Session Information
Date: Monday, November 6, 2017
Title: Systemic Lupus Erythematosus – Clinical Aspects and Treatment Poster II: Damage and Comorbidities
Session Type: ACR Poster Session B
Session Time: 9:00AM-11:00AM
Background/Purpose: Systemic Lupus Erythematosus (SLE) is an autoimmune disease with increased cardiovascular and infectious complications due to subclinical atherosclerosis, disease activity and treatment-related factors. The aim of this study was to identify risk factors for early infectious and non-infectious complications in SLE patients undergoing major surgery.
Methods: Retrospective comparative cohort study including patients with SLE (≥4 ACR criteria) that underwent major non-cardiac surgery between 2010-2015, and non-SLE patients paired 1:1 according to age, gender and type of surgery. Demographics, comorbidities, SLE variables, preoperative laboratory and risk assessment were analyzed. Main outcome was development of infectious, non-infectious complications and mortality 30 days after surgery. Differences between groups were evaluated: Student t-test or Mann-Whitney U test (continuous variables); Chi-square or Fisher’s exact test (categorical variables). Univariate logistic regression and multivariate analyses were done.
Results: 382 patients (191 SLE, 191 non-SLE) were included. Disease duration of SLE patients at surgery was 132 (0-468) months. Table 1 shows characteristics of surgical SLE and non-SLE patients. Variables associated with infectious complications in SLE patients: use of prednisone (OR 1.81, 95%CI 1.13-2.90, p=0.01); anemia (OR 2.43, 95%CI 1.45-4.08, p=0.001); hypoalbuminemia (OR 2.58, 95%CI 1.55-4.30, p<0.001), and lymphopenia (OR 2.43, 95%CI 1.52-3.89, p<0.001). Multivariate analysis retained hypoalbuminemia, anemia and lymphopenia. Variables associated with non-infectious complications: anemia (OR, 1.93, 95%CI 1.03-3.64, p=0.03) and hypoalbuminemia (OR 2.11, 95%CI 1.16-3.86, p=0.01). More patients with SLE died (p=0.02). Table 2 shows characteristics of SLE patients with and without any postoperative complication. Variables associated with any complication: SLEDAI-2K (OR 1.1, 95%CI 1.01-1.20, p=0.02); nephritis (OR 10.08, 95%CI 1.21-83.63, p=0.03); use of aspirin (OR 2.68, 95%CI 1.19-6.02, p=0.01); low C3 (OR 2.00, 95%CI 1.06-3.80, p=0.03); anemia (OR 2.68, 95%CI 1.39-5.18, p=0.003); hypoalbuminemia (OR 3.49, 95%CI 1.83-6.66, p<0.001), and lymphopenia (OR 2.36, 95%CI 1.30-4.26, p=0.004). Only use of aspirin was retained in multivariate analysis. More patients with complications died (p<0.001).
Conclusion: SLE patients present higher frequency of postoperative early complications and mortality compared to non-SLE patients. Hypoalbuminemia, anemia, lymphopenia and use of aspirin are independent risk factors.
