|Year : 2017 | Volume
| Issue : 4 | Page : 1210-1213
Hospitalization of systemic lupus patients: Causes and outcomes
Sabry A Shoeib1, Alaa E Elhamid1, Emad M Elshebiny1, Yasser A Shehata2, Amr A Elshormilisy3, Mohammed R Mazen1
1 Internal Medicine Department, Faculty of Medicine, Menoufia university, Menoufia, Egypt
2 Public Health and Community Medicine Department, Faculty of Medicine, Menoufia University, Shebeen Elkom, Menoufia, Egypt
3 Department of Rheumatology and Clinical Immunology, Faculty of Medicine, Helwan University, Cairo Governorate, Egypt
|Date of Submission||04-Dec-2016|
|Date of Acceptance||19-Mar-2017|
|Date of Web Publication||04-Apr-2018|
Mohammed R Mazen
Source of Support: None, Conflict of Interest: None
The aim of this study was to describe the most common causes of admission of Egyptian patients with systemic lupus erythematosus (SLE) and the outcomes of these hospitalizations.
SLE is a prototypic multisystem autoimmune disorder with a broad spectrum of clinical presentations. Studying the causes and outcomes of SLE patients will guide rheumatologists in better management of cases to improve outcomes.
Patients and methods
The charts of patients with SLE who were hospitalized at our Department of Internal Medicine during a 10-month period from August 2015 to June 2016 were reviewed in a retrospective manner, and their demographic, clinical, and laboratory data were collected.
There were 85 admissions of 40 patients with SLE. Seventeen (42.5%) patients were admitted twice or more. The mean length of stay for all admissions was 8 days (2–30). The most common cause of admission was active SLE (62 events, 72.9%). SLE was initially diagnosed in 11 (27.5%) patients in our department of internal medicine. Other causes of hospitalization were infections (9.4%), drug complications (2.4%), thromboembolic events (3.5%), and assessment of the disease (10.6%). Three (3.5%) hospitalizations resulted in death.
Our study of this Egyptian SLE population confirms the findings of previous studies suggesting that active SLE and infection remain the most common causes of hospitalization of patients with SLE.
Keywords: length of stay, remission, systemic lupus erythematosus
|How to cite this article:|
Shoeib SA, Elhamid AE, Elshebiny EM, Shehata YA, Elshormilisy AA, Mazen MR. Hospitalization of systemic lupus patients: Causes and outcomes. Menoufia Med J 2017;30:1210-3
|How to cite this URL:|
Shoeib SA, Elhamid AE, Elshebiny EM, Shehata YA, Elshormilisy AA, Mazen MR. Hospitalization of systemic lupus patients: Causes and outcomes. Menoufia Med J [serial online] 2017 [cited 2020 Apr 8];30:1210-3. Available from: http://www.mmj.eg.net/text.asp?2017/30/4/1210/229235
| Introduction|| |
Systemic lupus erythematosus (SLE) is a chronic, multifaceted autoimmune disease that causes a wide variety of signs and symptoms. As a highly heterogenous disease, SLE may lead to varied disease severity and outcomes among individuals. The clinical course of SLE is variable and may be characterized by periods of remissions and of chronic or acute relapses. Women, especially in their 20s and 30s, are affected more frequently than are men.
The intensity of the clinical manifestations of SLE may vary among different groups of patients, which could range from mild rashes and arthritis to debilitating fever, fatigue, and arthralgia and to severe organ failure and life-threatening disease in worst cases.
Prevalence ranges from 20 to 150 cases per 100 000 population, with the highest prevalence reported in Brazil, and appears to be increasing as the disease is recognized more readily and survival increases. In the USA, people of African, Hispanic, or Asian ancestry, as compared with those of other racial or ethnic groups, tend to have an increased prevalence of SLE and greater involvement of vital organs.
