Renal biopsies in Puerto Rico patients with lupus nephritis.

The purpose of was to evaluate the renal pathology findings as described by the World Health Organization classification for systemic lupus erythematosus (SLE) in a group of Puerto Rico patients with lupus nephritis and determine the association with clinical and laboratory findings. The medical records from patients seen at the Lu pus Clinic from 1985 to 2005 were reviewed and patients with a performed renal biopsy included. All patients fulfilled the American ColIege of Rheumatology criteria for SLE. Data gathered from the medical records included demographics, cumulative clinical manifestations and serologic tests at the time of the renal biopsy. There were 139 patients with lupus nephntis (LN) and 71 patients (51%) had a renal biopsy done. From these 86% were females and their mean age at LN diagnosis was 25 years. The mean time between diagnosis of LN and renal biopsy was 1.5 years. The most frequent renal pathology was membranous glomewlonephritis (GN) class V (37%) followed by mesangial GN class II (23%). All groups were similar in clinical manifestations and laboratory parameters. The majority of Puerto Rico patients with LN had membranous GN class V. This data is different from other ethnic groups were diffuse GN type IV has been described as most prevalent.

Outcome and predictors of kidney disease progression in Puerto Ricans with systemic lupus erythematosus initially presenting with mild renal involvement.

OBJECTIVES: The aims of this study were to determine the outcomes and predictors of renal disease progression in Puerto Ricans with systemic lupus erythematosus (SLE) initially presenting mild renal involvement. METHODS: A retrospective cohort of 61 patients with SLE (per American College of Rheumatology classification) with mild renal involvement was studied. Mild renal disease was defined as glomerular filtration rate (GFR) of 90 mL/min or higher in the presence of proteinuria (>0.25 g/d, but <3.5 g/d), hematuria, and/or urinary cellular casts. Demographic parameters, clinical manifestations, serologic markers, comorbidities, pharmacologic treatments, disease activity, and damage accrual were determined at onset of renal disease. Factors associated with renal disease progression were evaluated using recurrent event survival analysis. RESULTS: Of 61 patients, 55 (90.2%) were women. The mean (SD) age at renal onset was 29 (11.2) years, and the mean (SD) follow-up period was 5.1 (3.4) years. Thirty-eight patients had a decline in GFR. Thirty-two had a mild decline (GFR = 60-89 mL/min), 5 developed moderate to severe renal insufficiency (GFR = 15-59 mL/min), and 1 evolved to end-stage renal disease (GFR < 15 mL/min). In the Cox model, low C4 levels and proteinuria greater than 0.5 g/d were associated with an earlier decline in GFR. CONCLUSIONS: Most Puerto Rican patients with SLE initially presenting with mild renal involvement had a decrease in GFR after an average of 5 years of kidney disease, although most had a mild dysfunction. Low C4 levels and proteinuria were predictors of an earlier decline in GFR. We emphasize that awareness of these factors may contribute to early identification of individuals at risk for renal deterioration.

Efficacy of two cyclophosphamide regimens for the treatment of lupus nephritis in Puerto Ricans: low vs. standard dose.

INTRODUCTION: The clinical outcome and therapeutic response to immunosuppressive agents vary among patients with lupus nephritis of different ethnic populations. Thus, we evaluated the efficacy of two established treatment protocols for lupus nephritis (low-dose versus standard-dose cyclophosphamide) in Puerto Ricans with systemic lupus erythematosus (SLE). METHODS: A retrospective cohort of 49 adult patients with SLE treated with intravenous low or standard-dose cyclophosphamide for clinical or biopsy confirmed lupus nephritis was studied. Demographic parameters, clinical manifestations, autoantibodies and pharmacological treatments were determined prior to cyclophosphamide treatment. Renal parameters, disease activity, damage accrual and corticosteroid use were determined before and after treatment. Cyclophosphamide-associated adverse events were also examined. Univariable and bivariable analyses were used to evaluate group differences. RESULTS: Thirty-nine SLE patients received the standard-dose treatment and ten patients the low-dose therapy. Prior to cyclophosphamide infusion, demographic parameters, clinical manifestations, autoantibodies profile, disease damage and pharmacologic treatments were similar in both groups. Disease activity was higher in the low-dose group. After cyclophosphamide therapy, significant improvement of renal parameters (increase in the glomerular filtration rate and decrease in hematuria, pyuria, urinary cellular casts, proteinuria and hypertension) were observed only for patients that received the standard-dose therapy. Disease activity and corticosteroids requirement decreased in both groups after treatment. No differences were observed for adverse events associated with cyclophosphamide. CONCLUSIONS: The standard-dose cyclophosphamide therapy appears to be more effective, and similar in terms of drug safety, than the low-dose regime for lupus nephritis in Puerto Ricans with SLE.

