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30.09.2023 | Observational Research

In-hospital mortality and associated factors in patients with systemic lupus erythematosus: analysis over more than 11 years in a reference hospital center

verfasst von: Michelle Arrucha-Cozaya, Nuria Cecilia Zamora-Zúñiga, Dafhne Miranda-Hernández, Reyna Bustamante-González, Gabriela Martínez-Díaz, Drusila Tovar-Rodríguez, Berenice López-Zamora, María Del Pilar Cruz-Domínguez, Abraham Edgar Gracia-Ramos, Miguel Angel Saavedra

Erschienen in: Rheumatology International | Ausgabe 12/2023

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Abstract

Systemic lupus erythematosus (SLE) is a disease that affects the immune system, and it can lead to increased morbidity and mortality. The primary causes of mortality for individuals with SLE are disease activity, infections, drug toxicity, and other health conditions. The aim of this study is to estimate the mortality rate of patients with SLE who are hospitalized, describe the causes of death, and identify factors associated with mortality. The study was conducted at a referral hospital from 2009 to 2021, utilizing a nested case–control design. The records of patients with SLE who were hospitalized in the Department of Rheumatology were reviewed. Cases were identified as individuals who died during their hospitalization, while controls were those who were discharged alive during the same period. Elective hospitalizations were not included in the study. The primary causes of death were recorded, and demographic, clinical, laboratory, and immunological variables were analyzed as potential risk factors associated with in-hospital mortality. The study included 105 patients who died while hospitalized and 336 who were discharged alive. The estimated mortality rate was 10.93 deaths per 1000 hospital admissions per year. The leading causes of death were SLE activity (20%), infections (34.2%), or a combination of both (24.8%). Risk factors associated with in-hospital mortality were any infection (OR 2.5, CI 95% 1.2–5.2), nosocomial infections (OR 5.0, CI 95% 1.8–13.7), SLEDAI-2K > 2 (OR 2.0, CI 95% 1.02–3.8), lymphopenia (OR 2.1, CI 95% 1.01–4.6), anemia (OR 2.9, CI 95% 1.4–5.7), and thrombocytopenia (OR 3.3, CI 95% 1.7–6.4). Disease activity and infections, particularly nosocomial infections, are significant causes of mortality in hospitalized patients with SLE. Furthermore, hematological manifestations play a significant role in in-hospital mortality for these patients.

Dörner T, Furie R (2019) Novel paradigms in systemic lupus erythematosus. Lancet 393:2344–2358. https://doi.org/10.1016/S0140-6736(19)30546-XCrossRefPubMed

Ocampo-Piraquive V, Nieto-Aristizábal I, Cañas CA, Tobón GJ (2018) Mortality in systemic lupus erythematosus: causes, predictors and interventions. Expert Rev Clin Immunol 14:1043–1053. https://doi.org/10.1080/1744666X.2018.1538789CrossRefPubMed

Tselios K, Gladman DD, Sheane BJ, Su J, Urowitz M (2019) All-cause, cause-specific and age-specific standardised mortality ratios of patients with systemic lupus erythematosus in Ontario, Canada over 43 years (1971–2013). Ann Rheum Dis 78:802–806. https://doi.org/10.1136/annrheumdis-2018-214802CrossRefPubMed

Hersh AO, Trupin L, Yazdany J, Panopalis P, Julian L, Katz P, Criswell LA, Yelin E (2010) Childhood-onset disease as a predictor of mortality in an adult cohort of patients with systemic lupus erythematosus. Arthritis Care Res (Hoboken) 62:1152–1159. https://doi.org/10.1002/acr.20179CrossRefPubMed

Ambrose N, Morgan TA, Galloway J, Ionnoau Y, Beresford MW, Isenberg DA; UK JSLE Study Group (2016) Differences in disease phenotype and severity in SLE across age groups. Lupus 25:1542–1550. https://doi.org/10.1177/0961203316644333CrossRef

Ingvarsson RF, Landgren AJ, Bengtsson AA, Jönsen A (2019) Good survival rates in systemic lupus erythematosus in southern Sweden, while the mortality rate remains increased compared with the population. Lupus 28:1488–1494. https://doi.org/10.1177/0961203319877947CrossRefPubMed

Bultink IEM, de Vries F, van Vollenhoven RF, Lalmohamed A (2021) Mortality, causes of death and influence of medication use in patients with systemic lupus erythematosus vs matched controls. Rheumatology (Oxford) 60:207–216. https://doi.org/10.1093/rheumatology/keaa267CrossRefPubMed