Table 1
| Variable | SLE (n=191) | Non-SLE (n=191) | p |
| Female gender | 169 (88) | 169 (88) | 1 |
| Age at surgery-years | 39 (19-76) | 39 (18-74) | 0.72 |
| Comorbidities | |||
| Obesity | 80 (42) | 95 (50) | 0.15 |
| Smoking | 60 (31) | 57 (30) | 0.82 |
| Diabetes mellitus | 15 (8) | 25 (13) | 0.13 |
| Hypertension | 78 (41) | 59 (31) | 0.05 |
| Dyslipidemia | 58 (30) | 38 (20) | 0.02 |
| Cardiac failure | 10 (5) | 4 (2) | 0.17 |
| ESRD | 51 (27) | 41 (21) | 0.28 |
| Cerebrovascular disease | 11 (6) | 2 (1) | 0.02 |
| Cancer | 17 (9) | 30 (16) | 0.06 |
| Preoperative risk according to type of surgical procedure | |||
| Low | 0 | 0 | – |
| Medium | 180 (94) | 180 (94) | 1 |
| High | 11 (6) | 11 (6) | 1 |
| Surgery indication | |||
| Elective procedure | 133 (70) | 148 (77) | 0.1 |
| Urgent procedure | 45 (24) | 35 (18) | 0.25 |
| Emergency procedure | 13 (7) | 8 (4) | 0.37 |
| Charlson comorbidity index-% | 85 (19) | 90 (21) | <0.001 |
| Use of prednisone before surgery | 109 (57) | 25 (13) | <0.001 |
| Steroids during surgery | 116 (61) | 106 (56) | 0.3 |
| Equivalent prednisone dose during surgery-mg | 50 (6.25-1250) | 50 (12.5-1250) | 0.29 |
| Use of immunosuppressants before surgery | 84 (44) | 13 (7) | <0.001 |
| Preoperative laboratory characteristics at surgery | |||
| Hemoglobin―g/dl | 11.9 (4.9-17.5) | 12.7 (5.1-23.1) | 0.04 |
| Leukocytes/mm3 | 6800 (13.4-29400) | 7400 (300-29000) | 0.01 |
| Neutrophils/mm3 | 4803 (765-27636) | 4695 (12.9-22344) | 0.73 |
| Lymphocytes/mm3 | 961 (82-3496) | 1598 (0-4640) | <0.001 |
| Platelets―K/ul | 210 (6-490) | 249 (2-585) | <0.001 |
| Serum creatinine―mg/dl | 0.8 (0.2-21.4) | 0.7 (0.1-20.4) | 0.92 |
| Albumin―g/dl | 3.9 (0.6-5.2) | 4.1 (0.9-5.4) | 0.001 |
| Anemia | 129 (68) | 105 (55) | 0.01 |
| Hypoalbuminemia | 59 (31) | 30 (16) | 0.001 |
| Lymphopenia <1000 | 103 (54) | 37 (19) | <0.001 |
| Surgical time―hours | 2.5 (0.7-8.4) | 2.3 (0-9) | 0.98 |
| Bleeding―ml | 135 (5-7000) | 150 (10-5000) | 0.84 |
| Blood transfusion―units | 0 (0-9) | 0 (0-6) | 0.17 |
| Days of mechanical ventilation | 0 (0-24) | 0 (0-19) | 0.11 |
| Days of intensive care unit | 0 (0-31) | 0 (0-31) | 0.57 |
| Total days of hospital stay | 7 (0-236) | 6 (1-70) | 0.13 |
| Complications | |||
| Any complication | 82 (43) | 58 (30) | 0.01 |
| Days after surgery | 3 (0-30) | 3 (1-21) | 0.59 |
| Infectious postoperative complications (any) | 58 (30) | 41 (21) | 0.06 |
| Septic shock | 10 (5) | 7 (4) | 0.62 |
| Pneumonia | 13 (7) | 5 (3) | 0.08 |
| Urinary tract infection | 12 (6) | 11 (6) | 1 |
| Surgical wound | 5 (3) | 2 (1) | 0.44 |
| Bacteremia | 3 (2) | 5 (3) | 0.72 |
| Cellulitis | 6 (3) | 2 (1) | 0.28 |
| Abdominal sepsis | 16 (8) | 15 (8) | 1 |
| Diarrhea | 2 (1) | 0 | 0.49 |