The 10-year survival rate is about 70%. Improvement of SLE can be attributed to a number of factors such as the early diagnosis of renal disease, better serological monitoring, more judicious use of corticosteroids and cytotoxic agents, availability and advancement of renal replacement therapy, and better management of associated complications like infection, hyperlipidemia, and hypertension. Despite the overall improvement in the survival from SLE, 10–25% of patients are known to die within 10 years of disease onset. The major cause of death in the first few years of illness is active disease manifested in the form of nervous, renal, or cardiovascular complications, or infection due to immunosuppression, and late deaths are caused by end-stage renal disease, treatment complications (including infection and coronary disease), non-Hodgkin's lymphoma, or lung cancer.
| Patients and Methods|| |
The charts of SLE patients who were hospitalized between August 2015 and June 2016 in the Internal Medicine Department in University Hospital of Menoufia Governorate in Egypt were retrospectively reviewed. This study follows the ethical standards of our institution. Informed consent from all patients and controls was obtained in accordance with the guidelines laid down by the local ethical committee.
All patients fulfilled at least four or more criteria for the diagnosis of SLE laid down by Systemic Lupus International Collaborating Clinics.
All patients included in this study were subjected to detailed medical history taking and complete physical examination.
The clinical parameters of the disease were studied for each patient. These include the affection of various systems by the disease [skin, kidney, central nervous system (CNS), joints, serous membranes, heart, and lungs].
All were subjected to the following evaluations: complete blood count, protein/creatinine ratio, erythrocyte sedimentation rate, C-reactive protein level, complement 3 and complement 4 levels, antinuclear antibodies, anti-dsDNA, antiphospholipid antibodies, combs test, and albumin. Disease activity in patients was assessed using the Systemic Lupus Erythematosus Disease Activity Index score, which was published in 1992. This index measures disease activity within the last 10 days.
Data entry, coding, and analysis were conducted using SPSS (released 2011, IBM SPSS statistics for Windows, version 20.0; IBM Corp., Armonk, New York, USA).
The following statistical tests were applied:
- Description of quantitative variables in the form of mean ± SD
- Description of qualitative variables by frequency and percentage
- Kruskal–Wallis test to estimate the difference in mean values between more than two groups
- Fisher's exact test to assess the relationship between two or more qualitative groups
- Level of significance: The level of significance of our data was 95%. Hence, P values greater than 0.05 were considered nonstatistically significant; P values less than 0.05 were considered statistically significant; and P values less than 0.01 were considered highly statistically significant.
| Results|| |
This study included 40 patients with SLE who were admitted at least once in our department. Of them, 34 (85%) patients were female and six (15%) were male. The mean ± SD age at diagnosis was 25.5 ± 10.7 years, and at admission the mean ± SD age was 28 ± 10.1 years.
Our study elaborated all the discharge diagnoses, which represented the cause of admission of these cases. The most common cause of hospitalization was active lupus disease (62 events, 72.9%). Among those patients admitted with active disease, nephritis (28 events, 45.2%) and hematological causes (16 events, 25.8%) were the most common, followed by pneumonitis and alveolar hemorrhage (five events, 8.1%), arthritis (five events, 8.1%), and carditis (three events, 4.8%). The least common were serositis (two cases), cerebritis (one case), pancreatitis due to active disease (one case), and pseudointestinal obstruction (one case) [Table 1].
|Table 1: Causes of hospitalization in patients with systemic lupus erythematosus, with frequency and percentage|
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Infection was responsible for eight (9.4%) admissions. The majority were bacterial and included pneumonia (four cases), gastrointestinal (two cases), and CNS infection (one case); one case was due to viral infection (cytomegalovirus infection). Adverse drug reactions (2.4%) and thromboembolic complications (3.5%) were uncommon causes for admission. Nine cases were hospitalized for assessment of the disease [Table 1].
There was a difference in the length of hospitalization on the basis of the cause of hospitalization. The mean ± SD length of hospitalization was 7.98 ± 5.6 days, and there was a significant difference in the length of stay between different causes of hospitalizations. Patients with active disease and thromboembolic events had a higher mean length of hospitalization (8.35 days and 16.33 days, respectively; P = 0.001). The mean ± SD length of stay for admissions with infection was 6.62 ± 3.5 days, and the mean ± SD length of stay of patients admitted for assessment of disease was 3.2 ± 1.09 days [Table 2].
|Table 2: Length of stay during hospitalizations in different causes of hospitalization|
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The mortality rate was 3.5%, with only three hospitalizations resulting in death: one with pulmonary embolism (PE), one with CNS infection, and the last case with active disease.
| Discussion|| |
In this retrospective study we illustrate the main causes of hospitalization of patients with SLE in Menoufia Governorate in Egypt. No similar studies had been held in Egypt. Although a few studies on hospitalization of SLE patients had been conducted earlier [9–14], they involved North Americans ,,, Asians, and North African Tunisian patients.
