Prognosis for Hospitalized Patients with Systemic Lupus Erythematosus in China: 5-Year Update of the Jiangsu Cohort

Abstract

Objective: To identify early signs associated with poor prognosis in Chinese patients with systemic lupus erythematosus (SLE) through a large population-based follow-up study.

Methods: Medical records of > 2,500 SLE patients that first hospitalized between 1999-2009 were collected from 26 centers across Jiangsu province, China, and entered into a database. These patients were followed-up for 5 to 15 years, and those remained contact and had known survival status in 2015 were assessed for the association of factors presented at the initial hospitalization with mortality at two time points (≤1year and > 1year). The independency of mortality factors was evaluated using multivariate Cox regression analysis.

Results: Among 1,372 patients we assessed, 92.3% were women and 17.2% were deceased in 2015. The main causes of death were infection (30.1%), neuropsychiatric impairment (14.8%), renal failure (14.4%) and cardiopulmonary involvement (8.5%). Hazard ratios (HR) of independent predictors for mortality (≤1year and > 1year, respectively) included hospital presentation of neuropsychiatric involvement (2.03 and 1.91), cardiopulmonary involvement (1.94 and 1.61) and increased serum creatinine (2.52 and 2.58). Patients older than 45 years and with disease durations more than 2 years at admission had unfavorable short-term outcome (HR 1.76 and 1.79), while the presence of anti-dsDNA and anti-Sm antibodies indicated diverse prognosis after 1 year (HR 1.60 and 0.45). Treatment with cyclophosphamide was beneficial for patient's first-year outcome (HR 0.50), and anti-malarial drugs significantly reduced the risk of mortality over different time points (HR 0.48 and 0.54). SLEDAI score, proteinuria or hypocomplementemia was not independently associated with the outcome in this cohort.

Conclusion: SLE patients presented with vital organ damages rather than active disease at initial hospitalization are likely to have a poor outcome, especially for those with neuropsychiatric, cardiopulmonary involvements and renal insufficiency. Early and effective intervention with the use of anti-malarial drugs may decrease mortality.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Number of SLE patients recruited each calendar year (1999–2009).

Fig 2. Causes of death among the 236 deceased patients.

The most often seen cause of death was infection (30.1%), followed by neuropsychiatric impairments (14.8%), renal failure (14.4%) and cardiopulmonary involvements (8.5%). Ill-defined causes of death, classified as unknown here, represented 25.4% of the total deaths.

Fig 3. Kaplan-Meier estimated survival curves for deceased cases with known time of death (n = 219).

Nearly a half (47.9%) of the patients died within 1 year after first hospitalization.

Fig 4. Different causes of death between early and late deceased patients.

Compared with those died within 1 year after first hospitalization, patients died 1 year later had more cardiopulmonary related deaths (14.0% vs. 3.8%) but less neuropsychiatric related deaths (8.8% vs. 23.8%).

Fig 5. Cumulative survival rates by individual variables.

a) Kaplan-Meier survival estimates according to neuropsychiatric involvement. b) Kaplan-Meier survival estimates according to cardiopulmonary involvement. c) Kaplan-Meier survival estimates according to serum creatinine level.

Fig 6. Major therapeutic option for SLE patients with various manifestations during the first hospitalization.

a) For patients with or without neuropsychiatric involvement. b) For patients with or without cardiopulmonary involvement. c) For patients with or without increased serum creatinine level.