Background/Purpose:

Hematologic manifestations are found in up to 30% of SLE patients. Although splenectomy is considered an acceptable therapeutic option for both refractory thrombocytopenia and autoimmune hemolytic anemia in different primary hematologic disorders, its role in SLE has been controversial, mainly because of its potential surgical complications and possible association with SLE flares. The aim of this study was to determine safety and efficacy of splenectomy in a cohort of SLE patients when compared to patients with hematologic activity who only received medical treatment.

Methods:

We included all patients with SLE who fulfilled ≥4 ACR criteria and underwent splenectomy because of refractory hematologic activity between 2000 and 2016 in a tertiary care center in Mexico City. We also included SLE patients who were hospitalized during that same period because of hematologic activity, but who did not undergo surgical treatment. Patients with other rheumatic diseases (except for APS) were excluded. We recorded demographic, clinical and serologic characteristics at baseline and during follow-up.

Results:

We included 30 patients in whom splenectomy was performed and 32 patients with hematological activity without splenectomy. Most patients were female (87%) and mean age was 31 years. Patients who underwent surgery had lower platelet levels at baseline (23,500 vs 73,000/μl, p<0.01) and had a higher cumulative prednisone dose in the previous year (8.77 ± 5.93 vs 2.25 ± 1.08 grams, p<0.001). Regarding splenectomy, 83% were laparoscopic and there were surgical complications in 4 patients (13%), all of which resolved.

Mean follow-up time was 63 months in patients with splenectomy and 66 months in those without it. Patients who underwent surgery achieved remission in a shorter time (2.4 ± 1.2 vs 4.8 ± 3.8 months, p<0.01). However, after 12 months, there was no difference in the remission rates between both groups (78 vs 86%, p=0.44). Although the cumulative prednisone dose after one year of surgery/hospitalization was similar between groups (5.41 ± 3.54 vs 5.24 ± 3.71 gr, p=0.86), the prednisone dose in patients with splenectomy was lower than the previous year (5.41 ± 3.54 vs 8.77 ± 5.93 gr, p=0.02) whereas in patients without surgery it was higher (5.24 ± 3.71 vs 2.25 ± 1.08 gr, p <0.01). There were no differences in SLEDAI or SLICC damage index scores at one year or at the end of follow-up.

Major infections were more frequent in patients who underwent splenectomy (43 vs 9%, p<0.01). Among patients with infectious complications, 69% had a complete immunization schedule. After multivariate analysis, considering factors such as vaccination, splenectomy remained as an independent risk factor for infection during follow-up (RR 5.15, 95% CI 1.05-25.11, p 0.043).

Conclusion:

Splenectomy may seem like an attractive alternative for SLE patients with refractory hematologic activity, since it is associated with shorter time to remission and the possibility of lowering glucocorticoid doses. However, it represents a significant risk factor for major infections, regardless of the patients’ immunosuppressive treatment and vaccination status.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/hematologic-activity-in-systemic-lupus-erythematosus-is-splenectomy-our-best-choice/