Objectives-This review examines the burden and patterns of disease in systemic lupus erythematosus (SLE) and the influence and interactions of gender, ethnicity, age, and psychosocial attributes with respect to disease progression, focusing on issues relevant to clinical practice and research. Methods-PubMed literature search complemented by review of bibliographies listed in identified articles.Results-An increased risk among reproductive age women is clearly seen in African Americans in the United States. However, in other populations, a different pattern is generally seen, with the highest age-specific incidence rates occurring in women after age 40 years. The disease is 2 to 4 times more frequent, and more severe, among nonwhite populations around the world and tends to be more severe in men and in pediatric and late-onset lupus. SLE patients now experience a higher than 90% survival rate at 5 years. The less favorable survival experience of ethnic minorities is possibly related to socioeconomic status rather than to ethnicity per se, and adequate social support has been shown to be a protective factor, in general, in SLE patients. Discordance between physician and patient ratings of disease activity may affect quality of care.Conclusions-Our understanding of ways to improve outcomes in SLE patients could benefit from patient-oriented research focusing on many dimensions of disease burden. Promising research initiatives include the inclusion of community-based patients in longitudinal studies, use of selfassessment tools for rating disease damage and activity, and a focus on self-perceived disease activity and treatment compliance. Ethnicity, a broader construct than is implied by the term "race," encompasses genetic, geographic, cultural, social, and other characteristics shared within a population (2-4). Not surprisingly, the phenotypic expression of lupus varies between individuals of different ethnic groups. A growing body of research has sought to characterize the influence of socioeconomic (5) factors and ethnicity on the incidence, activity, and progression of the disease. Less attention has been paid to the influence of psychosocial factors on disease progression (Fig. 1). In this article, we review relevant research findings pertaining to these dimensions of SLE, focusing on studies conducted in the past 30 years. We also highlight current data gaps and discuss recommendations for future research. Keywords MethodsThis review is based on publications found through searches of the MEDLINE database for relevant articles using the combination search terms of lupus and (epidemiology, incidence, prevalence, mortality, gender, ethnicity, damage, quality of life). References within these selected reports were also reviewed. We included epidemiological studies of incidence or prevalence that spanned the years 1975 to 2000, and mortality studies of cohorts assembled in 1975 or later. The mortality studies were limited to inception or near-inception cohorts (that is, cohorts of patients who entered the...

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Objective. Antiphospholipid Syndrome Alliance For Clinical Trials and International Networking (APS ACTION)Results. Based on the analysis of 120 full-text papers, the overall aPL frequency was estimated as 6% for PM, 13.5% for ST, 11% for MI, and 9.5% for DVT. Limitations of the literature were that 60% of the papers were published before 2000, all 3 criteria aPL tests were performed in only 11% of the papers, 36% of papers used a low-titer aCL cutoff, anti-␤ 2 GPI cutoff was quite heterogeneous, aPL confirmation was performed in only one-fifth of papers, and the study design was retrospective in nearly half of the papers. Conclusion. It is difficult to determine the frequency of a "clinically significant aPL profile" in patients with aPL-related clinical outcomes due to the lack of robust data. Our best estimates of the incidence of aPL-associated events should be confirmed with appropriately designed population studies.

