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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2019  |  Volume : 30  |  Issue : 3  |  Page : 743-746
Experience of systemic lupus erythematosus in South-Western Bangladesh


1 Department of Nephrology, Shahid Sheikh Abu Naser Specialized Hospital, Khulna, Bangladesh
2 Department of Neurology, Shahid Sheikh Abu Naser Specialized Hospital, Khulna, Bangladesh
3 Department of Plastic Surgery and Burn Unit, Shahid Sheikh Abu Naser Specialized Hospital, Khulna, Bangladesh

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Date of Submission22-Jul-2018
Date of Acceptance29-Aug-2018
Date of Web Publication26-Jun-2019
 

How to cite this article:
Ul Azim MA, Salam A, Abdullah SN. Experience of systemic lupus erythematosus in South-Western Bangladesh. Saudi J Kidney Dis Transpl 2019;30:743-6

How to cite this URL:
Ul Azim MA, Salam A, Abdullah SN. Experience of systemic lupus erythematosus in South-Western Bangladesh. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Sep 19];30:743-6. Available from: http://www.sjkdt.org/text.asp?2019/30/3/743/261365


To the Editor,

Systemic lupus erythematosus (SLE) is an autoimmune disease with variable manifestations. It is a heterogeneous disease of disordered immunity, with multi-system inflammatory involvement. Renal involvement is a frequent feature occurring in 40%–75% of patients, most often within five years of the disease onset.[1],[2],[3],[4],[5] The course of lupus nephritis (LN) is highly variable and multiple clinical, serological, histopathological, and time-dependent factors are responsible for its ultimate prognosis.[6],[7]

The clinical features of SLE have been extensively described from different geographical parts in the world, with some variations among different racial groups. The data on SLE among Bangladeshi patients are rare in the literature. Therefore, we carried out a cross-sectional study in the Department of Nephrology, Shahid Sheikh Abu Naser Specialized Hospital, Khulna during the period of four years to observe the clinical profile and outcome of patients suffering from SLE in this south-western region of Bangladesh.

A total of 28 patients diagnosed with SLE based on the criteria of the American College of Rheumatology were included in the study after obtaining ethical clearance from the Institutional Ethical Committee. Preliminary investigations were performed as per the standard care at our institute.

Mean follow-up period after diagnosis was 14.3 ± 2.67 months. The age range was from 11 to 50 years with a mean age of 25.4 ± 9.05 years. The maximum number of cases was found to be in the range of 21–30 years. Twenty-four out of 28 patients (86%) of the patients were female and four patients (14%) were male with a male-to-female ratio of 1:6. Four patients were children (<15 years).

In this study, 23 out of 28 patients (82%) had renal involvement. Of 23 patients, eight patients had impaired renal function (serum creatinine >1.5 mg/dL) at the time of diagnosis. Of these, after obtaining an informed consent 14 patients underwent renal biopsies performed under local anesthesia with Bard automated biopsy gun. Both histopathological and IF studies were carried out and the results were classified into the Classes I to VI according to the International Society of Nephrology Renal Pathology Society 2003 LN classification system. Majority of the patients, that is, 10 (71.4%) belonged to Class IV. The class-wise distribution of various histopatho-logical parameters is given in [Table 1].
Table 1: International Society of Nephrology-Renal Pathology Society Classification, 2003-class distribution of patients with lupus nephritis.

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Four patients had hypothyroidism along with SLE. One patient had autoimmune hemolytic anemia. Three patients developed herpes zoster infection during follow-up. During follow-up, three (10.8%) patients died; four (14.2%) patients lost follow-up and the rest 21 (75%) patients remained well with or without medications.

