Factors associated with damage accrual in patients with systemic lupus erythematosus: results from the Systemic Lupus International Collaborating Clinics (SLICC) Inception Cohort.
OBJECTIVE
We studied damage accrual and factors determining development and progression of damage in an international cohort of systemic lupus erythematosus (SLE) patients.


METHODS
The Systemic Lupus International Collaborating Clinics (SLICC) Inception Cohort recruited patients within 15 months of developing four or more 1997 American College of Rheumatology (ACR) criteria for SLE; the SLICC/ACR damage index (SDI) was measured annually. We assessed relative rates of transition using maximum likelihood estimation in a multistate model. The Kaplan-Meier method estimated the probabilities for time to first increase in SDI score and Cox regression analysis was used to assess mortality.


RESULTS
We recruited 1722 patients; mean (SD) age 35.0 (13.4) years at cohort entry. Patients with damage at enrolment were more likely to have further worsening of SDI (SDI 0 vs ≥1; p<0.001). Age, USA African race/ethnicity, SLEDAI-2K score, steroid use and hypertension were associated with transition from no damage to damage, and increase(s) in pre-existing damage. Male gender (relative transition rates (95% CI) 1.48 (1.06 to 2.08)) and USA Caucasian race/ethnicity (1.63 (1.08 to 2.47)) were associated with SDI 0 to ≥1 transitions; Asian race/ethnicity patients had lower rates of new damage (0.60 (0.39 to 0.93)). Antimalarial use was associated with lower rates of increases in pre-existing damage (0.63 (0.44 to 0.89)). Damage was associated with future mortality (HR (95% CI) 1.46 (1.18 to 1.81) per SDI point).


CONCLUSIONS
Damage in SLE predicts future damage accrual and mortality. We identified several potentially modifiable risk factors for damage accrual; an integrated strategy to address these may improve long-term outcomes.
Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK The Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
Ian N
IN
Bruce
Department of Statistical Science, University College London, London, UK.
Aidan G
AG
O'Keeffe
MRC Biostatistics Unit, Cambridge, UK.
Vern
V
Farewell
Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
John G
JG
Hanly
Department of Medicine, West Penn Allegheny Health System, Pittsburgh, Pennsylvania, USA.
Susan
S
Manzi
MRC Biostatistics Unit, Cambridge, UK.
Li
L
Su
Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada.
Dafna D
DD
Gladman
Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea.
Sang-Cheol
SC
Bae
Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada.
Jorge
J
Sanchez-Guerrero
Instituto Nacional de Ciencias Medicas y Nutrición, Mexico City, Mexico.
Juanita
J
Romero-Diaz
Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
Caroline
C
Gordon
Cedars-Sinai/David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
Daniel J
DJ
Wallace
Division of Rheumatology, University of Calgary, Alberta, Canada.
Ann E
AE
Clarke
Divisions of Clinical Immunology/Allergy and Clinical Epidemiology, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
Sasha
S
Bernatsky
Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA.
Ellen M
EM
Ginzler
Centre for Rheumatology Research, University College London, London, UK.
David A
DA
Isenberg
Centre for Rheumatology Research, University College London, London, UK.
Anisur
A
Rahman
Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA.
Joan T
JT
Merrill
Department of Medicine, Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama, USA.
Graciela S
GS
Alarcón
Department of Medicine, Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama, USA.
Barri J
BJ
Fessler
Division of Rheumatology, Centre Hospitalier Universitaire de Québec et Université Laval, Quebec City, Quebec, Canada.
Paul R
PR
Fortin
Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Michelle
M
Petri
Center for Rheumatology Research, Landspitali University Hospital, Reykjavik, Iceland.
Kristjan
K
Steinsson
Division of Rheumatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA.
Mary Anne
MA
Dooley
Lupus Research Unit, The Rayne Institute, St Thomas' Hospital, King's College London School of Medicine, London, UK.
Munther A
MA
Khamashta
Northwestern University and Feinberg School of Medicine, Chicago, Illinois, USA.
Rosalind
R
Ramsey-Goldman
Lanarkshire Centre for Rheumatology, Hairmyres Hospital, East Kilbride, UK.
Asad A
AA
Zoma
Department of Rheumatology, University Hospital Lund, Lund, Sweden.
Gunnar K
GK
Sturfelt
Department of Rheumatology, University Hospital Lund, Lund, Sweden.
Ola
O
Nived
Feinstein Institute for Medical Research, Manhasset, New York, USA.
Cynthia
C
Aranow
Feinstein Institute for Medical Research, Manhasset, New York, USA.
Meggan
M
Mackay
Josep Font Autoimmune Diseases Laboratory, IDIBAPS, Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain.
Manuel
M
Ramos-Casals
Unit for Clinical Therapy Research Inflammatory Diseases (ClinTRID), Karolinska Institute, Stockholm, Sweden.
Ronald F
RF
van Vollenhoven
UCSD School of Medicine, La Jolla, California, USA.
Kenneth C
KC
Kalunian
Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain.
Guillermo
G
Ruiz-Irastorza
Emory University, Atlanta, Georgia, USA.
Sam
S
Lim
Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA.
Diane L
DL
Kamen
University of Manitoba, Winnipeg, Manitoba, Canada.
Christine A
CA
Peschken
Division of Rheumatology, Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.
Murat
M
Inanc
Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada.
Murray B
MB
Urowitz
D000328:Adult; D015331:Cohort Studies; D018450:Disease Progression; D005006:Ethnicity; D005260:Female; D006304:Health Status; D006801:Humans; D053208:Kaplan-Meier Estimate; D008137:Longitudinal Studies; D008180:Lupus Erythematosus, Systemic / Q000401:mortality / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011788:Quality of Life; D055815:Young Adult
Corticosteroids; Inflammation; Outcomes research; Systemic Lupus Erythematosus