Objective. To assess whether hydroxychloroquine can delay renal damage development in lupus nephritis patients. Methods. Lupus nephritis patients (n ‫؍‬ 256) from the LUpus in MInorities, NAture versus nurture study (n ‫؍‬ 635), a multiethnic cohort of African Americans, Hispanics, and Caucasians, age >16 years with disease duration <5 years at baseline (T0) were studied. Renal damage was defined using the Systemic Lupus International Collaborating Clinics Damage Index (>1 of the following lasting at least 6 months: estimated/measured glomerular filtration rate <50%, 24-hour proteinuria >3.5 gm and/or end-stage renal disease, regardless of dialysis or transplantation). Patients with renal damage before T0 were excluded (n ‫؍‬ 53). The association between hydroxychloroquine use and renal damage (as defined, or omitting proteinuria) was estimated using Cox proportional regression analyses adjusting for potential confounders. Kaplan-Meier survival curves based on hydroxychloroquine intake or the World Health Organization (WHO) class glomerulonephritis were also derived. Results. Sixty-three (31.0%) of the 203 patients included developed renal damage over a mean ؎ SD disease duration of 5.2 ؎ 3.5 years. The most frequent renal damage domain item was proteinuria. Patients who received hydroxychloroquine (79.3%) exhibited a lower frequency of WHO class IV glomerulonephritis, had lower disease activity, and received lower glucocorticoid doses than those who did not take hydroxychloroquine. After adjusting for confounders, hydroxychloroquine was protective of renal damage occurrence in full (hazard ratio [HR] 0.12, 95% confidence interval [95% CI] 0.02-0.97, P ‫؍‬ 0.0464) and reduced (HR 0.29, 95% CI 0.13-0.68, P ‫؍‬ 0.0043) models. Omitting proteinuria provided comparable results. The cumulative probability of renal damage occurrence was higher in those who did not take hydroxychloroquine and those classified as WHO class IV glomerulonephritis (P < 0.0001). Conclusion. After adjusting for possible confounding factors, the protective effect of hydroxychloroquine in retarding renal damage occurrence in systemic lupus erythematosus is still evident.

Systemic lupus erythematosus (SLE) is a disease distributed worldwide, which occurs in both genders, and across racial/ethnic and age groups; however, higher rates are observed in adults, in women and in non-Caucasians. Genetic, environmental, sociodemographic and methodological issues are responsible not only for these differences but for the variable course and outcome of the disease. Non-Caucasians have a more severe disease with a higher risk for early mortality and damage accrual. Males also have a more severe disease; however, a negative impact of male gender on lupus outcomes has not been firmly established. Childhood-onset is associated with a more severe disease; moreover, it is also associated with higher damage and diminished survival; finally, late-onset lupus is mild but it is associated with higher damage accrual and a diminished survival. Areas covered: In this review, we discuss the incidence and prevalence of SLE, the impact of age, gender and race/ethnicity in SLE and in the survival of those affected. Expert commentary: Age, gender and race/ethnicity impact disease expression in SLE patients; despite improvements in survival, mortality in SLE remains almost three times higher than in the general population.

The renal domain of the damage index is associated with a shorter time to death when poverty, a strong predictor of this outcome, is removed from the model. Preventing renal damage in lupus patients has long-term prognostic implications.

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Objective. To determine the risk factors for recurrent lupus nephritis, allograft loss, and survival among patients with systemic lupus erythematosus (SLE) undergoing kidney transplantation.Methods. The archival records of all kidney transplant recipients with a prior diagnosis of SLE (according to the American College of Rheumatology criteria) from June 1977 to June 2007 were reviewed. Patients who had died or lost the allograft within 90 days of engraftment were excluded. Time-to-event data were examined by univariable and multivariable Cox proportional hazards regression analyses.Results. Two hundred twenty of nearly 7,000 renal transplantations were performed in 202 SLE patients during the 30-year interval. Of the 177 patients who met the criteria for study entry, the majority were women (80%) and African American (65%), the mean age was 35.6 years, and the mean disease duration was 11.2 years. Recurrent lupus nephritis was noted in 20 patients (11%), allograft loss in 69 patients (39%), and death in 36 patients (20%). African American ethnicity was found to be associated with a shorter time-to-event for recurrent lupus nephritis (hazard ratio [HR] 4.63, 95% confidence interval [95% CI] 1.29-16.65) and death (HR 2.47, 95% CI 0.91-6.71), although, with the latter, the association was not statistically significant. Recurrent lupus nephritis and chronic rejection of the kidney transplant were found to be risk factors for allograft loss (HR 2.48, 95% CI 1.09-5.60 and HR 2.72, 95% CI 1.55-4.78, respectively). In patients with recurrent lupus nephritis, the lesion in the engrafted kidney was predominantly mesangial, compared with a predominance of proliferative or membranous lesions in the native kidneys.Conclusion. African American ethnicity was independently associated with recurrent lupus nephritis. Allograft loss was associated with chronic transplant rejection and recurrence of lupus nephritis. Recurrent lupus nephritis is infrequent and relatively benign, without influence on a patient's survival.