The present study which included both adult patients and children was carried out to observe the clinical profile and outcome of patients suffering from SLE in this south-western region of Bangladesh. Mean age of the patients was 25.4 ± 9.05 years. Baqui et al showed the mean age of LN 26 ± 11.97 years.[8] Another study from Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh, in 2006 showed mean age of the LN patients of 25.5 ± 8.8 years.[9] Similar studies were carried out in Singapore and China showing the mean age of the patients as 35.4 years and 33 ± 14 years, respectively.[10],[11] A study in Iran showed a mean age of 25.6 ± 10.3 years.[12] The mean age of the patients of the study is concordant with the mean age of the patients of Iran but differs with the mean age of the patients of LN in China and Singapore. This supports the fact that our patients with LN were a decade younger than their Chinese counterparts indicating an earlier age of disease onset, more severe form of disease, or earlier mortality.[13]

In the present study, 24 of 28 patients (85.7%) were females with a male-to-female ratio of 1:6. which is similar to a previous study from BSMMU and Singapore with a male:female ratio of 1:5 and 1:4, respectively.[10],[14] However, the present study differs with the study carried out in Bangladesh showed a male: female ratio of 1:10.[8] However, this study showed a significant female predominance which is also seen in most of the studies.[15],[16],[17] A female phenotype is the major risk factor for the development of lupus. The female: male ratio increases from 2:1 in prepubertal children up to 4.5:1 in adolescence to the 8–12:1 reported in series of adult-onset patients, falling back to 2:1 in patients over 60 years of age.[7] These data are in accord with the theory that estrogens are probable precipitating factors in the emergence of lupus, whereas androgens are protective.[18]

In the present study, 82% of patients had renal involvement (LN). LN is one of the most common manifestations of SLE, occurring in about 50%–70% of the patients, and is the major cause of morbidity and mortality in the SLE population.[15] This is similar to other studies.[2],[8] The vast majority of patients (74%) in this study presented with Class IV LN, as has been seen in other studies carried out in Bangladesh and India, 64.7% and 55.4%, respectively.[7],[8] It is, thus, recommended that patients with SLE have a kidney biopsy as soon as the clinical features of kidney involvement become evident, to hasten the treatment decisions and to minimize the risk of inflammation induced chronic kidney damage.

Majority of the patients (75%) of the present study remained well with regular follow-up. Miah et al also showed similar results.[19] About 14.2% of these patients had hypothyroidism. This finding is in concordance with the findings of previous studies which showed that the prevalence of hypothyroidism was 17%.[20],[21],[22] However, one older study from Middlesex hospital, UK showed lower prevalence of hypothyroid (5.7%) in SLE patients.[23]

Autoimmune hemolytic anemia one of the hematological manifestations of SLE was seen in only one (3.5%) patient. Gormezano et al showed the similar result with the frequency of autoimmune hemolytic anemia in SLE as 49/1830 (3%).[24]

Herpes zoster is reported as the most prevalent viral infection in patients with SLE. A study from Taiwan showed that there was an increased risk of herpes zoster in SLE patients compared with non-SLE patients, particularly among males.[25] In the present study, a total of three instances of herpes zoster infection from 28 SLE patients during the follow-up period were identified. Among them, two were male patient.

SLE is not a very rare disease in this region. Prompt diagnosis and treatment of patients with SLE are important. Renal biopsy provides information on the class of LN and guide to manage the patient. Regular follow-up and adherence to treatment are very good way to remain well in long term.

Conflict of interest: None declared.



 
   References Top

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Al Attia HM. Lupus nephritis among Arabs - Differences with other races; emphasis on clinicopathological and serological perspectives. Saudi J Kidney Dis Transpl 2000;11: 370-80.  Back to cited text no. 1
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2.
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Citera G, Wilson WA. Ethnic and geographic perspectives in SLE. Lupus 1993;2:351-3.  Back to cited text no. 4
    
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Satish S, Deka P, Shetty MS. A clinico-pathological study of lupus nephritis based on the International Society of Nephrology-Renal Pathology Society 2003 classification system. J Lab Physicians 2017;9:149-55.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Baqui MN, Akhter S, Kabir E, Islam MS. A clinicopathological study on lupus nephritis; experience of 34 cases from Bangladesh. J Nephropharmacol 2016;5:19-23.  Back to cited text no. 8
    
9.
Akhter S. A Study on Histopathological Patterns of Lupus Nephritis [Thesis]. Dhaka: Bangladesh Sheikh Mujib Medical University, Pathology; 2006.  Back to cited text no. 9
    
