Session Information
Date: Sunday, October 21, 2018
Title: Pediatric Rheumatology – Clinical Poster I: Lupus, Sjögren’s Disease, and Myositis
Session Type: ACR Poster Session A
Session Time: 9:00AM-11:00AM
Background/Purpose: There is a paucity of data regarding the early hospital readmission rates in newly diagnosed childhood lupus nephritis (cLN). We conducted a retrospective study to characterize the early hospital readmission rates in cLN and identify risk factors associated with these readmissions.
Methods: 76 cLN cases evaluated from 1/1/2008 to 4/2/2017 were included in the study. The readmission rate within 30 days following a hospitalization due to newly diagnosed cLN was calculated. The characteristics of the early readmitted cases were compared with those of whom were not early readmitted using chi-square, fisher exact test, independent t-test or Mann- Whitney U tests as appropriate; variables with a P-value <0.10 were included in a multivariable analysis using stepwise linear logistic regression.
Results: The 30-day readmission rate following hospitalization for cLN was 1 per 5.8 admissions (17.1%). Clinical characteristics of these cases are listed in tables 1, 2 and 3. Not receiving pulsed methylprednisolone (30.8% vs 3.2%, p=<0.001), stage 2 hypertension on day 1 (76.9% vs 41.3%, p=0.019), higher white blood cell count on admission (5.7 x 103/mm3 vs 5.0 x 103/mm3, p=0.022) and at discharge (13.7 x 103/mm3 vs 8.8 x 103/mm3, p=0.23) , diuretic treatment (69.2% vs 34.9%, p=0.021), anti-hypertensives other than angiotensin-converting enzyme inhibitors(76.9% vs 49%, p=0.042) and albumin infusions (46.2% vs 12.7%, p=0.004) predicted early readmission in univariable analysis. In multivariable analysis the absence of treatment with pulsed methylprednisolone was a risk factor for early readmission (OR=21.4 (2.89-158.82) p=0.002) whereas not receiving intravenous albumin had a protective effect (OR=0.12 (0.026-0.51) p=0.004).
Conclusion: One in 5.8 children (17.1%) hospitalized for newly diagnosed cLN were readmitted within 30 days of discharge. Not receiving pulsed steroids and receiving intravenous albumin on admission increased the risk of hospital readmission in newly diagnosed cLN.
|
Nephritis class |
All lupus nephritis patients (n/%) |
ERG (n/%) |
NERG (n/%) |
|
I |
1 /1.3 |
0/0 |
1/1.6 |
|
II |
5/ 6.6 |
0/0 |
5/7.9 |
|
III |
9/11.8 |
0/0 |
9/14.3 |
|
III/V |
5/6.6 |
0/0 |
5/7.9 |
|
IV |
27/35.5 |
6/46.2 |
21/33.3 |
|
IV/V |
20/26.3 |
3/23 |
17/27 |
|
V |
9/11.8 |
4/30.8 |
5/7.9 |
|
Table 1.-Distribution of nephritis classes between groups. ERG: Early readmitted group, NERG: Not early readmitted group. P value=0.151 |
|||
|
Variable |
Patients with lupus nephritis |
ERG |
NERG |
P value |
