Brief Report: How Do Patients With Newly Diagnosed Systemic Lupus Erythematosus Present? A Multicenter Cohort of Early Systemic Lupus Erythematosus to Inform the Development of New Classification Criteria.

OBJECTIVE: Systemic lupus erythematosus (SLE) presents with nonspecific signs and symptoms that are also found in other conditions. This study aimed to evaluate manifestations at disease onset and to compare early SLE manifestations to those of diseases mimicking SLE. METHODS: Academic lupus centers in Asia, Europe, North America, and South America collected baseline data on patients who were referred to them during the previous 3 years for possible SLE and who had a symptom duration of <1 year. Clinical and serologic manifestations were compared between patients diagnosed as having SLE and those diagnosed as having SLE-mimicking conditions. Diagnostic performance of the 1997 American College of Rheumatology (ACR) SLE classification criteria and the 2012 Systemic Lupus International Collaborating Clinics (SLICC) SLE classification criteria was tested. RESULTS: Data were collected on 389 patients with early SLE and 227 patients with SLE-mimicking conditions. Unexplained fever was more common in early SLE than in SLE-mimicking conditions (34.5% versus 13.7%, respectively; P < 0.001). Features less common in early SLE included Raynaud's phenomenon (22.1% versus 48.5%; P < 0.001), sicca symptoms (4.4% versus 34.4%; P < 0.001), dysphagia (0.3% versus 6.2%; P < 0.001), and fatigue (28.3% versus 37.0%; P = 0.024). Anti-double-stranded DNA, anti-ß2 -glycoprotein I antibodies, positive Coombs' test results, autoimmune hemolytic anemia, hypocomplementemia, and leukopenia were more common in early SLE than in SLE-mimicking conditions. Symptoms detailed in the ACR and SLICC classification criteria were significantly more frequent among those with early SLE. Fewer patients with early SLE were not identified as having early SLE with use of the SLICC criteria compared to the ACR criteria (16.5% versus 33.9%), but the ACR criteria demonstrated higher specificity than the SLICC criteria (91.6% versus 82.4%). CONCLUSION: In this multicenter cohort, clinical manifestations that could help to distinguish early SLE from SLE-mimicking conditions were identified. These findings may aid in earlier SLE diagnosis and provide information for ongoing initiatives to revise SLE classification criteria.

Canadian Rheumatology Association Recommendations for the Assessment and Monitoring of Systemic Lupus Erythematosus.

OBJECTIVE: To develop recommendations for the assessment of people with systemic lupus erythematosus (SLE) in Canada. METHODS: Recommendations were developed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. The Canadian SLE Working Group (panel of Canadian rheumatologists and a patient representative from Canadian Arthritis Patient Alliance) was created. Questions for recommendation development were identified based on the results of a previous survey of SLE practice patterns of members of the Canadian Rheumatology Association. Systematic literature reviews of randomized trials and observational studies were conducted. Evidence to Decision tables were prepared and presented to the panel at 2 face-to-face meetings and online. RESULTS: There are 15 recommendations for assessing and monitoring SLE, with varying applicability to adult and pediatric patients. Three recommendations focus on diagnosis, disease activity, and damage assessment, suggesting the use of a validated disease activity score per visit and annual damage score. Strong recommendations were made for cardiovascular risk assessment and measuring anti-Ro and anti-La antibodies in the peripartum period and conditional recommendations for osteoporosis and osteonecrosis. Two conditional recommendations were made for peripartum assessments, 1 for cervical cancer screening and 2 for hepatitis B and C screening. A strong recommendation was made for annual influenza vaccination. CONCLUSION: These are considered the first guidelines using the GRADE method for the monitoring of SLE. Existing evidence is largely of low to moderate quality, resulting in more conditional than strong recommendations. Additional rigorous studies and special attention to pediatric SLE populations and patient preferences are needed.

Pulmonary alveolar microlithiasis / Microlitiasis alveolar pulmonar

Pulmonary alveolar microlithiasis is an uncommon disease of unknown etiology, and is characterized by the presence of multiple sub-pleural and intra-alveolar microcalcifications. We present the case of a patient with rheumatoid arthritis and chronic renal disease, but with no respiratory symptoms.

La microlitiasis pulmonar alveolar es una enfermedad infrecuente, de etiología desconocida, caracterizada por la presencia de múltiples microcalcificaciones intraalveolares y subpleurales. Presentamos el caso de un paciente asintomático respiratorio, con historia clínica de artritis reumatoide y enfermedad renal crónica.

