Lupus (2016) 0,
1–7
http://lup.sagepub.com
PAPER
Gender differences in disease activity and clinical features in newly diagnosed systemic lupus erythematosus patients C Mun˜oz-Grajales1,2, LA Gonza´lez2, GS Alarco´n3 and J Acosta-Reyes4 1
Division of Rheumatology, Hospital Pablo Tobo´n Uribe, Medellı´ n, Colombia; 2Division of Rheumatology, Universidad of Antioquia, Medellı´ n, Colombia; 3Department of Medicine, Division of Rheumatology and Clinical Immunology, The University of Alabama at Birmingham, Birmingham, AL, USA; and 4Department of Public Health, Universidad del Norte, Barranquilla, Colombia
Objective: The objective of this paper is to compare disease activity and clinical features at diagnosis in male and female patients with systemic lupus erythematosus (SLE). Methods: This was a cross-sectional study in which every male patient (n ¼ 40) was matched with three female patients of the same age (5 years) and racial/ethnic group; disease activity as per the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and disease manifestations at the time of diagnosis were compared. Results: Alopecia and anti-Ro antibodies were more frequent in female patients. No statistically significant difference in any other disease characteristics was found. However, male gender was associated with a risk of severe disease activity at the time of diagnosis (as determined by SLEDAI 12 score) independent of age, racial/ ethnic group, anti-Ro positivity or time to criteria accrual (OR: 3.11 95% CI, 1.09–8.92; p ¼ 0.035). Conclusion: In newly diagnosed SLE patients, male gender is associated with higher disease activity despite the fact that male and female patients seem to experience similar overall disease manifestations. Lupus (2016) 0, 1–7. Key words: Systemic lupus erythematosus; gender; male; SLEDAI (Systemic Lupus Erythematosus Disease Activity Index)
Introduction Systemic lupus erythematosus (SLE) occurs predominantly in women of reproductive age, with a ratio of 9:1 compared to patients of the opposite sex.1 SLE is quite infrequent among men, who constitute 4% to 22% of the patients in different studies.2–4 This frequency distribution has limited the possibility of studying newly diagnosed male SLE patients. Males develop a similar spectrum of disease manifestations as females, although some studies suggest that males show a higher rate of renal, and haematological manifestations, laboratory abnormalities, and a higher mortality rate.4–18 Nevertheless, the overall perception is that males develop more severe SLE manifestations; however, recent cohort studies have shown similar Systemic
Lupus Erythematosus Disease Activity Index (SLEDAI) average scores for patients of both genders. In contrast, damage occurs more frequently, is of higher magnitude and accrues faster in males than in females according to data from different cohort studies including lupus in minorities (LUMINA), the Latin-American lupus study group (GLADEL) and the Systemic Lupus Erythematosus in Gullah Health (SLEIGH).9,10,19 The aim of the present study is to examine the influence of gender on disease activity and disease features in newly diagnosed SLE patients from the Department of Rheumatology at the Universidad de Antioquia.
Methods Type and place of study
Correspondence to: Jorge Acosta-Reyes, Department of Public Health, Universidad del Norte, Km 5 Via Puerto Colombia, Barranquilla, 081007, Colombia. Email: [email protected] Received 6 August 2015; accepted 1 February 2016
This cross-sectional study was conducted in patients from the Department of Rheumatology at the Hospital Universitario de San Vicente Fundacio´n, Medellı´ n, Colombia, between 2000 and 2011.
! The Author(s), 2016. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav
Downloaded from lup.sagepub.com at La Trobe University on March 1, 2016
10.1177/0961203316635286
Gender differences in disease activity in SLE C Mun˜oz-Grajales et al.
