MCCause of death in sle?

[tarsuc]

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i was convinced this was lupus nephropathy,

but some friends have said its coronary artery disease,

and some claim its infections

And i couldnt find any convincing sources.

Most forums say its renal, but is that reliable?

anyone?

 

[21385]

i was convinced this was lupus nephropathy,

but some friends have said its coronary artery disease,

and some claim its infections

And i couldnt find any convincing sources.

Most forums say its renal, but is that reliable?

anyone?

I think you're mixing lupus with scleroderma.

For lupus, the most common cause of death is cardiac (I remember this by thinking of libman sachs endocarditis/myocarditis).

For scleroderma, the most common cause of death is pulmonary (think of interstitial fibrosis + pulmonary hypertension) BUT renal is the most deadly COMPLICATION of scleroderma.

 

[ijn]

It has nothing to do with endocarditis. Proinflammtory states are major risk factors for coronary artery disease just like diabetes or dyslipidemia. Rheumatoid arthritis has the same phenomenon.

 

[tarsuc]

thanks 21385 and ijn.

its posts like these that still confuse me.

http://www.usmleforum.com/files/forum/2010/5/489621.php

 

[21385]

It has nothing to do with endocarditis. Proinflammtory states are major risk factors for coronary artery disease just like diabetes or dyslipidemia. Rheumatoid arthritis has the same phenomenon.

haha, thx for correcting my post. You're right -- I just use libman sachs (since it only happens in lupus) as a way to remember that cardiac is the most common cause of death in lupus patients.

 

[Myxedema]

From Robbins Pathologic Basis of Disease, 8th Edition, Chapter 6 - "Diseases of the Immune System":

The course of the disease is variable and unpredictable. Rare acute cases result in death within weeks to months. More often, with appropriate therapy, the disease is characterized by flare-ups and remissions spanning a period of years or even decades. During acute flare-ups, increased formation of immune complexes and the accompanying complement activation often result in hypocomplementemia. Disease exacerbations are usually treated by corticosteroids or other immunosuppressive drugs. Even without therapy, in some patients the disease may run a benign course with skin manifestations and mild hematuria for years. The outcome has improved significantly, and an approximately 90% 5-year and 80% 10-year survival can be expected. The most common causes of death are renal failure and intercurrent infections. Coronary artery disease is also becoming an important cause of death. Patients treated with steroids and immunosuppressive drugs incur the usual risks associated with such therapy.

 

[preDoGuy24]

From Robbins Pathologic Basis of Disease, 8th Edition, Chapter 6 - "Diseases of the Immune System":

Robbins is the go to path bible, ill remember that.

Goljan has it down as infection dt immune suppression. Pathoma says immune suppression and renal failure are common causes of death but no most common.

For some reason I thought kidney too.

Sent from my HTC Sensation 4G using Tapatalk

 

[calvnandhobbs68]

SLE Y U NO CHOOSE MOST COMMON COD??

 

[hrain]

Robbins is the go to path bible, ill remember that.

Goljan has it down as infection dt immune suppression. Pathoma says immune suppression and renal failure are common causes of death but no most common.

For some reason I thought kidney too.

Sent from my HTC Sensation 4G using Tapatalk

FA says clearly that nephritis is the most common cause of death. However,
I remember reading somewhere that it depended on treated sle vs untreated...prolonged use of corticosteroids or other immunosuppressants tip the scale toward infection,
While prolonged use of NSAIDs push it more
Toward nephritis as the major CoD.

 

[tarsuc]

Gr8. thanks guys.

 

[Jamiu22]

From Robbins Pathologic Basis of Disease, 8th Edition, Chapter 6 - "Diseases of the Immune System":

It's definitely lupus nephritis - we had a two day seminar at my school on just lupus - imagine how boring that was...where was house when you needed him "It's not lupus!!!"

 

[ijn]

The majority don't die of renal failure. Heart disease is #1. Robbins is wrong and/or using outdated data. I don't trust the Bible and I certainly don't trust Robbins without question.

http://onlinelibrary.wiley.com/doi/10.1002/art.21955/full

Renal disease was responsible for only 34 out of 1255 deaths in the largest cohort study to date. As compared to 126 for heart attacks and 313 for all vascular disease.

 

[hrain]

The majority don't die of renal failure. Heart disease is #1. Robbins is wrong and/or using outdated data. I don't trust the Bible and I certainly don't trust Robbins without question.

http://onlinelibrary.wiley.com/doi/10.1002/art.21955/full

Renal disease was responsible for only 34 out of 1255 deaths in the largest cohort study to date. As compared to 126 for heart attacks and 313 for all vascular disease.

This is correct, but I believe the study indicates that while heart disease
And vascular disease killed more patients in the study, those were considered NOT 'directly'-lupus related deaths...whatever that means.

"Within the observation interval, 1,255 deaths occurred; lupus was the assigned cause of death in 291 cases (3.8 events per 1,000 person-years). The most common types of deaths NOT directly attributed to SLE were deaths due to circulatory disease (ICD-9 codes 390–459); this includes all types of heart disease, arterial disease, and cerebrovascular events (strokes). Other common types of deaths resulted from neoplasms (ICD-9 codes 140–239), nephritis (ICD-9 codes 580–589), and infections (ICD-9 codes 001–139; these codes do not include pneumonia [ICD-9 codes 480–486] or the term bacteremia [ICD-9 code 790.7], although they do include the term septicemia [ICD-9 code 038]). Circulatory disease was the identified cause of 313 deaths, for a rate of 4.1 events per 1,000 person-years; cancer was the cause ascribed to 114 deaths, for a rate of 1.5 events per 1,000 person-years; and infection (not including pneumonia) was identified as the cause of 45 deaths, for a rate of 0.6 events per 1,000 person-years....

