A Population-based Study of Perinatal Infection Risk in Women with and without Systemic Lupus Erythematosus and their Infants

Calcineurin inhibitors in the treatment of systemic lupus erythematosus during pregnancy: A narrative review with emphasis on efficacy and safety

Systemic lupus erythematosus (SLE) predominantly affects child-bearing women, leading to an elevated risk of maternal and fetal complications and adverse pregnancy outcomes. Since some medications can cross the placental barrier that persist a threat to both mother and fetus, the risk-benefit ratio of SLE medications should be taken into consideration during pregnancy. Calcineurin inhibitor (CNI), mainly including cyclosporin A, tacrolimus, and voclosporin, is a category of immunosuppressive agents that inhibit calcium/calmodulin-dependent phosphatase calcineurin to block T cell activation. Based on the current clinical evidence, CNI is an alternative in pregnant SLE patients with persistent disease activity (especially lupus nephritis patients) and non-responders to azathioprine. However, there is no comprehensive review that summarizes the efficacy and safety profile of CNI for SLE management during pregnancy. This review presents a summary on the utilization of CNI for SLE management during pregnancy, including the mechanism of action, gestational amelioration of lupus flare, and the balance of maternal benefit-fetal risk, which may provide more references for the management of SLE pregnancies.

Rethinking the pros and cons of randomized controlled trials and observational studies in the era of big data and advanced methods: a panel discussion

Randomized controlled trials (RCTs) have traditionally been considered the gold standard for medical evidence. However, in light of emerging methodologies in data science, many experts question the role of RCTs. Within this context, experts in the USA and Canada came together to debate whether the primacy of RCTs as the gold standard for medical evidence, still holds in light of recent methodological advances in data science and in the era of big data. The purpose of this manuscript, aims to raise awareness of the pros and cons of RCTs and observational studies in order to help guide clinicians, researchers, students, and decision-makers in making informed decisions on the quality of medical evidence to support their work. In particular, new and underappreciated advantages and disadvantages of both designs are contrasted. Innovations taking place in both of these research methodologies, which can blur the lines between the two, are also discussed. Finally, practical guidance for clinicians and future directions in assessing the quality of evidence is offered.

2022 Chinese guideline for the management of pregnancy and reproduction in systemic lupus erythematosus

Systemic lupus erythematosus (SLE), a prevalent autoimmune disease predominantly affecting women of childbearing age, presents ongoing challenges despite notable advances in diagnosis and treatment. Although survival rates for SLE patients have significantly improved, pregnancy continues to pose a considerable obstacle. Addressing this critical need for enhanced reproductive and prenatal care, there is a pressing imperative to establish standardized protocols for peri-gestational monitoring and treatment in SLE patients. This guideline is jointly sponsored by the National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), the Chinese Systemic Lupus Erythematosus Treatment and Research Group (CSTAR), and the Chinese Research Committee of Pregnancy and Reproduction in Autoimmune Rheumatic Diseases (CHOPARD). Thirteen pertinent clinical questions have been generated through several rounds of rigorous clinical and methodological expert discussions and selections for a comprehensive understanding of key aspects in this domain. Guided by thorough examination of research evidence and expert perspectives, the formulated recommendations aim to optimize pregnancy success rates, reduce maternal and infant mortality rates, and ultimately enhance the overall well-being of SLE patients.

Birth Outcomes and Rehospitalizations Among Pregnant Women With Rheumatoid Arthritis and Systemic Lupus Erythematosus and Their Offspring

OBJECTIVE

To compare obstetric/birth outcomes and rehospitalization among women with and without rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) and their infants.

METHODS

This population-based retrospective cohort study identified women with RA (n = 1,223) and SLE (n = 1,354) and unexposed women with singleton births 1987-2014 in Washington State in linked vital hospital discharge records. Outcomes, including cause-specific hospitalizations <2 years postpartum, were compared by estimating adjusted relative risks (RRs) and cause-specific rehospitalization hazard ratios (HRs) with 95% confidence intervals (95% CIs).

RESULTS

We observed increased risks of several adverse outcomes; RRs were often greatest for SLE. Women with RA/SLE more often required rehospitalization, most notably at <6 months postpartum (RA: 4% versus 2%; RR 2.22 [95% CI 1.62-3.04]; SLE: 6% versus 2%; RR 2.78 [95% CI 2.15-3.59]). Maternal postpartum rehospitalization was greatest for musculoskeletal conditions (RA: HR 19.1 [95% CI 13.6-26.8]; SLE: HR 29.8 [95% CI 22.1-40.1]). Infants of women with SLE more often had malformations (9% versus 6%; RR 1.46 [95% CI 1.21-1.75]), and increased mortality at <2 years (RR 2.11 [95% CI 1.21-3.67]). Infants of women with SLE also experienced more frequent rehospitalizations in their first year of life.

