Protective and risk factors related to recurrence and prognosis in lupus enteritis

Abstract

Background Lupus enteritis is one of the most serious gastrointestinal complications in SLE patients presenting with acute abdominal pain, which mainly caused by intestinal vasculitis. Severe bowel ischemia may lead to hemorrhage, intestinal infarction and fatal intestinal perforation resulting in significantly increased mortality and poor outcome. High-dose pulse intravenous corticosteroid has been proven to be an effective treatment for serious lupus enteritis. However, relapse is not rare even in those who show good responses to adequate steroid therapy and have gotten remission. Meanwhile, some patients present as corticosteroid-resistant or refractory lupus enteritis. In such cases, the reasons or predictive factors for severe adverse events, disease recurrence and the appropriate treatments addition to corticosteroid have not been well established.

Objectives To explore the potential predictive factors and the appropriate treatment that is associated with disease relapse and prognosis in lupus enteritis.

Methods A retrospective cohort study of inpatients admitted in the affiliated university hospital between 2002 and 2011 was performed. Demographic information, clinical symptoms, laboratory findings, imaging characteristics (abdominal CT scan, ultrasonography), medications (including corticosteroid, cyclophosphamide and other immunosuppressive agents) and outcome were documented. The endpoint of the study was defined as the occurrence of severe complications which need surgical intervention, disease recurrence or death.

Results (1) 97 out of 3823 SLE patients were diagnosed as lupus enteritis with the overall prevalence of 2.5%. (2) Among these 97 lupus enteritis patients, 13 died because of serious complications (13/97, 13.4%) and 2 presented with intestinal perforation during the remission-induction stage. The logistic regression multivariate analysis indicated that leukopenia, hypoalbuminemia and elevated serum amylase were risk factors for the occurrence of serious complications(WBC, OR= 0.640,95%CI 0.456~0.896, P =0.009; serum albumin OR= 0.891,95%CI 0.798~0.994, P =0.039; serum amylase OR= 7.719,95%CI 1.795~33.185, P =0.006), while intravenous cyclophosphamide (CYC) therapy acted as a protective factor (OR =0.220,95%CI 0.053~0.903, P =0.036). (3) 79 patients who got remission were followed-up for 2 to 96 months and 18 cases experienced relapse (18/79, 22.8%). The analysis adjusted by Cox proportional hazards models indicated that, high dose CYC therapy (≥1.0g/m2 per month) was a protective factor for relapse (HR=0.209, 95% CI 0.049~0.887, P =0.034), while severe thickness of the bowel (>8mm) was a risk factor(HR= 7.308, 95%CI 1.740~ 30.696, P =0.007).

Conclusions Lupus enteritis is one of the serious complications of SLE with high mortality. The current study demonstrated that leukopenia, hypoalbuminemia and elevated serum amylase were associated with severe adverse events, while CYC therapy led to better outcomes during remission-induction stage. Severe thickness of the bowel was a risk factor while high dose CYC therapy a protective factor for disease relapse in intensification therapy stage.