Lupus around the World
In-hospital mortality and its predictors in a cohort of SLE from Northern India
Lupus 0(0) 1–7 ! The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0961203320961474 journals.sagepub.com/home/lup
Sarit Sekhar Pattanaik, Hafis Muhammed, Rudrarpan Chatterjee, R Naveen, Able Lawrence, Vikas Agarwal, Durga P Misra, Latika Gupta, Ramnath Misra and Amita Aggarwal
Abstract Background: Mortality in SLE has a bimodal peak with early deaths mainly related to disease activity and infection. Although mortality has reduced over years, it is still two to three folds compared to the general population. In India due to increased burden of infection and limited access to health care, the causes may be different. Methods: Retrospective, review of records of all adult SLE patients fulfilling ACR 1997 criteria, who died in hospital between 2000-2019 at a teaching hospital in India was done. In addition, baseline clinical features were extracted for all adult SLE patients seen during this period. Infections were either bacteriologically proven or based on clinicradiological or serologic evidence. Active disease was defined as SLEDAI 2k 5. Logistic regression was performed to ascertain risk factors for mortality. Results: A total of 1337 (92% females) patient records were reviewed .The mean age at presentation was 29.9 9 years.60–75% of patients had fever, mucocutaneous disease and arthritis, while nephritis, hematologic, serositis and neurologic involvement was seen in 48.6%, 43.2%, 16% and 10.3% respectively as presenting mainfestations. There were 80 in hospital deaths .Infection was the most common cause of death, with 37 due to infection alone and in 24 disease activity also contributed. Only 18 deaths were due to active disease. Among bacterial infections lung was the most common site and gram negative organism were the most common pathogens. There were 10 deaths due to Tuberculosis (TB) and half of them had disseminated disease. Patients with disease activity had a SLEDAI of 14.8 6.4, with neurological, renal and cardiovascular involvement being the major contributors to mortality in 11, 7 and 6 cases respectively. Higher age at onset, male gender, fever, myositis, neurological, cardiovascular, gastrointestinal involvement, vasculitis, elevated serum creatinine at baseline were independent predictors of death. Conclusion: Infections are the most common cause of in-hospital mortality in SLE and TB still accounts for 15% of deaths related to infection. Vasculitis, myositis, cardiovascular and gastrointestinal involvement emerged as novel predictors of mortality in our cohort. Keywords SLE, mortality, infection, tuberculosis Date received: 19 July 2020; accepted: 3 September 2020
Introduction SLE is a multisystemic autoimmune disease, affecting women in the reproductive age group associated with significant morbidity and mortality. It is one of the leading causes of death in females, ranking amongst the top 20 causes of death in 5–64 years age group and is ranked 10th in 15–24 years age group.1 Early diagnosis, use of immunosuppressive agents, better
Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India Corresponding author: Amita Aggarwal, Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India. Email: [email protected]
2 care of patients with organ failure have led to a improved 5 year survival from 50-60% in 1950s to > 95% in 1990s and 10 yr survival reaching 90%.2 But studies reporting improved survival have been from developed countries.3 Even with the improved survival rates the mortality rates are 2 to 3 fold higher compared to age and sex matched population.4Survival studies from developing countries like India have shown dismal results with 5- and 10year survival of 68-77% and 50-60%, respectively. There is paucity of recent data however studies in pediatric age group have shown an improved survival.5–7 A bimodal pattern of death has been observed in patients with SLE. Early deaths (2 years) are mainly due to atherosclerotic vascular disease.8A recent meta-analysis attributed significant increase in mortality due to renal, cardiovascular, and infectious complications, showing a 4.68, 2.25, and 4.98 fold Standardized Mortality Ratio(SMR) respectively in SLE4.Studies from developing country like India have shown disease activity, septicemia and renal failure as the major cause of death,5–7with identical results from Africa and Brazil.9,10Infections and access to quality health care are still major challenges in developing country like India, hence there could be possible differences in causes of deaths. Thus, this study was designed to look at the causes of in hospital death and its predictors at a tertiary care hospital in India.
Patients and methods Patients This is retrospective, single centre, review of records of all adult SLE patients, seen at a tertiary care Rheumatology unit in North India over 20 years between 2000-2019.1976 records were screened, after excluding patients with juvenile SLE and overlap syndrome 1337 patients fulfilling ACR 1997 criteria11 were selected. The records of the 80 patients who died in hospital were retrieved from the case sheets and electronic records using the hospital information system.
Methods Data of demographic profile, duration of disease, first and last hospital visit and baseline organ involvement was collected for all cases. In addition haematological, biochemical, serological parameters, infections and data on use of immunosuppressive agents were collected in all cases with mortality. Active disease was defined as patients having SLEDAI 2k 5. The other disease variables and lab parameters were defined as per SLEDAI or ACR criteria. Infections were either
Lupus 0(0) bacteriologically proven or based on clinic radiological or serological evidence. The cause of death were categorized into infections, disease activity, cases with features of both infection and disease activity and others respectively.