CONCLUSION

Women with RA or SLE and their infants experienced adverse outcomes, particularly infants of women with SLE. Maternal/infant rehospitalization was more common; most marked in the early months postpartum. Close follow-up during these time periods is crucial to minimize adverse outcomes.

Increased risk of severe infections and mortality in patients with newly diagnosed systemic lupus erythematosus: a population-based study

OBJECTIVE

To evaluate the risk of severe infection and infection-related mortality among patients with newly diagnosed SLE.

METHODS

We conducted an age- and gender-matched cohort study of all patients with incident SLE between 1 January 1997 and 31 March 2015 using administrative health data from British Columbia, Canada. Primary outcome was the first severe infection after SLE onset necessitating hospitalization or occurring during hospitalization. Secondary outcomes were total number of severe infections and infection-related mortality.

RESULTS

We identified 5169 SLE patients and matched them with 25 845 non-SLE individuals from the general population, yielding 955 and 1986 first severe infections during 48 367 and 260 712 person-years follow-up, respectively. The crude incidence rate ratios for first severe infection and infection-related mortality were 2.59 (95% CI: 2.39, 2.80) and 2.20 (95% CI: 1.76, 2.73), respectively. The corresponding adjusted hazard ratios were 1.82 (95% CI: 1.66, 1.99) and 1.61 (95% CI: 1.24, 2.08). SLE patients had an increased risk of a greater total number of severe infections with crude rate ratio of 3.24 (95% CI: 3.06, 3.43) and adjusted rate ratio of 2.07 (95% CI: 1.82, 2.36).

CONCLUSION

SLE is associated with increased risks of first severe infection (1.8-fold), a greater total number of severe infections (2.1-fold) and infection-related mortality (1.6-fold).

Use of E-values for addressing confounding in observational studies-an empirical assessment of the literature

BACKGROUND

E-values are a recently introduced approach to evaluate confounding in observational studies. We aimed to empirically assess the current use of E-values in published literature.

METHODS

We conducted a systematic literature search for all publications, published up till the end of 2018, which cited at least one of two inceptive E-value papers and presented E-values for original data. For these case publications we identified control publications, matched by journal and issue, where the authors had not calculated E-values.

RESULTS

In total, 87 papers presented 516 E-values. Of the 87 papers, 14 concluded that residual confounding likely threatens at least some of the main conclusions. Seven of these 14 named potential uncontrolled confounders. 19 of 87 papers related E-value magnitudes to expected strengths of field-specific confounders. The median E-value was 1.88, 1.82, and 2.02 for the 43, 348, and 125 E-values where confounding was felt likely to affect the results, unlikely to affect the results, or not commented upon, respectively. The 69 case-control publication pairs dealt with effect sizes of similar magnitude. Of 69 control publications, 52 did not comment on unmeasured confounding and 44/69 case publications concluded that confounding was unlikely to affect study conclusions.

CONCLUSIONS

Few papers using E-values conclude that confounding threatens their results, and their E-values overlap in magnitude with those of papers acknowledging susceptibility to confounding. Facile automation in calculating E-values may compound the already poor handling of confounding. E-values should not be a substitute for careful consideration of potential sources of unmeasured confounding. If used, they should be interpreted in the context of expected confounding in specific fields.

Assessment of the Accuracy of Identification of Selected Disabilities and Conditions in Hospital Discharge Data for Pregnant Women

BACKGROUND

Linked birth certificate-hospital discharge records are a valuable resource for examining pregnancy outcomes among women with disability conditions. Few studies relying on these data have been able to assess the accuracy of identification of preexisting disability conditions. We assessed the accuracy of International Classification of Diseases version 9 (ICD9) codes for identifying selected physical, sensory, and intellectual conditions that may result in disability. As ICD9 codes were utilized until recently in most states, this information is useful to inform analyses with these records.

METHODS

We reviewed 280 of 311 (90%) medical records of pregnant women with disabilities based on ICD9 codes and 390 of 8,337 (5%) records of pregnant women without disabilities who had deliveries at a large university medical center. We estimated sensitivity, specificity, and positive predictive values (PPV) using the medical record as gold standard. We adjusted for verification bias using inverse probability weighting and imputation.

RESULTS

The estimated sensitivity of ICD9 codes to identify women with disabilities with deliveries 2009-2012 was 44%; PPV was 98%, improving over time. Although sensitivity was <50% for some conditions, PPVs were 87%-100% for all conditions except intellectual disability (67%). Many physical conditions had complete verification and no underreporting.

CONCLUSIONS

These results are helpful for new studies using historical data comparing outcomes among women with and without these conditions and to inform interpretation of results from earlier studies. Assessment of the accuracy of disabilities as identified by ICD version 10 codes is warranted.