|
Number of patients |
76 |
13 |
63 |
|
|
Age (years)a |
14.2 (11.6-15.9) |
13.9 (11.5 – 15.2) |
14.3 (11.9 – 16.0) |
0.793 |
|
Length of stay (days)a |
6 (3.25-9.0) |
7.0 (4.0-9.0) |
6.0 (3.0-9.0) |
0.608 |
|
Gender (n/%) Female Male |
. 62/81.6 14/18.4 |
. 8/61.5 5/38.5 |
. 54/85.7 9/14.3 |
0.040 |
|
Ethnicity (n/%) African American White Hispanic Asian Other |
. 47/61.8 9/11.8 15/19.7 3/3.9 2/2.6 |
. 8/61.5 1/7.7 4/30.8 0/0 0 /0 |
. 39/61.9 8/12.7 11/17.5 3 /4.8 2 /3.1 |
0.622 |
|
Insurance (n/%) Medicaid Private insurance Tricare insurance None |
. 44/57.9 28/36.8 3/3.9 1/1.3 |
. 9/69.2 4/30.8 0/0 0/0 |
. 35/55.5 24/38.1 3 /4.8 1/ 1.6 |
0.574 |
|
Table 2. – Demographic and health insurance coverage characteristics. . ERG: Early readmitted group, NERG: Not early readmitted group. aMedian and interquartile ranges. |
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|
Variable |
Total (n=76) |
ER (n=13) |
NER (n=63) |
P |
|
Stage 2 HTN on admission (n/%) |
36/47.36 |
10/76.9 |
26/41.3 |
0.019 |
|
Treated with Pulsed MPN (n/%) |
70/92.1 |
9/69.2 |
61/96.8 |
0.007 |
|
Treated with albumin infusion (n/%) |
14/18.34 |
6/46.2 |
8/12.7 |
0.011 |
|
Treated with diuretics (n/%) |
31/40.78 |
9/69.2 |
22/34.9 |
0.022 |
|
Treated with Non-ACE anti-HTN (n/%) |
39/51.31 |
10/76.9 |
29/46 |
0.042 |
|
WBC on admission (x 103/mm3) |
5.0 (3.7-7.2) |
5.7 (4.1-9.1) |
5.0 (3.4-6.6) |
0.022 |
|
WBC on discharge (x 103/mm3) |
9.2 (6.6-14.6) |
13.7 (9.2-16.4) |
8.830 (6.0-13.9) |
0.023 |
|
Discharged on NSAID |
6 (7.9%) |
3 (23.1%) |
3 (4.8%) |
0.059 |
|
Lymphocyte count (x 103/mm3) |
1.3 (0.9-1.9) |
1.3 (1.2-2.3) |
1.2 (0.7-1.7) |
0.074 |
|
Serum albumin (g/dL)* |
2.2 ± 0.6 |
1.9 ± 0.6 |
2.2 ± 0.5 |
0.099 |
|
New lupus diagnosis (n/%) |
35/46.1 |
9/69.2 |
26/41.3 |
0.066 |
|
Arthritis (n/%) |
29/38.2 |
7/53.8 |
22/34.9 |
0.224 |
|
Cutaneous involvement (n/%) |
42/55.3 |
7/53.8 |
35/55.6 |
0.910 |
|
Mucosal involvement (n/%) |
16/21.1 |
3/23.1 |
13/20.6 |
1 |
|
Neurologic involvement (n/%) |
7/9.2 |
0/0 |
7/11.1 |
0.596 |
|
Pericarditis (n/%) |
24/31.5 |
7/53.8 |
17/27 |
0.155 |
|
Pleuritis (n/%) |
31/40.7 |
6/46.2 |
25/39.7 |
0.443 |
|
Ascites (n/%) |
13/17.1 |
2/15.4 |
11/17.5 |
0.682 |
|
Anasarca (n/%) |
15/19.7 |
4/30.8 |
11/17.5 |
0.273 |
|
BMI (percentile) |
75.3 (44.3-88.7) |
73.1 (45.9-88.1) |
76.6 (43.5-89) |
0.896 |
|
Weight change at discharge (Kg.) |
-0.1 (-1.1 to +1.8) |
-0.9 (-2.9 to 1.3) |
0 (-0.8 to 2) |
0.245 |
|
Treated with cyclophosphamide (n/%) |
39/51.3 |
9/69.2 |
30/47.6 |
0.156 |
|
Treated with mycophenolic acid (n/%) |
21/27.6 |
3/23.1 |
18/28.6 |
1 |
|
Treated with HXQ (n/%) |
43/56.6 |
5/38.5 |
38/60.3 |
0.148 |
|
ACE inhibitor on discharge (n/%) |
26/34.2 |
3/23.1 |
23/36.5 |
0.524 |