Impact of age on clinical manifestations and outcome in Puerto Ricans with rheumatoid arthritis.

INTRODUCTION: Disease expression and outcomes in rheumatoid arthritis (RA) vary among different ethnic groups. There are limited data on the impact of age on disease severity and outcomes among Hispanics. Thus, we determined the demographic characteristics, clinical manifestations, comorbidities, pharmacologic profile, and functional status among Puerto Ricans with RA of different age groups. METHODS: A cross-sectional study was conducted in 214 Puerto Rican patients with RA (per American College of Rheumatology classification criteria). Demographic features, health-related behaviors, cumulative RA manifestations, treatment profiles, disease activity (Disease Activity Score 28), comorbid conditions, and functional status (Health Assessment Questionnaire) were determined at study visit. Three age groups were studied: <40, 40-59, and > or =60 years. Data were examined using univariable and multivariable (logistic regression) analyses. RESULTS: The mean (SD) age of the study population was 56.5 (13.6) years with a mean disease duration (SD) of 10.8 (9.7) years; 180 patients (84.1%) were women. In the multivariable analyses, patients aged > or =60 years were more likely to have joint deformities, extra-articular manifestations, and comorbidities such as dyslipidemia, arterial hypertension, diabetes mellitus, vascular events, osteoarthritis, low back pain, and osteoporosis. In addition, older patients used corticosteroids more frequently. No differences were found for the use of disease-modifying anti-rheumatic drugs or biologic agents. CONCLUSIONS: Puerto Rican RA patients aged > or =60 years present a severe type of disease having more joint damage, extra-articular manifestations, and comorbidities than younger patients. These disparities must be considered when establishing effective therapy for older RA patients.

Prevalence of spondyloarthropathy in Puerto Rican patients with inflammatory bowel disease.

INTRODUCTION: Inflammatory arthritis is the most common extraintestinal manifestation in patients with inflammatory bowel disease (IBD). Approximately 20% of all IBD patients will present with peripheral arthritis, sacroiliitis, or spondylitis. The purpose of this study was to determine the prevalence of spondyloarthropathy and sacroiliitis in Puerto Rican patients with IBD. METHODS: Patients were obtained from the IBD specialty clinic and all had a diagnosis of ulcerative colitis or Crohn's disease. All the patients who agreed to participate were entered in the study. Patients completed a questionnaire and underwent a physical examination. Radiologic examination of the lumbosacral spine and sacroiliac joints was performed. Blood samples were obtained for determining human leukocyte antigen class I and were serologically analyzed in the pathology department laboratory. Data were analyzed by using SPSS 10.0 for Windows. RESULTS: One hundred patients were enrolled; 57% had ulcerative colitis, and 43% had Crohn's disease. Fifty percent were female, and the mean age was 37 years (standard deviation 14.96 years). Seventy-seven percent reported history of joint pain, and 47% reported limitation due to joint pain. Physical examination revealed peripheral synovitis in five patients and spinal tenderness in 46 patients. Of the 100 patients, 42 had inflammatory back pain and fulfilled the criteria for spondyloarthropathy. Radiographs were obtained in 76 patients. They revealed grade 2 or greater sacroiliitis in 10 patients (13%) and ankylosing spondylitis in two patients (2.6%). Of the 82 patients with blood samples, human leukocyte antigen B27 was found in five patients (6%). CONCLUSIONS: Of the study population of Puerto Ricans with IBD, 42% had spondyloarthropathy. This prevalence is higher than reported in Caucasians (20%-30%). Sacroiliitis had a similar prevalence as reported in Caucasians, but the prevalence of peripheral arthritis was much lower.

Systemic lupus erythematosus presenting as acute iceric hepatitis: a case report.

Liver involvement in systemic lupus erythematosus (SLE) is infrequent. The coexistence of SLE and autoimmune hepatitis is rare (1.3-1.7%). We report a case of a 27 year old female with no history of systemic illnesses or alcohol abuse that presented with acute hepatitis with jaundice, abdominal pain, and increased liver function tests. Viral markers were negative. ANA was strongly positive. Patient was suspected to have SLE but no definite diagnosis made. She remained asymptomatic for 9 years but then she had recurrence of hepatitis. She also presented with malar rash, arthritis, and proteinuria. At that time a liver biopsy showed autoimmune hepatitis. Other tests which confirmed SLE included a positive antidsDNA, positive antismith antibody and decreased complement levels. She was started on prednisone 40 mg with mild improvement of symptoms and transaminase values, but when azathioprine 100 mg was added a marked improvement in liver function tests was observed. After a year in azathioprine she remained with SLE in remission. To our knowledge this is the third reported case and the first in the Western Hemisphere of jaundice as the initial presentation of SLE.

