug use (OR = 0.634 95%CI (0.451-0.892), P = 0.009, I² = 56.0%). Infected SLE patients had a significantly higher level of 1) 24-h urinary protein (SMD = 0.560 95%CI (0.300-0.810), P < 0.001, I² = 0%), 2) CRP (SMD = 0.437 95%CI (0.184-0.691), P = 0.001, I² = 68.6%), and 3) SLE Collaborating Clinics damage index (SDI) (SMD = 0.451 95%CI (0.238-0.664), P < 0.001, I² = 0.0%), along with a significantly lower level of albumin (SMD = -0.400 95%CI (-0.610--0.200), P < 0.001, I² = 0.0%). After adjustment for false discovery rate (FDR), lymphopenia and serositis were no longer associated with the occurrence of infection; however, the remaining factors were still associated with infection in SLE. According to the nine-star scoring system of NOS, 71.79% of the studies were considered as high methodological quality (low risk of bias). No significant publication bias, except for renal involvement, was detected from funnel plots or Egger's and Begg's test, while this publication bias of renal involvement did not impact the pooled estimates.

CONCLUSION

We identified many factors including thrombocytopenia, anemia, hypoproteinemia, hypocomplementemia, hypoalbuminemia, higher level of CRP, higher SDI score, renal involvement and diabetes mellitus that were associated with infection in SLE patients. In addition, glucocorticoids (especially high-dose) and immunosuppressants (e.g. cyclophosphamide) rendered SLE patients more susceptible to infection, while antimalarial drug administration (hydroxychloroquine) was a protective factor against infection in SLE patients. SLE patients with the above clinical characteristics and risk factors might be at high risk from infection, which might contribute to the early identification of infection in SLE patients for better prognosis.

Systemic lupus erythematosus and risk of infection

INTRODUCTION

Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects almost every organ system and it is treated with immunomodulation and immunosuppression. SLE patients have an intrinsically dysfunctional immune system which is exacerbated by disease activity and leaves them vulnerable to infection. Treatment with immunosuppression increases susceptibility to infection, while hydroxychloroquine use decreases this risk. Infectious diseases are a leading cause of hospitalization and death.

AREAS COVERED

This narrative review provides an overview of recent epidemiology and predictors of infections in SLE, delineates the risk of infection by therapeutic agent, and provides suggestions for risk mitigation. Articles were selected from Pubmed searches conducted between September 2019 and January 2020.

EXPERT OPINION

Despite the large burden of infection, effective and safe preventative care such as universal hydroxychloroquine use and vaccination are underutilized. Future efforts should be directed to quality improvement, glucocorticoid reduction, and validation of risk indices that identify patients at the highest risk of infection.

Impact of infections in autoimmune rheumatic diseases and pregnancy

PURPOSE OF REVIEW

To provide an update about the impact of infections in autoimmune rheumatic diseases (ARDs), from the analysis of the role of infections in pregnant women without ARDs, to the identification of maternal-fetal infections and their role in the maternal-fetal outcome of women with ARDs.

RECENT FINDINGS

Recent studies indicate that patients with ARDs and pregnancy are also susceptible to presenting infections of varying degrees, including serious infections, which contribute to the morbidity and mortality observed in pregnancy and postpartum of these patients.Any type of infectious agent will interact with a hormonal, immunological and metabolic environments modified by ARD, treatments, and by the changes inherent in pregnancy. Therefore, infections in the pregnancy of patients with ARDs should be considered as a risk factor for an unfavorable maternal-fetal outcome.

SUMMARY

The recognition of infections in the pregnancy of ARDs as a risk factor is the first step to prevent, identify, and treat them in a timely manner, and thus contribute to the favorable course of pregnancy in these patients. Patients with ARDs and major organ involvement, use of high doses of steroids, immunosuppressant and biological therapies, adolescence, and obesity are populations susceptible to developing infections.

Risk factors of infection-associated mortality in children with lupus nephritis in under-resourced areas

INTRODUCTION

Treatment of lupus nephritis class III, IV and V with immunosuppressive therapy increases patient survival but poses a risk of infection-related mortality. This study was conducted to evaluate risk factors for fatal infection in children with lupus nephritis in under-resourced areas.

METHODS

Medical records of patients, who were admitted to a tertiary-care university-based hospital from January 2002 to July 2018 with the diagnosis of systemic lupus erythematosus, were reviewed. Only patients aged less than 18 years with lupus nephritis and documented infection were included in the study. The primary outcome was infection-associated mortality. The logistic regression model was used to identify independent variables associated with fatal infection. Predicted probabilities of infection-related mortality adjusted for factors significant in multivariate analysis were calculated using marginal effects at representative values.

RESULTS

Infection-related deaths occurred in 27 of 179 patients (15.1%). Hospital-acquired infections occurred in 72 of 375 episodes of hospital admissions (19.2%) and 13 hospital-acquired infections (18.1%) resulted in fatal infection. Invasive fungal infections were the leading cause of death (44.4%) and pulmonary infections were the predominant site (55.5%). Haemoglobin levels and glomerular filtration rates were significantly lower in deceased versus surviving patients. Percentages of patients with hospital-acquired infections, invasive fungal infections and pulmonary infections were significantly higher in deceased than surviving patients. Urine protein, the neutrophil-to-lymphocyte ratio, cumulative methylprednisolone dose and daily prednisolone dose were significantly higher in deceased than surviving patients. In multivariate analysis, a neutrophil-to-lymphocyte ratio more than 20, invasive fungal infections and high daily prednisolone dose were independently predictive of fatal infection with adjusted odds ratio of 3.02 (95% confidence interval 1.02-8.97, p = 0.04), 15.08 (95% confidence interval 4.72-48.24, p < 0.001) and 1.03 (95% confidence interval 1.01-1.06, p = 0.04), respectively. A high daily prednisolone dose intensified the impact of invasive fungal infections and high neutrophil-to-lymphocyte ratio on predicted probability of infection-associated mortality.

CONCLUSIONS

Prevention of invasive fungal infections and minimization of daily prednisolone should be emphasized in routine clinical practice of children with lupus nephritis in under-resourced areas to achieve better survival. Children with lupus nephritis and a high neutrophil-to-lymphocyte ratio should be under cautious surveillance for infection.