Over a period of 10 months, 85 hospitalizations of 40 patients with SLE occurred because of a variety of reasons. Our study reports that active disease is the most common cause of hospitalization in SLE patients (72.9%), similar to the results in the literature [9–11], except that the rate of admission for this cause is higher than that reported in the Northern America (17.5–35%), and Tunisian (43%) study. However, it remains similar to the results of the Asian population (58–80.8% of admissions due to disease flare),. These discrepancies may be due to ethnic and socioeconomic characteristics and differences in healthcare systems.
An overall 45.2% of hospitalizations for active disease were due to lupus nephritis, whereas nephritis as a cause constituted only 30% of admissions in the Tunisian study and 26.3% of admissions in the North American study. The second presentation for active disease was hematological (25.8%), whereas it was the most common presentation for active disease in the Tunisian study (56.3%) and saw a rate of 26.3% in the North American study. Neuropsychiatric manifestations were rare, similar to other studies,. Lupus pneumonitis and alveolar hemorrhage were responsible for 8.1% of active disease hospitalizations in our study, whereas there were no such case in the Tunisian study, and only 2.6% of cases with disease flare were pneumonitis cases in the North American study. Arthritis presentation constituted 8.1% of active disease hospitalizations; 30% of patients with active disease hospitalization in the Tunisian study had arthritis compared with no patients with arthritis in the North American study. There was one hospitalization with active disease-related pancreatitis and another hospitalization with active disease that presented with pseudointestinal obstruction in our study, with no similar presentations in other studies.
The second most common cause of hospitalization of SLE patients was assessment of the disease (10.6%), similar to the Tunisian study, except that in the latter the rate was higher (26.5%).
One of the leading causes of hospitalization in our study was infections despite the significant improvement in the management of SLE, but it remains one of the main causes of admissions due to immunodeficiency and immunosuppressive drugs and participates greatly in the morbidity and mortality of SLE patients ,,,. Pneumonia was the major cause of infection (50%), similar to the Tunisian study, while being less common in the North American study (25%). Gastrointestinal infection was seen in 25% of cases; one case was due to CNS infection, similar to the North American study, and one due to viral infection (cytomegalovirus infection).
An overall 3.5% of hospitalizations were due to thromboembolic events, which is more than those documented in the Tunisian and North American studies (1.5 and 1.9%, respectively). They were in the form of PE in one case, PE and Budd–Chiari in another case, and cavernous sinus thrombosis associated with active disease in a third case. These data are quite similar to those of the Tunisian study, which saw two cases: one with PE and the other with cerebral venous thrombosis.
The mean ± SD hospitalization length was 7.98 ± 5.6 days, and there was a significance difference in the length of patient stay between different causes of hospitalizations, with active disease and thromboembolic events resulting in higher mean length of stay (8.35 and 16.33 days, respectively; P = 0.001). The mean ± SD length of stay for admissions with infection was 6.62 ± 3.5 days. The mean ± SD length of stay of patients admitted for assessment of disease was 3.2 ± 1.09 days.
In comparison with the North American study, in which the average length of hospitalization was 8.5 days, in our study 10.8% of hospitalizations were ICU stays in comparison with 14.3% in the North American study. This was significantly higher than the proportion reported in the reviewed literature, which quoted 4–4.9% of SLE hospital admissions requiring ICU admission. This may reflect a lower threshold for ICU admission, a higher proportion of more severely ill SLE patients being admitted, or more patients being treated as outpatients where possible, so that when they are admitted they are the sickest SLE patients. There were no predictive factors for those requiring ICU care versus those who did not.
