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Abstract Number: 1618

Risk Factors for Development of Early Infectious and Non-Infectious Complications in Systemic Lupus Erythematosus Patients Undergoing Major Surgery

Lauro Quintanilla-González1, Gonzalo Torres-Villalobos2 and Andrea Hinojosa-Azaola3, 1Immunology & Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, 2Departmen of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, 3Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico

Meeting: 2017 ACR/ARHP Annual Meeting

Date of first publication: September 18, 2017

Keywords: complications, Lupus, outcomes and surgery

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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



Disclosure: L. Quintanilla-González, None; G. Torres-Villalobos, None; A. Hinojosa-Azaola, None.

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 .
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