Pons-Estel GJ, Catoggio LJ, Cardiel MH, Bonfa E, Caeiro F, Sato E, Massardo L, Molina Restrepo JF, Toledano MG, Barile-Fabris LA, Amigo MC, Acevedo-Vásquez EM, Abadi I, Wojdyla D, Alarcón-Riquelme ME, Alarcón GS, Pons-Estel BA, GLADEL, (2015) Lupus in Latin-American patients: lessons from the GLADEL cohort. Lupus 24:536–545. https://doi.org/10.1177/0961203314567753CrossRefPubMed

Scherlinger M, Mertz P, Sagez F, Meyer A, Felten R, Chatelus E, Javier RM, Sordet C, Martin T, Korganow AS, Guffroy A, Poindron V, Richez C, Truchetet ME, Blanco P, Schaeverbeke T, Sibilia J, Devillers H, Arnaud L (2020) Worldwide trends in all-cause mortality of autoimmune systemic diseases between 2001 and 2014. Autoimmun Rev 19:102531. https://doi.org/10.1016/j.autrev.2020.102531CrossRefPubMed

10.

Etchegaray-Morales I, Mendoza-Pinto C, Munguía-Realpozo P, Osorio-Peña ÁD, Ibañez-Ovando S, Pineda C, García-Carrasco M (2022) Systemic lupus erythematosus, a leading cause of death in young Mexican females: a nationwide population-based study, 2000–2020. Rheumatol Int 42:1715–1720. https://doi.org/10.1007/s00296-022-05154-9CrossRefPubMed

11.

Urowitz MB, Bookman AA, Koehler BE, Gordon DA, Smythe HA, Ogryzlo MA (1976) The bimodal mortality pattern of systemic lupus erythematosus. Am J Med 60:221–225. https://doi.org/10.1016/0002-9343(76)90431-9CrossRefPubMed

12.

Vega-Morales D, Hernández-Galarza IJ, Galarza-Delgado DÁ (2018) Causes of hospital mortality in patients with rheumatoid arthritis and systemic lupus erythematosus in a university hospital: 1998–2015 analysis. J Rheumatol 45:583–584. https://doi.org/10.3899/jrheum.170735CrossRefPubMed

13.

Pattanaik SS, Muhammed H, Chatterjee R, Naveen R, Lawrence A, Agarwal V, Misra DP, Gupta L, Misra R, Aggarwal A (2020) In-hospital mortality and its predictors in a cohort of SLE from Northern India. Lupus 29:1971–1977. https://doi.org/10.1177/0961203320961474CrossRefPubMed

14.

Adwan MH, Qasem U, Mustafa KN (2020) In-hospital mortality in patients with systemic lupus erythematosus: a study from Jordan 2002–2017. Rheumatol Int 40:711–717. https://doi.org/10.1007/s00296-020-04538-zCrossRefPubMed

15.

Lim SS, Helmick CG, Bao G, Hootman J, Bayakly R, Gordon C, Drenkard C (2019) Racial disparities in mortality associated with systemic lupus erythematosus - Fulton and DeKalb Counties, Georgia, 2002-2016. MMWR Morb Mortal Wkly Rep 68:419–422. https://doi.org/10.15585/mmwr.mm6818a4CrossRefPubMedPubMedCentral

16.

Gianfrancesco MA, Dall'Era M, Murphy LB, Helmick CG, Li J, Rush S, Trupin L, Yazdany J (2021) Mortality Among Minority Populations with Systemic Lupus Erythematosus, Including Asian and Hispanic/Latino Persons - California, 2007–2017. MMWR Morb Mortal Wkly Rep 70:236–239. https://doi.org/10.15585/mmwr.mm7007a2

17.

Guo Q, Liang M, Duan J, Zhang L, Kawachi I, Lu TH (2021) Age differences in secular trends in black-white disparities in mortality from systemic lupus erythematosus among women in the United States from 1988 to 2017. Lupus 30:715–724. https://doi.org/10.1177/0961203321988936CrossRefPubMed

18.