The mortality rate was 3.5%, with only three hospitalizations resulting in death: one with PE, one with CNS infection, and the last case with active disease, which was quiet similar to the results of the Tunisian study (3%). In all, 66.6% of mortality cases were in ICU hospitalizations. This is consistent with the mortality rate among ICU patients in the literature, which ranged from 29 to 79%,. Overall mortality for SLE inpatients was 5.6% in the North American study. This proportion is higher than our study mortality rate, which is consistent with all inpatient mortality in other studies (ranging from 3.1 to 4.8%),.
| Conclusion|| |
Our study of the Egyptian SLE population in Menoufia Governorate confirms the findings of previous studies suggesting that active SLE and infection remain the most common causes of hospitalization of patients with SLE.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Feng X, Pan W, Liu L, Wu M, Ding F, Hu H, et al.
Prognosis for hospitalized patients with systemic lupus erythematosus in china: 5-year update of the Jiangsu cohort. PLoS One 2016; 11
Bahlas SM, Ali Jali I, Atik H, Aldhahri WK. Outcome of systemic lupus erythematosus in hospitalized patients: a 2 year retrospective analysis. Life Sci J 2014; 11
Askanase A, Shum K, Mitnick H. Systemic lupus erythematosus: an overview. Soc Work Health Care 2012; 51
Pons-Estel GJ, Alarćon GS, Scofield L, Reinlib L, Cooper GS. Understanding the epidemiology and progression of systemic lupus erythematosus. Semin Arthritis Rheum 2010; 39
Mok CC, Lee KW, Ho CT, Lau CS, Wong RWS. A prospective study of survival and prognostic indicators of systemic lupus erythematosus in a southern Chinese population. Rheumatology 2000; 39
Bernatsky S, Boivin JF, Joseph L, Manzi S, Ginzler E, Gladman DD, et al.
Mortality in systemic lupus erythematosus. Arthritis Rheum 2006; 54
Petri M, Orbai AM, Alarcon GS, Gordon C, Merrill JT, Fortin PR, et al.
Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum 2012; 64
Bombardier C, Gladman DD, Urowitz MB, Caron D, Chang CH. Derivation of the SLEDAI. A disease activity index for lupus patients. The Committee on Prognosis Studies in SLE. Arthritis Rheum 1992; 35
Edwards CJ, Lian TY, Badsha H, Teh CL, Arden N, Chng HH. Hospitalization of individuals with systemic lupus erythematosus: characteristics and predictors of outcome. Lupus 2003; 12
Lee J, Dhillon N, Pope J. All-cause hospitalizations in systemic lupus erythematosus from a large Canadian referral centre. Rheumatology (Oxford) 2013; 52
Petri M, Genovese M. Incidence of and risk factors for hospitalizations in systemic lupus erythematosus: a prospective study of the Hopkins Lupus Cohort. J Rheumatol 1992; 19
Lee J, Peschken C, Muangchan C, Silverman E, Pineau C, Smith CD, et al.
The frequency of and associations with hospitalization secondary to lupus flares from the 1000 Faces of Lupus Canadian cohort. Lupus 2013; 22
Krishnan E. Hospitalization and mortality of patients with systemic lupus erythematosus. J Rheumatol 2006; 33
Jallouli M, Hriz H, Cherif Y, Marzouk S, Snoussi M, Frikha F, et al.
Causes and outcome of hospitalisations in Tunisian patients with systemic lupus erythematosus. Lupus Sci Med 2014; 1
Teh CL, Chan GYL, Lee J. Systemic lupus erythematosus in a tertiary, east Malaysian hospital: admission, readmission and death. Int J Rheum Dis 2008; 11
Goldblatt F, Chambers S, Rahman A, Isenberg DA. Serious infections in British patients with systemic lupus erythematosus: hospitalisations and mortality. Lupus 2009; 18
Alzeer AH, Al-Arfaj A, Basha SJ, Alballa S, Al-Wakeel J, Al-Arfaj H, et al.
Outcome of patients with systemic lupus erythematosus in intensive care unit. Lupus 2004; 13
Whitelaw DA, Gopal R, Freeman V. Survival of patients with SLE admitted to an intensive care unit – A retrospective study. Clin Rheumatol 2005; 24
[Table 1], [Table 2]