| Prosthetic | 1 (0.5) | 0 | 1 |
| Osteomyelitis | 0 | 1 (0.5) | 1 |
| Non-infectious postoperative complications (any) | 33 (17) | 24 (13) | 0.25 |
| Thrombosis | 8 (4) | 2 (1) | 0.1 |
| Bleeding | 8 (4) | 6 (3) | 0.78 |
| Hemorrhagic shock | 8 (4) | 5 (3) | 0.57 |
| Cardiogenic shock | 2 (1) | 0 | 0.49 |
| Arrhythmia | 3 (2) | 0 | 0.24 |
| Acute kidney injury | 10 (5) | 8 (4) | 0.81 |
| Hypocalcaemia | 0 | 7 (4) | 0.01 |
| Second intervention | 17 (9) | 7 (4) | 0.05 |
| Second hospitalization | 12 (6) | 6 (3) | 0.22 |
| Hospital stay > 31 days | 12 (6) | 3 (2) | 0.03 |
| Postoperative death | 11 (6) | 2 (1) | 0.02 |
| Days from surgery to death | 4 (1-25) | 6 (1-10) | 1 |
Table 2
| Variable | With complications | Without complications | p |
| (n=82) | (n=109) | ||
| Female | 71 (87) | 98 (90) | 0.5 |
| Age at SLE diagnosis-years | 25 (12-75) | 24 (8-63) | 0.63 |
| Age at surgery-years | 36 (19-76) | 39 (19-72) | 0.64 |
| Disease duration at surgery-months | 108 (0-468) | 156 (0-456) | 0.04 |
| Comorbidities | |||
| Obesity | 31 (38) | 49 (45) | 0.37 |
| Smoking | 26 (32) | 34 (31) | 1 |
| Diabetes mellitus | 4 (5) | 11 (10) | 0.27 |
| Hypertension | 38 (46) | 40 (37) | 0.18 |
| Dyslipidemia | 24 (29) | 34 (31) | 0.87 |
| Cardiac failure | 5 (6) | 5 (5) | 0.74 |
| ESRD | 24 (29) | 27 (25) | 0.51 |
| Cerebrovascular disease | 7 (9) | 4 (4) | 0.21 |
| Cancer | 8 (10) | 9 (8) | 0.8 |
| SLE criteria at diagnosis | |||
| Malar rash | 43 (52) | 57 (52) | 1 |
| Discoid lupus | 3 (4) | 9 (8) | 0.23 |
| Photosensitivity | 33 (40) | 34 (31) | 0.22 |
| Oral ulcers | 35 (43) | 45 (41) | 0.88 |
| Arthritis | 66 (80) | 91 (83) | 0.7 |
| Serositis | 22 (27) | 27 (25) | 0.86 |
| Renal involvement | 44 (54) | 48 (44) | 0.19 |
| Neurologic involvement | 4 (5) | 8 (7) | 0.56 |
| Hematologic | 47 (57) | 62 (57) | 1 |
| Immunologic-n+/n (%) | 67/72 (93) | 82/96 (85) | 0.14 |
| Positive ANA-n+/n (%) | 70/73 (96) | 93/103 (90) | 0.24 |
| Positive anti-dsDNA-n+/n (%) | 60/67 (90) | 77/96 (80) | 0.13 |
| Secondary APS | 19 (23) | 19 (17) | 0.36 |
| SLEDAI-2K before surgery | 4 (0-16) | 2 (0-18) | 0.04 |
| SLICC/ACR damage index before surgery | 2 (0-8) | 1 (0-6) | 0.16 |
| Severe SLE manifestation before surgery | 13 (16) | 13 (12) | 0.52 |
| Time since last severe SLE manifestation-days | 45 (13-90) | 43 (15-90) | 0.93 |
| Hemolytic anemia | 0 | 2 (15) | 0.48 |
| Thrombocytopenia | 3 (23) | 2 (15) | 1 |
| Lupus nephritis | 7 (54) | 1 (8) | 0.03 |
| Serositis | 2 (15) | 1 (8) | 1 |
| Constitutional symptoms | 0 | 3 (23) | 0.22 |
| Cutaneous | 0 | 2 (15) | 0.48 |
| Preoperative SLE treatment | |||
| Prednisone | 51 (62) | 58 (53) | 0.23 |
| Prednisone dose-mg | 10 (2.5-75) | 7.5 (2.5-100) | 0.03 |