2
Patient selection and inclusion criteria Male and female patients 16 years of age with newly diagnosed SLE (30 days) and fulfilling at least four of the American College of Rheumatology (ACR) revised and updated classification criteria for SLE were eligible to participate in the study.20,21 All patients have been referred to Rheumatology after presenting to the hospital emergency room. Patients with cancer and/or other uncontrolled comorbidities at the time of lupus diagnosis (n ¼ 3), those with an incomplete clinical history (n ¼ 21), and those with less than three months of follow-up treatment (n ¼ 25) were excluded. For every male patient three female patients were matched for age (5 years) and for racial/ethnic group. Variables The SLEDAI-2K version was used to assess disease activity. It was scored based on the available clinical data at the time of diagnosis and up to one month after as a maximum.22 The corresponding categories were established as follows: low or no activity 4 points, moderate activity 5 to 11 points, and high activity 12 points.23,24 Clinical and laboratory variables that were not included in the SLEDAI were determined six months after SLE diagnosis. Variables from the following domains were included: (a) socio-demographic (age and race/ethnicity); (b) clinical (number of ACR criteria), time to criteria accrual, disease onset type, disease manifestations according to the organ system involved (mucocutaneous, musculoskeletal, neurological, cardiovascular, pulmonary, renal and haematological) and specific clinical manifestations as per the ACR classification criteria.20,21 Other clinical manifestations attributable to lupus such as alopecia, Raynaud’s phenomenon, thrombosis and antiphospholipid syndrome were also included, as were (c) laboratory [urine laboratory (proteinuria, cell casts and haematuria)] and immunological variables (anti-double-stranded DNA (anti-dsDNA), anti-Sm, anti-ribonucleoprotein (anti-RNP), antiRo, anti-La, lupus anticoagulant, anticardiolipin (immunoglobulin (Ig)M and IgG) antibodies) and C3 and C4 complement levels); and (d) kidney biopsy results according to the International Society of Nephrology/Renal Pathology Society Classification.25 Onset of disease was defined as time in which 4 SLE classification criteria were accrued (acute 30 days; insidious >30 days). Time to criteria accrual was calculated as the time elapsing between the first SLE criterion and the
diagnosis, and was categorized as 12 months. Statistical analyses We carried out comparisons between male and female patients’ features. Data distribution was evaluated using a Kolmogorov-Smirnov test. Quantitative variables with a normal distribution are shown as means (m) and standard deviations (SD) whereas those without it are shown as medians (me) and interquartile ranges (IQR). Categorical variables were examined with the Chisquare test or Fisher’s exact test as indicated. A p value
1–7
http://lup.sagepub.com
PAPER
Gender differences in disease activity and clinical features in newly diagnosed systemic lupus erythematosus patients C Mun˜oz-Grajales1,2, LA Gonza´lez2, GS Alarco´n3 and J Acosta-Reyes4 1
Division of Rheumatology, Hospital Pablo Tobo´n Uribe, Medellı´ n, Colombia; 2Division of Rheumatology, Universidad of Antioquia, Medellı´ n, Colombia; 3Department of Medicine, Division of Rheumatology and Clinical Immunology, The University of Alabama at Birmingham, Birmingham, AL, USA; and 4Department of Public Health, Universidad del Norte, Barranquilla, Colombia
Objective: The objective of this paper is to compare disease activity and clinical features at diagnosis in male and female patients with systemic lupus erythematosus (SLE). Methods: This was a cross-sectional study in which every male patient (n ¼ 40) was matched with three female patients of the same age (5 years) and racial/ethnic group; disease activity as per the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and disease manifestations at the time of diagnosis were compared. Results: Alopecia and anti-Ro antibodies were more frequent in female patients. No statistically significant difference in any other disease characteristics was found. However, male gender was associated with a risk of severe disease activity at the time of diagnosis (as determined by SLEDAI 12 score) independent of age, racial/ ethnic group, anti-Ro positivity or time to criteria accrual (OR: 3.11 95% CI, 1.09–8.92; p ¼ 0.035). Conclusion: In newly diagnosed SLE patients, male gender is associated with higher disease activity despite the fact that male and female patients seem to experience similar overall disease manifestations. Lupus (2016) 0, 1–7. Key words: Systemic lupus erythematosus; gender; male; SLEDAI (Systemic Lupus Erythematosus Disease Activity Index)
Introduction Systemic lupus erythematosus (SLE) occurs predominantly in women of reproductive age, with a ratio of 9:1 compared to patients of the opposite sex.1 SLE is quite infrequent among men, who constitute 4% to 22% of the patients in different studies.2–4 This frequency distribution has limited the possibility of studying newly diagnosed male SLE patients. Males develop a similar spectrum of disease manifestations as females, although some studies suggest that males show a higher rate of renal, and haematological manifestations, laboratory abnormalities, and a higher mortality rate.4–18 Nevertheless, the overall perception is that males develop more severe SLE manifestations; however, recent cohort studies have shown similar Systemic
Lupus Erythematosus Disease Activity Index (SLEDAI) average scores for patients of both genders. In contrast, damage occurs more frequently, is of higher magnitude and accrues faster in males than in females according to data from different cohort studies including lupus in minorities (LUMINA), the Latin-American lupus study group (GLADEL) and the Systemic Lupus Erythematosus in Gullah Health (SLEIGH).9,10,19 The aim of the present study is to examine the influence of gender on disease activity and disease features in newly diagnosed SLE patients from the Department of Rheumatology at the Universidad de Antioquia.