Taylor T, Anastasiou C, Ja C, Rush S, Trupin L, Dall’Era M, Katz P, Barbour KE, Greenlund KJ, Yazdany J, Gianfrancesco MA (2023) Causes of death among individuals with systemic lupus erythematosus by race and ethnicity: a population-based study. Arthritis Care Res (Hoboken) 75:61–68. https://doi.org/10.1002/acr.24988CrossRefPubMed

19.

Petri M, Orbai AM, Alarcón GS, Gordon C, Merrill JT, Fortin PR, Bruce IN, Isenberg D, Wallace DJ, Nived O, Sturfelt G, Ramsey-Goldman R, Bae SC, Hanly JG, Sánchez-Guerrero J, Clarke A, Aranow C, Manzi S, Urowitz M, Gladman D, Kalunian K, Costner M, Werth VP, Zoma A, Bernatsky S, Ruiz-Irastorza G, Khamashta MA, Jacobsen S, Buyon JP, Maddison P, Dooley MA, van Vollenhoven RF, Ginzler E, Stoll T, Peschken C, Jorizzo JL, Callen JP, Lim SS, Fessler BJ, Inanc M, Kamen DL, Rahman A, Steinsson K, Franks AG Jr, Sigler L, Hameed S, Fang H, Pham N, Brey R, Weisman MH, McGwin G Jr, Magder LS (2012) Derivation and validation of the systemic lupus international collaborating clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum 64:2677–2686. https://doi.org/10.1002/art.34473CrossRefPubMedPubMedCentral

20.

Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, Derksen RH, de Groot PG, Koike T, Meroni PL, Reber G, Shoenfeld Y, Tincani A, Vlachoyiannopoulos PG, Krilis SA (2006) International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 4:295–306. https://doi.org/10.1111/j.1538-7836.2006.01753.xCrossRefPubMed

21.

Fors Nieves CE, Izmirly PM (2016) Mortality in systemic lupus erythematosus: an updated review. Curr Rheumatol Rep 18:21. https://doi.org/10.1007/s11926-016-0571-2CrossRefPubMed

22.

Anastasiou C, Trupin L, Glidden DV, Li J, Gianfrancesco M, Shiboski S, Schmajuk G, Yazdany J (2021) Mortality among hospitalized individuals with systemic lupus erythematosus in the US between 2006 and 2016. Arthritis Care Res 73:1444–1450. https://doi.org/10.1002/acr.24356CrossRef

23.

Urowitz MB, Gladman DD, Tom BD, Ibañez D, Farewell VT (2008) Changing patterns in mortality and disease outcomes for patients with systemic lupus erythematosus. J Rheumatol 35:2152–2158. https://doi.org/10.3899/jrheum.080214CrossRefPubMed

24.

Voss A, Laustrup H, Hjelmborg J, Junker P (2013) Survival in systemic lupus erythematosus, 1995–2010. A prospective study in a Danish community. Lupus 22:1185–1191. https://doi.org/10.1177/0961203313498796CrossRefPubMed

25.

Elfving P, Puolakka K, Kautiainen H, Virta LJ, Pohjolainen T, Kaipiainen-Seppänen O (2014) Mortality and causes of death among incident cases of systemic lupus erythematosus in Finland 2000–2008. Lupus 23:1430–1434. https://doi.org/10.1177/0961203314543919CrossRefPubMed

26.

Costi LR, Iwamoto HM, Neves DCDO, Caldas CAM (2017) Mortality from systemic erythematosus lupus in Brazil: evaluation of causes according to the government health database. Rev Bras Reumatol Engl Ed 57:574–582. https://doi.org/10.1016/j.rbre.2017.09.001CrossRefPubMed

27.

Rabbani MA, Habib HB, Islam M, Ahmad B, Majid S, Saeed W, Shah SM, Ahmad A (2009) Survival analysis and prognostic indicators of systemic lupus erythematosus in Pakistani patients. Lupus 18:848–855. https://doi.org/10.1177/0961203309103410CrossRefPubMed

28.

Wadee S, Tikly M, Hopley M (2007) Causes and predictors of death in South Africans with systemic lupus erythematosus. Rheumatology 46:1487–1491. https://doi.org/10.1093/rheumatology/kem180CrossRefPubMed

29.

Dhital R, Pandey RK, Poudel DR, Oladunjoye O, Paudel P, Karmacharya P (2020) All-cause hospitalizations and mortality in systemic lupus erythematosus in the US: results from a national inpatient database. Rheumatol Int 40:393–397. https://doi.org/10.1007/s00296-019-04484-5CrossRefPubMed

30.