|
Hemoglobin (g/dL)* |
10.4 ± 1.9 |
10.4 ± 2.0 |
10.3 ± 1.9 |
0.895 |
|
Platelet count (x 103/mm3)* |
251.5 ± 124.6 |
217.8 ± 99.8 |
258.5 ± 128.7 |
0.287 |
|
ESR (mm/hr)* |
88.3 ± 38.4 |
88.7 ± 38.8 |
88.3 ± 38.7 |
0.969 |
|
Serum creatinine (mg/dL) |
0.9 (0.7-1.5) |
1 (0.6-1.45) |
0.9 (0.7-1.5) |
0.983 |
|
EGFR (ml/min/1.73 m2) * |
69.4 ± 35.5 |
64 ± 27.2 |
70.5 ± 37.1 |
0.550 |
|
AKI on admission (n/%) |
49/64.5 |
9/69.2 |
40/63.5 |
0.762 |
|
UPCR (mg/mg) |
2.89 (1.17-4.96) |
4.22 (1.50-5.49) |
2.68 (1.16-4.96) |
0.481 |
|
C3 (mg/dL) |
39 (22-54.5) |
30 (20-62.5) |
39 (23-53) |
0.994 |
|
C4 (mg/dL) |
5 (3-9.25) |
5 (3.5-19.5) |
5 (3-8) |
0.403 |
|
Days between discharge and readmission |
49.5 (15.5-255.5) |
12 (5-18) |
132 (35-318) |
<0.001 |
|
Days between SLE DX and nephritis DX |
5.5 (2-45.25) |
1 (-0.5-21.5) |
1 (0-18) |
0.127 |
|
Days between nephritis symptoms onset and biopsy |
19 (8-43) |
18 (10-61) |
19 (17.7-37.7) |
0.726 |
|
SLEDAI-2K |
22 (19-29) |
22.0 (19.0 – 29.5) |
23.0 (19.0 – 9.0) |
0.837 |
|
SLEDAI-renal |
12 (8-12) |
12 (8-12) |
12 (8-12) |
0.897 |
|
NIH Activity index (0-24) |
6 (2.75-11) |
6 (1.5-11) |
6 (2.5-11) |
0.678 |
|
NIH Chronicity index (0-12) |
1 (0-4) |
1 (0-4) |
1 (0-3.5) |
0.970 |
|
Admitted to PICU (n/%) |
12/15.8 |
1/7.7 |
11/17.5 |
0.679 |
|
Table 3. – Clinical and laboratory characteristics of patients admitted with a new diagnosed of lupus nephritis. Values represent number and percentage, median and interquartile range or mean + SD BMI: Body mass index, HXQ: Hydroxychloroquine, ACE: Angiotensin-converting enzyme, EGFR: Estimated glomerular filtration rate, AKI: Acute kidney injury defined as EGFR < 80 ml/min/1.73 m2, UPCR: Urine protein: creatinine ratio in spotted urine,DX: Diagnosis, SLEDAI-2K: SLE disease activity index 2000, NIH: National Institute of Health, PICU: Pediatric intensive care unit. |
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To cite this abstract in AMA style:
Herrera Guerra AA, Prahalad S, Rouster-Stevens KA, Garro R, Bryan L, Hong Y. Readmission Rate within 30 Days of Hospitalization Due to New Onset Lupus Nephritis and Associated Risk Factors: The Importance of Intravenous Pulse Methylprednisolone Therapy [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 9). https://acrabstracts.org/abstract/readmission-rate-within-30-days-of-hospitalization-due-to-new-onset-lupus-nephritis-and-associated-risk-factors-the-importance-of-intravenous-pulse-methylprednisolone-therapy/. Accessed .« Back to 2018 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/readmission-rate-within-30-days-of-hospitalization-due-to-new-onset-lupus-nephritis-and-associated-risk-factors-the-importance-of-intravenous-pulse-methylprednisolone-therapy/