Methods Type and place of study
Correspondence to: Jorge Acosta-Reyes, Department of Public Health, Universidad del Norte, Km 5 Via Puerto Colombia, Barranquilla, 081007, Colombia. Email: [email protected] Received 6 August 2015; accepted 1 February 2016
This cross-sectional study was conducted in patients from the Department of Rheumatology at the Hospital Universitario de San Vicente Fundacio´n, Medellı´ n, Colombia, between 2000 and 2011.
! The Author(s), 2016. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav
Downloaded from lup.sagepub.com at La Trobe University on March 1, 2016
10.1177/0961203316635286
Gender differences in disease activity in SLE C Mun˜oz-Grajales et al.
2
Patient selection and inclusion criteria Male and female patients 16 years of age with newly diagnosed SLE (30 days) and fulfilling at least four of the American College of Rheumatology (ACR) revised and updated classification criteria for SLE were eligible to participate in the study.20,21 All patients have been referred to Rheumatology after presenting to the hospital emergency room. Patients with cancer and/or other uncontrolled comorbidities at the time of lupus diagnosis (n ¼ 3), those with an incomplete clinical history (n ¼ 21), and those with less than three months of follow-up treatment (n ¼ 25) were excluded. For every male patient three female patients were matched for age (5 years) and for racial/ethnic group. Variables The SLEDAI-2K version was used to assess disease activity. It was scored based on the available clinical data at the time of diagnosis and up to one month after as a maximum.22 The corresponding categories were established as follows: low or no activity 4 points, moderate activity 5 to 11 points, and high activity 12 points.23,24 Clinical and laboratory variables that were not included in the SLEDAI were determined six months after SLE diagnosis. Variables from the following domains were included: (a) socio-demographic (age and race/ethnicity); (b) clinical (number of ACR criteria), time to criteria accrual, disease onset type, disease manifestations according to the organ system involved (mucocutaneous, musculoskeletal, neurological, cardiovascular, pulmonary, renal and haematological) and specific clinical manifestations as per the ACR classification criteria.20,21 Other clinical manifestations attributable to lupus such as alopecia, Raynaud’s phenomenon, thrombosis and antiphospholipid syndrome were also included, as were (c) laboratory [urine laboratory (proteinuria, cell casts and haematuria)] and immunological variables (anti-double-stranded DNA (anti-dsDNA), anti-Sm, anti-ribonucleoprotein (anti-RNP), antiRo, anti-La, lupus anticoagulant, anticardiolipin (immunoglobulin (Ig)M and IgG) antibodies) and C3 and C4 complement levels); and (d) kidney biopsy results according to the International Society of Nephrology/Renal Pathology Society Classification.25 Onset of disease was defined as time in which 4 SLE classification criteria were accrued (acute 30 days; insidious >30 days). Time to criteria accrual was calculated as the time elapsing between the first SLE criterion and the
diagnosis, and was categorized as 12 months. Statistical analyses We carried out comparisons between male and female patients’ features. Data distribution was evaluated using a Kolmogorov-Smirnov test. Quantitative variables with a normal distribution are shown as means (m) and standard deviations (SD) whereas those without it are shown as medians (me) and interquartile ranges (IQR). Categorical variables were examined with the Chisquare test or Fisher’s exact test as indicated. A p value