Utility of untimed single urine protein/creatinine ratio as a substitute for 24-h proteinuria for assessment of proteinuria in systemic lupus erythematosus.

INTRODUCTION: In this study, we determined: (1) the utility of an untimed sample of urine protein/creatinine ratio (PCR) as a screening test for proteinuria, (2) its ability to accurately measure proteinuria, and (3) cutoff values for PCR predicting protein content in a 24-h urine collection sample (24hP) of 0.5, 1.0, and 2.0 g/day. METHODS: Analysis was performed on data from a single lupus cohort (2008-2014). Proteinuria was measured in a 24hP and with PCR. On the basis of 24hP, samples were divided into 4 groups: group 1, <0.5 g/day; group 2, 0.5-0.99 g/day; group 3, 1-1.99 g/day; and group 4, ≥2 g/day. To determine the validity of PCR in screening for proteinuria, the Pearson correlation coefficient was determined for the urine samples with normal PCR (<0.05 g/mmol) and normal 24hP (<0.5 g/day). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PCR were calculated. To determine the ability of PCR to accurately measure the level of proteinuria, in addition to the correlation between 24hP and PCR, agreement was determined by intraclass correlation coefficient, concordance correlation coefficient, and Bland-Altman plot between 24hP/24hC and PCR. The best cutoffs for PCR predicting a 24hP of 0.5, 1.0, and 2.0 g/day were determined with the receiver operating characteristic curve. RESULTS: The correlation of the samples with normal PCR as well as 24hP (n = 552) was 0.29 (p < 0.0001). PCR sensitivity and specificity against 24hP were 91 % and 83 %, respectively. The PPV was 82.5 %, and the NPV was 91.4 %. The correlation for all samples (n = 1233) was high, but low to moderate for groups 1, 2, 3, and 4. The agreement for all samples was appropriate but poor for groups 1, 2, 3, and 4. PCR cutoffs for 24hP of 0.5, 1.0, and 2.0 g/day were 0.08, 0.16, and 0.35 g/mmol, respectively. CONCLUSIONS: PCR can be used as a screening test for proteinuria, and the best cutoff value to predict a 24hP of 0.5 g/day is 0.08 g/mmol (800 mg/g). The accurate level of proteinuria should be measured by the gold standard test, 24hP.

Uso de IECA o ARA II más espironolactona y su relación con hiperkalemia en pacientes ambulatorios / Use of ace inhibitors or ARA II plus spironolactone and their relationship with hyperkalemia in day care patients

Objetivo: establecer la relación existente entre la combinación farmacológica de un inhibidor de la enzima convertidora de angiotensina (IECA) o un bloqueante del receptor de angiotensina tipo II (ARA II) más espironolactona y los niveles de potasio sérico en los pacientes adultos con insuficiencia cardiaca y tasa de filtración glomerular (TFG) mayor o igual a 60 mL/min, que acuden a la consulta de cardiología de dos centros hospitalarios de la ciudad de Manizales.Diseño: estudio de tipo prospectivo, observacional, de casos incidentes.Material y métodos: se incluyeron 30 pacientes con diagnóstico de insuficiencia cardiaca, que recibían la combinación farmacológica IECA o ARA II más espironolactona, cuya depuración de creatinina fuera mayor o igual a 60 mL/min. Se hizo seguimiento durante seis meses, evaluando cada mes electrolitos y pruebas de función renal. El análisis estadístico, para las variables cualitativas, se realizó con la prueba de Chi cuadrado; para las variables cuantitativas se utilizó la prueba de t de Student. Se utilizó el programa EpiInfo Versión 6.04 d y Epidata 3.1...

Objective: to establish the relationship between the pharmacologic combination of an angiotensin converting enzyme (ACE) inhibitor or an angiotensin receptor blocking agent Type II(ARA II) plus spironolactone and the serum potassium levels in adult patients with heart failure, and glomerular filtration rate (GFR) higher or equal to 60 mL/min, who go for consultation in the cardiology unit of hospital centers in the city of Manizales. Design: prospective, observational study of incident cases. Material and methods: 30 patients with diagnosis of heart failure were included. They weregiven the pharmacologic combination of ACE inhibitors or ARA II plus spironolactone, with a creatinine clearance of more or equal to 60 mL/min. They were followed for 6 months, monthly assessments of the electrolytes as well as renal function. The statistical analysis for the quantitative variables was carried out with the Chi square test; for the quantitative variables the Student t wasused. The EpiInfo program Version 6.04 and Epidate 3.1 were used.Results: 368 patients with diagnosis of heart failure were found, 126 of them lived in Manizalez, of which 54 had creatinine clearance...