Clinical manifestations and vascular events in patients with lupus erythematosus anticardiolipin antibodies and raynaud's phenomenon.

BACKGROUND: Raynaud's phenomenon (RP) and anticardiolipin antibodies (ACL) are two common clinical manifestations in patients with systemic lupus erythematosus (SLE). RP may lead to digital or limb loss. ACL are associated to thrombotic episodes. It is not yet clear if there is an association between RP and the presence of ACL in patients with SLE. OBJECTIVES: To study if the presence of both RP and ACL in patients with SLE may be associated with certain clinical manifestations or thrombotic events compared to SLE patients without RP or ACL. METHODS: SLE patients from two lupus clinics were recruited. The patients were divided into 4 groups. Patients with RP and positive ACL (RP+ ACL+), patients with RP but negative ACL (RP+ ACL-), patients with negative RP and positive ACL (RP- ACL+), and patients that were negative for RP and ACL (RP- ACL-) used as the control group. Demographic data, diagnostic criteria, clinical manifestations, history of arterial thrombosis, venous thrombosis and abortions were recorded. A physical examination was done. Anticardiolipin antibodies IgG and IgM were done in the rheumatology laboratory at the University of Puerto Rico School of Medicine. Descriptive statistics as well as analysis of variances (ANOVA), and polytomous logistic regression were used. RESULTS: 236 patients with SLE were studied. There was a tendency toward an increase in arterial thrombosis (p-value = 0.094) and venous thrombosis (p-value = 0.067) in the group that were positive for RP and ACL (RP+ ACL+). Although it was not statistical significant, when polytomous logistic regression was used, both arterial and venous thrombosis had an increase in relative risk 3.21 for arterial and 3.11 for venous thrombosis. Abortions were not increased in any of the four groups. Clinical manifestations from SLE did not differ among the four groups. CONCLUSIONS: Patients with both RP and ACL seem to be at an increase risk for both arterial and venous thrombotic events; these patients may benefit from an antiplatelet medication to prevent these events to occur.

Respiratory virus shedding in a cohort of on-duty healthcare workers undergoing prospective surveillance.

BACKGROUND: Healthcare-associated transmission of respiratory viruses is a concerning patient safety issue. DESIGN: Surveillance for influenza virus among a cohort of healthcare workers (HCWs) was conducted in a tertiary care children's hospital from November 2009 through April 2010 using biweekly nasal swab specimen collection. If a subject reported respiratory symptoms, an additional specimen was collected. Specimens from ill HCWs and a randomly selected sample from asymptomatic subjects were tested for additional respiratory viruses by multiplex polymerase chain reaction (PCR). RESULTS: A total of 1,404 nasal swab specimens were collected from 170 enrolled subjects. Influenza circulated at very low levels during the surveillance period, and 74.2% of subjects received influenza vaccination. Influenza virus was not detected in any specimen. Multiplex respiratory virus PCR analysis of all 119 specimens from symptomatic subjects and 200 specimens from asymptomatic subjects yielded a total of 42 positive specimens, including 7 (16.7%) in asymptomatic subjects. Viral shedding was associated with report of any symptom (odds ratio [OR], 13.06 [95% confidence interval, 5.45-31.28]; [Formula: see text]) and younger age (OR, 0.96 [95% confidence interval, 0.92-0.99]; [Formula: see text]) when controlled for sex and occupation of physician or nurse. After the surveillance period, 46% of subjects reported working while ill with an influenza-like illness during the previous influenza season. CONCLUSIONS: In this cohort, HCWs working while ill was common, as was viral shedding among those with symptoms. Asymptomatic viral shedding was infrequent but did occur. HCWs should refrain from patient care duties while ill, and staffing contingencies should accommodate them.

Mortality study in Puerto Ricans with systemic lupus erythematosus

OBJECTIVE: To determine the most common causes of death among Puerto Ricans with systemic lupus erythematosus. METHODS: Chart and record review of all deaths related to SLE complications from 1960 to 1994 at the University of Puerto Rico Hospital. RESULTS: Out of 662 patients diagnosed with SLE 161 (24) died. There were 151 (94) females and 10 (6) males. Mean duration of disease was 11.5 years. Mean age at death was 37 years. The primary causes of death were infection in 44 (27), uremia in 42 (26), cardiovascular complications in 33 (20), central nervous system complications in 18 (11), and pulmonary complications (other than infectious pneumonia) in 12 (7). CONCLUSIONS: The most common causes of death in SLE were infections and renal disease.