| Prednisone dose ≥10 mg/d | 31 (61) | 25 (43) | 0.08 |
| Cyclophosphamide | 4 (5) | 1 (0.9) | 0.16 |
| Cyclophosphamide dose-mg | 1000 (500-1200) | 1000 (1000-1000) | 1 |
| Azathioprine | 23 (28) | 35 (32) | 0.63 |
| Azathioprine dose-mg | 50 (25-150) | 75 (50-200) | 0.17 |
| Mycophenolate mofetil | 10 (12) | 9 (8) | 0.46 |
| Mycophenolate mofetil dose-mg | 1500 (500-3000) | 1000 (750-2500) | 0.4 |
| Methotrexate | 1 (1) | 3 (3) | 0.63 |
| Methotrexate dose-mg | 15 (15-15) | 10 (7.5-17.5) | 0.65 |
| Antimalarials | 32 (39) | 34 (31) | 0.28 |
| Aspirin | 19 (23) | 11 (10) | 0.01 |
| Oral anticoagulants | 13 (16) | 16 (15) | 0.84 |
| Preoperative serologic characteristics | |||
| Positive anti-dsDNA-n+/n (%) | 50/75 (67) | 61/80 (76) | 0.21 |
| Low complement C3-n+/n (%) | 47/74 (64) | 39/84 (46) | 0.03 |
| Low complement C4-n+/n (%) | 39/73 (53) | 41/82 (50) | 0.74 |
| Charlson comorbidity index-% | 82 (23) | 87 (16) | 0.39 |
| Steroids during surgery | 45 (56) | 70 (64) | 0.29 |
| Equivalent prednisone dose during surgery-mg | 50 (12.5-1250) | 50 (6.2-1250) | 0.99 |
| Preoperative laboratory characteristics at surgery | |||
| Hemoglobin―g/dl | 10.8 (4.9-16.3) | 12.7 (5.2-17.5) | <0.001 |
| Leukocytes/mm3 | 6450 (13.4-29400) | 7100 (1800-17200) | 0.35 |
| Neutrophils/mm3 | 5152 (765-27636) | 4547 (972-14635) | 0.64 |
| Lymphocytes/mm3 | 726 (140-2840) | 1074 (82-3496) | <0.001 |
| Platelets―K/ul | 203 (6-418) | 217 (32-490) | 0.07 |
| Serum creatinine―mg/dl | 1 (0.2-21) | 0.7 (0.3-16.7) | 0.29 |
| Albumin―g/dl | 3.5 (0.6-5) | 4 (1.3-5.2) | <0.001 |
| Anemia | 65 (79) | 64 (59) | 0.003 |
| Hypoalbuminemia | 38 (46) | 21 (20) | <0.001 |
| Lymphopenia <1000 | 54 (66) | 49 (45) | 0.005 |
| Postoperative death | 11 (13) | 0 | <0.001 |
| SLE activity 30 days after surgery | 12 (15) | 0 | <0.001 |
| Thrombocytopenia | 3 (4) | 0 | 0.07 |
| Nephritis | 2 (3) | 0 | 0.18 |
| Diffuse alveolar hemorrhage | 3 (4) | 0 | 0.07 |
| Myocarditis | 1 (1) | 0 | 0.42 |
| Serositis | 1 (1) | 0 | 0.42 |
| Seizures | 1 (1) | 0 | 0.42 |
| Cutaneous | 1 (1) | 0 | 0.42 |
To cite this abstract in AMA style:
Quintanilla-González L, Torres-Villalobos G, Hinojosa-Azaola A. Risk Factors for Development of Early Infectious and Non-Infectious Complications in Systemic Lupus Erythematosus Patients Undergoing Major Surgery [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/risk-factors-for-development-of-early-infectious-and-non-infectious-complications-in-systemic-lupus-erythematosus-patients-undergoing-major-surgery/. Accessed .« Back to 2017 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/risk-factors-for-development-of-early-infectious-and-non-infectious-complications-in-systemic-lupus-erythematosus-patients-undergoing-major-surgery/