Wu XY, Yang M, Xie YS, Xiao WG, Lin J, Zhou B, Guan X, Luo CN, Che N, Liu XZ, Wang C, Teng JL, Cheng XB, Ye JN, Su YT, Shi H, Yin YF, Liu MR, Sun Y, Hu QY, Zhou ZC, Chi HH, Liu Y, Zhang X, Chen JW, Zhang MJ, Zhao DB, Yang CD, Wu LJ, Liu HL (2019) Causes of death in hospitalized patients with systemic lupus erythematosus: a 10-year multicenter nationwide Chinese cohort. Clin Rheumatol 38:107–115. https://doi.org/10.1007/s10067-018-4259-zCrossRefPubMed

31.

Aguirre-Valencia D, Suárez-Avellaneda A, Ocampo-Piraquive V, Posso-Osorio I, Naranjo-Escobar J, Nieto-Aristizábal I, Tobón GJ, Cañas CA (2019) Mortality in patients with systemic lupus erythematosus in Colombia: a case series. Clin Rheumatol 38:1865–1871. https://doi.org/10.1007/s10067-019-04546-wCrossRefPubMed

32.

Lertwises S, Rattanasupar A, Chang A (2023) Factors predictive of in-hospital mortality in patients with systemic lupus erythematosus: a single-centre retrospective analysis. Acta Med Acad 52:37–46. https://doi.org/10.5644/ama2006-124.400CrossRefPubMedPubMedCentral

33.

Rees F, Doherty M, Grainge MJ, Lanyon P, Davenport G, Zhang W (2016) Mortality in systemic lupus erythematosus in the United Kingdom 1999–2012. Rheumatology (Oxford) 55:854–860. https://doi.org/10.1093/rheumatology/kev424CrossRefPubMed

34.

Thomas G, Mancini J, Jourde-Chiche N, Sarlon G, Amoura Z, Harlé JR, Jougla E, Chiche L (2014) Mortality associated with systemic lupus erythematosus in France assessed by multiple-cause-of-death analysis: mortality and systemic lupus erythematosus. Arthritis Rheum 66:2503–2511. https://doi.org/10.1002/art.38731CrossRef

35.

Yen EY, Shaheen M, Woo JMP, Mercer N, Li N, McCurdy DK, Karlamangla A, Singh RR (2017) 46-year trends in systemic lupus erythematosus mortality in the United States, 1968 to 2013: a nationwide population-based study. Ann Intern Med 167:777–785. https://doi.org/10.7326/M17-0102CrossRefPubMedPubMedCentral

36.

Li D, Yoshida K, Feldman CH, Speyer C, Barbhaiya M, Guan H, Solomon DH, Everett BM, Costenbader KH (2020) Initial disease severity, cardiovascular events and all-cause mortality among patients with systemic lupus erythematosus. Rheumatology (Oxford) 59:495–504. https://doi.org/10.1093/rheumatology/kez288CrossRefPubMed

37.

Segura BT, Bernstein BS, McDonnell T, Wincup C, Ripoll M, V, Giles I, Isenberg D, Rahman A, (2020) Damage accrual and mortality over long-term follow-up in 300 patients with systemic lupus erythematosus in a multi-ethnic British cohort. Rheumatology (Oxford) 59:524–533. https://doi.org/10.1093/rheumatology/kez292CrossRefPubMed

38.

Hernández-Rodríguez JC, Durán-Romero AJ, Muñoz-Jiménez A, Conejo-Mir J, Pereyra-Rodríguez JJ (2020) Trends in mortality from lupus in Spain from 1980 to 2018. Lupus 29:1719–1726. https://doi.org/10.1177/0961203320952864CrossRefPubMed

39.

Elfving P, Kariniemi S, Kautiainen H, Virta LJ, Kaipiainen-Seppänen O, Puolakka K (2021) Mortality in SLE patients compared with population controls in Finland in years 2000–2015. Rheumatology (Oxford) 60:4238–4244. https://doi.org/10.1093/rheumatology/keaa917CrossRefPubMed

40.

Lorenzo-Vizcaya A, Isenberg D (2021) Analysis of trends and causes of death in SLE patients over a 40-years period in a cohort of patients in the United Kingdom. Lupus 30:702–706. https://doi.org/10.1177/0961203320988607CrossRefPubMed

41.