Maternal Systemic Lupus Erythematosus, Rheumatoid Arthritis, and Risk for Autism Spectrum Disorders in Offspring: A Meta-analysis

This study assessed the relationships between maternal systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA) and risk for autism spectrum disorders (ASDs) in offspring. Seven observational studies, including 25,005 ASD cases and 4,543,321 participants, were included for meta-analysis. Pooled results by using random-effects models suggested that maternal RA was associated with an increased risk for ASDs [odds ratio (OR) 1.39, 95% confidence interval (CI) 1.16-1.67], while maternal SLE was associated with an increased risk for ASDs only in western population (OR 1.91, 95% CI 1.02-3.57). Further study is warranted to confirm these results.

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.

Maternal and fetal complications associated with systemic lupus erythematosus: An updated meta-analysis of the most recent studies (2017-2019)

BACKGROUND

Recent guidelines provide better treatment and management of pregnancy in women with systemic lupus erythematosus (SLE). In this analysis, we aimed to systematically assess the maternal and fetal complications associated with SLE using the most recent studies (2017-2019) to obtain an updated result of the present situation.

METHODS

http://www.clinicaltrials.gov, MEDLINE, Cochrane Central, Web of Science, EMBASE, and Google Scholar were searched for English based studies comparing maternal and fetal complications in pregnant women with versus without SLE. Maternal and fetal complications were the endpoints in this analysis. The RevMan software 5.3 (latest version) was the most suitable analytical software for this analysis. Data were represented by risk ratio (RR) with 95% confidence interval (CI).

RESULTS

A total number of eight million eight hundred and twelve thousand two hundred seventy-two (8,812,272) participants were included in this analysis, consisting of 9696 SLE-associated pregnancy. Based on an analysis of recently published studies (2017-2019), pre-eclampsia/eclampsia was significantly higher in pregnant women with SLE (RR: 3.38, 95% CI: 3.15-3.62; P = .00001). SLE was also associated with an increased risk of stillbirth (RR: 16.49, 95% CI: 2.95-92.13; P = .001) and fetal loss (RR: 7.55, 95% CI: 4.75-11.99; P = .00001). Abortion (RR: 4.70, 95% CI: 3.02-7.29; P = .00001) and the risk for cesarean section due to complications (RR: 1.38, 95% CI: 1.11-1.70; P = .003) were also significantly higher in pregnant women with SLE. In addition, fetal complications including preterm birth (RR: 2.33, 95% CI: 1.78-3.05; P = .00001), infants who were small for gestational age (RR: 2.50, 95% CI: 1.41-4.45; P = .002) and infants with low birth weight (RR: 4.78, 95% CI: 3.65-6.26; P = .00001) were also significantly higher in newborns from mothers with SLE. Moreover, the risk of newborns who were admitted to the neonatal intensive care unit (RR: 2.79, 95% CI: 2.31-3.37; P = .00001), newborns with an APGAR score <7 within 1 minute (RR: 2.47, 95% CI: 1.68-3.62; P = .00001) and 5 minutes (RR: 3.63, 95% CI: 2.04-6.45; P = .0001) respectively, were significantly highly associated with SLE.

CONCLUSIONS

Based on the most recent studies, we could conclude that maternal and fetal complications were significantly higher in SLE-associated pregnancy. Therefore, SLE should still be considered a severe risk factor for pregnancy.

Clinical outcomes and predictors of maternal and fetal complications in pregnancies of patients with systemic lupus erythematosus

INTRODUCTION

Systemic Lupus Erythematosus (SLE) mostly affects women during their childbearing years. Fertility is preserved in SLE patients, but pregnancy is often characterized by a high number of maternal and fetal complications. Adverse pregnancy outcomes (APO) have been widely studied over the last decades and several investigators have focused on the potential clinical and serological predictors of maternal and fetal complications. Areas covered: In this review, we analyzed maternal and fetal complications in SLE patients and predictors of APO. Active disease in the 6 months before conception, lupus nephritis, anti-phospholipid (aPL), anti-SSA/Ro and/or anti-SSB/La antibodies have been identified as the most consistent predictors of maternal and fetal complications to date. However, molecular mechanisms and underlying immunological pathways involved in APO still remain elusive. Expert opinion: Difficulties in assessing prevalence and predictors of APO in SLE patients are due to lack of uniformity in the definitions and methods used in the different studies. In addition, some maternal and fetal complications are difficult to diagnose and to differentiate from each other. Preconception counseling is paramount to prevent APO, and it should consider four main factors: disease activity/lupus nephritis, safety of drugs, aPL, anti-SSA/Ro, and/or anti-SSB/La antibodies.