It seems clear that certain types of deaths, primarily related to lupus activity (such as renal disease), have decreased over time. However, the trend for circulatory disease shows no such decline, a finding suggested as well by Bjornadal et al (19). This may reflect in part the complex nature of cardiovascular disease in SLE. Classic atherosclerosis risk factors, such as hypertension and hypercholesterolemia, do play a role, although recent work has suggested that additional risk is conferred by some disease-related characteristics, such as SLE duration and, perhaps, severity (26). However, other elements, such as medication exposures, may also alter atherosclerosis risk in SLE."

Basically, I think it's saying that what's interesting is that renal disease deaths due to lupus are declining, while cardiac/vascular deaths - regardless of underlying cause - are not.

 

[Myxedema]

Don't forget that renal and cardiovascular disease are closely linked to one another. Allow me to present another literature:

Renal damage is the most important predictor of mortality within the damage index: data from LUMINA LXIV, a multiethnic US cohort.
Rheumatology (Oxford). 2009 May;48(5):542-5.
...
RESULTS:
A total of 635 SLE patients were studied of whom 97 (15.3%) have died over a mean (s.d.) total disease duration of 5.7 (3.7) years. Patients were predominantly women [570 (89.8%)]; their mean (s.d.) age was 36.5 (12.6) years; 126 (19.8%) had developed renal damage, 62 (9.3%) cardiovascular, 48 (7.8%) pulmonary and 34 (5.4%) peripheral vascular damage. When excluding poverty from the multivariable model, the renal domain of the SDI was independently associated with a shorter time to death (hazard ratio = 1.65; 95% CI 1.03, 2.66)

 

[MrBeauregard]

From the UpToDate article Overview of the therapy and prognosis of systemic lupus erythematosus in adults:

Causes of death — The major cause of death in the first few years of illness is active disease (eg, CNS, renal, or cardiovascular disease) or infection due to immunosuppression, while late deaths are caused by the illness (eg, end-stage renal disease), by treatment complications (including infection and coronary disease), by non-Hodgkin lymphoma, and by lung cancer [141,143-147]. The frequency of the different causes of death can be illustrated by the following observations:

• The largest study included survival data and causes of death in a total of 9547 patients who were followed for an average of 8.1 years [147]. Standardized mortality rates (SMR) of SLE patients to expected rates for a age- and sex-adjusted population were noted for circulatory disease (SMR 1.7), especially heart disease (SMR 1.7); for non-Hodgkin lymphoma (SMR 2.8); for lung cancer (SMR 19.4); for infections (SMR 9.0), especially pneumonia (SMR 7.2); and for renal disease (SMR 4.3). Those at particularly high risk for mortality were younger, female, and black, with disease duration of less than one year.

• One study evaluated the causes of death in 408 patients with SLE followed over a mean period of 11 years; 144 (35 percent) died [148]. The major causes of death were active lupus (34 percent), infection (22 percent), cardiovascular disease (16 percent), and cancer (6 percent). Deaths that resulted directly from SLE and infection were common among younger patients; the risk of death directly due to SLE was highest in the first three years after diagnosis.

• Another prospective study followed 1000 patients for 10 years [135]. The most frequent causes of death were active SLE (26 percent), infection (25 percent), and thromboses (26 percent) [135].

• In a cohort of 4747 Swedish patients who were diagnosed with SLE between 1964 and 1995, the proportions of deaths due to cardiovascular events, SLE, and malignant disease were 42 percent, 21 percent, and 12 percent, respectively [149].

Serious infection is most often due to immunosuppressive therapy. (See "Secondary immune deficiency induced by drugs and biologics".) Patients at particular risk are those treated with both glucocorticoids and cyclophosphamide, especially if the white blood cell count is less than 3000/microL and/or if high-dose glucocorticoids are given [150,151]. Lymphopenia (<1000/microL) at presentation may be an independent risk factor [152]. (See "General toxicity of cyclophosphamide and chlorambucil in inflammatory diseases" and "Major side effects of systemic glucocorticoids".)

Premature coronary artery disease is being increasingly recognized as a cause of late mortality. (See "Coronary heart disease in systemic lupus erythematosus".)

 

[21385]

it's definitely CV. Even the most common leading cause of death in chronic renal disease is CV.

Those who died might have renal complications but that's not the reason why they died.

 

[ijn]

Yeah. I'd think of it this way - what actually kills you with renal failure that can't be managed with dialysis? The problem is that there's no dialysis equivalent for CHF that can keep you in a holding pattern with the organ in 100% failure. In my mind people with chronic inflammatory conditions like SLE and rheumatoid arthritis are essentially vasculopaths like a diabetic or a hypertensive.

 

[MLT2MT2DO]

FWIW

FA 2013 under diffuse proliferative glomerulonephritis:
"Most common cause of death in SLE."

 

[CassieBagley]

Do "most common cause" questions come up on the Step, or do they moreso ask you to pick which disease is more likely simply based on prevalence? I've had multiple cases where pathoma, goljan, and robbins differ on statistics for most common causes of stuff. Anyone had an NMBE that requires most common cause knowledge? Haven't taken one yet