Moghaddam B, Marozoff S, Li L, Sayre EC, Zubieta JAA (2021) All-cause and cause-specific mortality in systemic lupus erythematosus: a population-based study. Rheumatology (Oxford) 61:367–376. https://doi.org/10.1093/rheumatology/keab362CrossRefPubMed

42.

Anver H, Dubey S, Fox J (2019) Changing trends in mortality in systemic lupus erythematosus? An analysis of SLE inpatient mortality at University Hospital Coventry and Warwickshire NHS Trust from 2007 to 2016. Rheumatol Int 39:2069–2075. https://doi.org/10.1007/s00296-019-04450-1CrossRefPubMed

43.

Cuchacovich R, Gedalia A (2009) Pathophysiology and clinical spectrum of infections in systemic lupus erythematosus. Rheum Dis Clin North Am 35:75–93. https://doi.org/10.1016/j.rdc.2009.03.003CrossRefPubMed

44.

Singh JA, Cleveland JD (2021) Hospitalized infections in Lupus: a nationwide study of types of infections, time trends, health care utilization, and in-hospital mortality. Arthritis Rheumatol 73:617–630. https://doi.org/10.1002/art.41577CrossRefPubMed

45.

Navarro-Zarza JE, Alvarez-Hernández E, Casasola-Vargas JC, Estrada-Castro E, Burgos-Vargas R (2010) Prevalence of community-acquired and nosocomial infections in hospitalized patients with systemic lupus erythematosus. Lupus 19:43–48. https://doi.org/10.1177/0961203309345776CrossRefPubMed

46.

Kedves M, Kósa F, Kunovszki P, Takács P, Szabó MZ, Karyekar C, Lofland JH, Nagy G (2020) Large-scale mortality gap between SLE and control population is associated with increased infection-related mortality in lupus. Rheumatology (Oxford) 59:3443–3451. https://doi.org/10.1093/rheumatology/keaa188CrossRefPubMed

47.

Oud L, Garza J (2023) The association of systemic lupus erythematosus with short-term mortality in sepsis: a population-level analysis. J Investig Med 71:419–428. https://doi.org/10.1177/10815589221150641CrossRefPubMed

48.

Yin P, Li J, Wen Q, Qiu Y, Liang W, Wang J, Yu J, Zhong Z, Yang X, Yu X, Ye Q, Huang F (2020) Infection-related hospitalization after intensive immunosuppressive therapy among lupus nephritis and ANCA glomerulonephritis patients. Ren Fail 42:474–482. https://doi.org/10.1080/0886022X.2020.1763400CrossRefPubMedPubMedCentral

49.

Gatto M, Saccon F, Zen M, Bettio S, Iaccarino L, Punzi L, Doria A (2016) Success and failure of biological treatment in systemic lupus erythematosus: a critical analysis. J Autoimmun 74:94–105. https://doi.org/10.1016/j.jaut.2016.06.014CrossRefPubMed

50.

Moghazy A, Ibrahim AM (2021) Mortality in a cohort of Egyptian systemic lupus erythematosus patients: retrospective two-center study. Egypt Rheumatol Rehabil 48:14. https://doi.org/10.1186/s43166-021-00062-5CrossRef

51.

Miranda-Hernández D, Cruz-Reyes C, Monsebaiz-Mora C, Gómez-Bañuelos E, Ángeles U, Jara LJ, Saavedra MÁ (2017) Active haematological manifestations of systemic lupus erythematosus lupus are associated with a high rate of in-hospital mortality. Lupus 26:640–645. https://doi.org/10.1177/0961203316672926CrossRefPubMed

Titel: In-hospital mortality and associated factors in patients with systemic lupus erythematosus: analysis over more than 11 years in a reference hospital center
verfasst von: Michelle Arrucha-Cozaya
Nuria Cecilia Zamora-Zúñiga
Dafhne Miranda-Hernández
Reyna Bustamante-González
Gabriela Martínez-Díaz
Drusila Tovar-Rodríguez
Berenice López-Zamora
María Del Pilar Cruz-Domínguez
Abraham Edgar Gracia-Ramos
Miguel Angel Saavedra
Publikationsdatum: 30.09.2023
Verlag: Springer Berlin Heidelberg
Erschienen in: Rheumatology International / Ausgabe 12/2023
Print ISSN: 0172-8172
Elektronische ISSN: 1437-160X
DOI: https://doi.org/10.1007/s00296-023-05469-1

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