10.
Gan HC, Hyoon K, Fong KY. Clinical outcomes of patients with biopsy-proven lupus nephritis in NUH. Singapore Med J 2002; 43:614-6.  Back to cited text no. 10
    
11.
Zheng H, Chen Y, Ao W, et al. Antiphospho-lipid antibody profiles in lupus nephritis with glomerular microthrombosis: A prospective study of 124 cases. Arthritis Res Ther 2009; 11:R93.  Back to cited text no. 11
    
12.
Donadio JV Jr., Hart GM, Bergstralh EJ, Holley KE. Prognostic determinants in lupus nephritis: A long-term clinicopathologic study. Lupus 1995;4:109-15.  Back to cited text no. 12
    
13.
Ong C, Nicholls K, Becker G. Ethnicity and lupus nephritis: An Australian single centre study. Intern Med J 2011;41:270-8.  Back to cited text no. 13
    
14.
Faroque MO, Hadiuzzaman KM, Islam SF, et al. Presentation and treatment outcomes of 100 lupus nephritis patients: Single center study. Mymensingh Med J 2016;25:308-15.  Back to cited text no. 14
    
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Singh S, Zhou XJ, Ahn C, Saxena R. A retrospective analysis of clinical presentation of lupus nephritis. Am J Med Sci 2011; 342:467-73.  Back to cited text no. 15
    
16.
Nezhad ST, Sepaskhah R. Correlation of clinical and pathological findings in patients with lupus nephritis: A five-year experience in Iran. Saudi J Kidney Dis Transpl 2008;19:32-40.  Back to cited text no. 16
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17.
Yong JL, Killingsworth MC, Lai K. Renal biopsy pathology in a cohort of patients from Southwest Sydney with clinically diagnosed systemic lupus erythematosus. Int J Nephrol Renovasc Dis 2013;6:15-26.  Back to cited text no. 17
    
18.
Cameron JS. Lupus nephritis. J Am Soc Nephrol 1999;10:413-24.  Back to cited text no. 18
    
19.
Miah T, Haque MA, Mahmood T, Tarafder BK. Clinical profile, management and outcome of lupus. Mymensingh Med J 2008;17:S6-11.  Back to cited text no. 19
    
20.
Appenzeller S, Pallone AT, Natalin RA, Costallat LT. Prevalence of thyroid dysfunction in systemic lupus erythematosus. J Clin Rheumatol 2009;15:117-9.  Back to cited text no. 20
    
21.
Blanco MC, Almagro RM, García-Figueras Mateos C, Rodríguez Gutiérrez FJ. Relationship between hypothyroidism and autoimmunity in systemic lupus erythematosus patients: An initial approach. Endocr Abstr 2014;35:P1003.  Back to cited text no. 21
    
22.
Chan AT, Al-Saffar Z, Bucknall RC. Thyroid disease in systemic lupus erythematosus and reumaroidathritis. Rheumatology 2001;40:353-4.  Back to cited text no. 22
    
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Pyne D, Isenberg DA. Autoimmune thyroid disease in systemic lupus erythematosus. Ann Rheum Dis 2002;61:70-2.  Back to cited text no. 23
    
24.
Gormezano NW, Kern D, Pereira OL, et al. Autoimmune hemolytic anemia in systemic lupus erythematosus at diagnosis: Differences between pediatric and adult patients. Lupus 2017;26:426-30.  Back to cited text no. 24
    
25.
Chen HH, Chen YM, Chen TJ, Lan JL, Lin CH, Chen DY. Risk of herpes zoster in patients with systemic lupus erythematosus: A three-year follow-up study using a nationwide population-based cohort. Clinics (Sao Paulo) 2011;66:1177-82  Back to cited text no. 25
    

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Correspondence Address:
Muhammed Arshad Ul Azim
Department of Nephrology, Shahid Sheikh Abu Naser Specialized Hospital, Khulna
Bangladesh
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DOI: 10.4103/1319-2442.261365

PMID: 31249246

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