Statistics and ethics Categorical variables are expressed as number. Continuous variables are expressed as Mean SD. p value of
In-hospital mortality and its predictors in a cohort of SLE from Northern India
Lupus 0(0) 1–7 ! The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0961203320961474 journals.sagepub.com/home/lup
Sarit Sekhar Pattanaik, Hafis Muhammed, Rudrarpan Chatterjee, R Naveen, Able Lawrence, Vikas Agarwal, Durga P Misra, Latika Gupta, Ramnath Misra and Amita Aggarwal
Abstract Background: Mortality in SLE has a bimodal peak with early deaths mainly related to disease activity and infection. Although mortality has reduced over years, it is still two to three folds compared to the general population. In India due to increased burden of infection and limited access to health care, the causes may be different. Methods: Retrospective, review of records of all adult SLE patients fulfilling ACR 1997 criteria, who died in hospital between 2000-2019 at a teaching hospital in India was done. In addition, baseline clinical features were extracted for all adult SLE patients seen during this period. Infections were either bacteriologically proven or based on clinicradiological or serologic evidence. Active disease was defined as SLEDAI 2k 5. Logistic regression was performed to ascertain risk factors for mortality. Results: A total of 1337 (92% females) patient records were reviewed .The mean age at presentation was 29.9 9 years.60–75% of patients had fever, mucocutaneous disease and arthritis, while nephritis, hematologic, serositis and neurologic involvement was seen in 48.6%, 43.2%, 16% and 10.3% respectively as presenting mainfestations. There were 80 in hospital deaths .Infection was the most common cause of death, with 37 due to infection alone and in 24 disease activity also contributed. Only 18 deaths were due to active disease. Among bacterial infections lung was the most common site and gram negative organism were the most common pathogens. There were 10 deaths due to Tuberculosis (TB) and half of them had disseminated disease. Patients with disease activity had a SLEDAI of 14.8 6.4, with neurological, renal and cardiovascular involvement being the major contributors to mortality in 11, 7 and 6 cases respectively. Higher age at onset, male gender, fever, myositis, neurological, cardiovascular, gastrointestinal involvement, vasculitis, elevated serum creatinine at baseline were independent predictors of death. Conclusion: Infections are the most common cause of in-hospital mortality in SLE and TB still accounts for 15% of deaths related to infection. Vasculitis, myositis, cardiovascular and gastrointestinal involvement emerged as novel predictors of mortality in our cohort. Keywords SLE, mortality, infection, tuberculosis Date received: 19 July 2020; accepted: 3 September 2020
Introduction SLE is a multisystemic autoimmune disease, affecting women in the reproductive age group associated with significant morbidity and mortality. It is one of the leading causes of death in females, ranking amongst the top 20 causes of death in 5–64 years age group and is ranked 10th in 15–24 years age group.1 Early diagnosis, use of immunosuppressive agents, better
Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India Corresponding author: Amita Aggarwal, Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India. Email: [email protected]
2 care of patients with organ failure have led to a improved 5 year survival from 50-60% in 1950s to > 95% in 1990s and 10 yr survival reaching 90%.2 But studies reporting improved survival have been from developed countries.3 Even with the improved survival rates the mortality rates are 2 to 3 fold higher compared to age and sex matched population.4Survival studies from developing countries like India have shown dismal results with 5- and 10year survival of 68-77% and 50-60%, respectively. There is paucity of recent data however studies in pediatric age group have shown an improved survival.5–7 A bimodal pattern of death has been observed in patients with SLE. Early deaths (2 years) are mainly due to atherosclerotic vascular disease.8A recent meta-analysis attributed significant increase in mortality due to renal, cardiovascular, and infectious complications, showing a 4.68, 2.25, and 4.98 fold Standardized Mortality Ratio(SMR) respectively in SLE4.Studies from developing country like India have shown disease activity, septicemia and renal failure as the major cause of death,5–7with identical results from Africa and Brazil.9,10Infections and access to quality health care are still major challenges in developing country like India, hence there could be possible differences in causes of deaths. Thus, this study was designed to look at the causes of in hospital death and its predictors at a tertiary care hospital in India.
Patients and methods Patients This is retrospective, single centre, review of records of all adult SLE patients, seen at a tertiary care Rheumatology unit in North India over 20 years between 2000-2019.1976 records were screened, after excluding patients with juvenile SLE and overlap syndrome 1337 patients fulfilling ACR 1997 criteria11 were selected. The records of the 80 patients who died in hospital were retrieved from the case sheets and electronic records using the hospital information system.
Methods Data of demographic profile, duration of disease, first and last hospital visit and baseline organ involvement was collected for all cases. In addition haematological, biochemical, serological parameters, infections and data on use of immunosuppressive agents were collected in all cases with mortality. Active disease was defined as patients having SLEDAI 2k 5. The other disease variables and lab parameters were defined as per SLEDAI or ACR criteria. Infections were either
Lupus 0(0) bacteriologically proven or based on clinic radiological or serological evidence. The cause of death were categorized into infections, disease activity, cases with features of both infection and disease activity and others respectively.
Statistics and ethics Categorical variables are expressed as number. Continuous variables are expressed as Mean SD. p value of
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