Epidemiology and clinical management of systemic lupus erythematosus in China

Abstract

Systemic lupus erythematosus (SLE) is a diffuse autoimmune disease that impacts body systems and organs. SLE may cause damage in multiple organs, typically in the kidney that causes lupus nephritis (LN). Patients may suffer from adverse events associated with long-term SLE treatment and also related economic burden, especially among patients who developed LN. The first aim of the thesis was to assess complications in rheumatic and SLE patients and economic burden, knowledge and attitude to the treatment and disease among SLE patients in China. A secondary objective was to examine key factors and propose solutions to improve the health care.

A cross-sectional study was conducted from May to August 2018 among rheumatic patients to assess their bone mineral density (BMD). Descriptive statistical methods were used to depict the distribution of normal BMD, osteopenia and osteoporosis. Logistic regression models and random forest were used to identify risk factors of lower BMD. A cross-sectional study was carried out from June to December in 2021 among SLE patients, to assess factors associated with flares including disease relapse and progression to LN. To examine factors associated with knowledge of the treatment guidelines and attitude to SLE treatment, ordinal logistic regression and logistic regression model respectively were utilized respectively. A cost-effectiveness analysis was conducted to evaluate the first-line treatment of LN using a Markov model.

In the study regarding BMD, over 70% of rheumatic patients were female and 13.3% of the patients had SLE. 50.8%, 27.6%, 16.5% of the patients were diagnosed with osteoporosis in lumbar spine, femoral neck and total hips respectively. Age, female, smoking and glucocorticoids use were associated with lower BMD.

Considering disease flares, I found that 47.4% of the SLE patients had LN and 36.1% of the patients experienced relapse. The use of glucocorticoids (odds ratio [OR] = 0.53, 95% confidence interval [CI] = 0.39-0.73) was associated with the risk of relapse. Switching to another hospital, development of one or more chronic diseases and adverse events during treatment, and those having LN were also significantly associated with relapse. The development of one or more chronic diseases and change of hospital were also significantly associated with the development of LN among SLE patients.

I found that LN patients (OR = 2.09, 95% CI = 1.70-2.57) was associated with higher familiarity with the knowledge to SLE, and higher education was associated with the change to positive attitude after treatment for SLE patients.

In the cost-effectiveness analysis, the use of mycophenolate mofetil in both induction and maintenance therapy was cost-effective at a lifetime horizon, with a higher complete remission rate (57.2%) and lower risks of end-stage renal disease (3.3%) and mortality (36.0%) among cost-effective strategies.

In the thesis, multiple factors concerning treatment and management of SLE patients were examined and highlighted potential area for improvement in terms of disease flares, choice of treatment, patient education and healthcare utilization. Integrated solutions at the patient, clinical and healthcare levels could improve the management of SLE in China.