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Factors associated with damage accrual in patients with systemic lupus erythematosus: results from the Systemic Lupus International Collaborating Clinics (SLICC) Inception Cohort
  1. Ian N Bruce1,2,
  2. Aidan G O'Keeffe3,
  3. Vern Farewell4,
  4. John G Hanly5,
  5. Susan Manzi6,
  6. Li Su4,
  7. Dafna D Gladman7,
  8. Sang-Cheol Bae8,
  9. Jorge Sanchez-Guerrero7,
  10. Juanita Romero-Diaz9,
  11. Caroline Gordon10,
  12. Daniel J Wallace11,
  13. Ann E Clarke12,
  14. Sasha Bernatsky13,
  15. Ellen M Ginzler14,
  16. David A Isenberg15,
  17. Anisur Rahman15,
  18. Joan T Merrill16,
  19. Graciela S Alarcón17,
  20. Barri J Fessler17,
  21. Paul R Fortin18,
  22. Michelle Petri19,
  23. Kristjan Steinsson20,
  24. Mary Anne Dooley21,
  25. Munther A Khamashta22,
  26. Rosalind Ramsey-Goldman23,
  27. Asad A Zoma24,
  28. Gunnar K Sturfelt25,
  29. Ola Nived25,
  30. Cynthia Aranow26,
  31. Meggan Mackay26,
  32. Manuel Ramos-Casals27,
  33. Ronald F van Vollenhoven28,
  34. Kenneth C Kalunian29,
  35. Guillermo Ruiz-Irastorza30,
  36. Sam Lim31,
  37. Diane L Kamen32,
  38. Christine A Peschken33,
  39. Murat Inanc34,
  40. Murray B Urowitz7
  1. 1Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
  2. 2The Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
  3. 3Department of Statistical Science, University College London, London, UK
  4. 4MRC Biostatistics Unit, Cambridge, UK
  5. 5Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
  6. 6Department of Medicine, West Penn Allegheny Health System, Pittsburgh, Pennsylvania, USA
  7. 7Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
  8. 8Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
  9. 9Instituto Nacional de Ciencias Medicas y Nutrición, Mexico City, Mexico
  10. 10Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
  11. 11Cedars-Sinai/David Geffen School of Medicine at UCLA, Los Angeles, California, USA
  12. 12Division of Rheumatology, University of Calgary, Alberta, Canada
  13. 13Divisions of Clinical Immunology/Allergy and Clinical Epidemiology, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
  14. 14Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA
  15. 15Centre for Rheumatology Research, University College London, London, UK
  16. 16Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
  17. 17Department of Medicine, Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
  18. 18Division of Rheumatology, Centre Hospitalier Universitaire de Québec et Université Laval, Quebec City, Quebec, Canada
  19. 19Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  20. 20Center for Rheumatology Research, Landspitali University Hospital, Reykjavik, Iceland
  21. 21Division of Rheumatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
  22. 22Lupus Research Unit, The Rayne Institute, St Thomas’ Hospital, King's College London School of Medicine, London, UK
  23. 23Northwestern University and Feinberg School of Medicine, Chicago, Illinois, USA
  24. 24Lanarkshire Centre for Rheumatology, Hairmyres Hospital, East Kilbride, UK
  25. 25Department of Rheumatology, University Hospital Lund, Lund, Sweden
  26. 26Feinstein Institute for Medical Research, Manhasset, New York, USA
  27. 27Josep Font Autoimmune Diseases Laboratory, IDIBAPS, Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
  28. 28Unit for Clinical Therapy Research Inflammatory Diseases (ClinTRID), Karolinska Institute, Stockholm, Sweden
  29. 29UCSD School of Medicine, La Jolla, California, USA
  30. 30Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
  31. 31Emory University, Atlanta, Georgia, USA
  32. 32Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
  33. 33University of Manitoba, Winnipeg, Manitoba, Canada
  34. 34Division of Rheumatology, Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
  1. Correspondence to Professor Ian N Bruce, Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester M13 9PT, UK; ian.bruce{at}


Background and aims 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.

  • Systemic Lupus Erythematosus
  • Outcomes research
  • Corticosteroids
  • Inflammation

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