Elsevier

Gender Medicine

Volume 8, Issue 6, December 2011, Pages 365-371
Gender Medicine

Original research
Sex Differences in Disease Severity Among Patients With Systemic Lupus Erythematosus

https://doi.org/10.1016/j.genm.2011.10.003Get rights and content

Abstract

Background

Systemic lupus erythematosus (SLE), a prototypical autoimmune disease, often results in comorbidities from exposure to medications as well as from chronic inflammation. Identification of gender-based differences in comorbidities and disease severity may assist health practitioners in providing optimum care for those living with SLE.

Objective

The purpose of this study, which utilized hospital discharge data collected during a 7-year period to garner a large SLE patient sample, was to determine the effect of gender on SLE comorbidities and disease severity.

Methods

Patients were hospitalized in the Dallas-Fort Worth metropolitan statistical area between 1999 and 2005 and had a diagnosis of SLE. The sample consisted of 14,829 patients with SLE, 10% of which were male. ANOVAs were conducted to test for differences between males and females for disease severity, age, length of stay in the hospital, total hospital charges, and number of autoimmune diseases. Disease severity was measured with the SLE comorbidity index, which weights 14 conditions in SLE. We identified the top 30 comorbidities as well as the odds of experiencing the secondary illnesses by gender.

Results

Male patients had significantly greater disease severity compared with female patients. Additionally, female patients had more autoimmune diagnoses compared with male patients. Male patients were more likely to have cardiovascular and renal comorbidities compared with female patients. Female patients had significantly greater odds of diagnoses of urinary tract infection, hypothyroidism, depression, esophageal reflux, asthma, and fibromyalgia.

Conclusions

Although the prevalence of SLE among males is rare, male patients have the potential for greater disease severity and are more likely to suffer from cardiovascular and renal disease. Gender differences in disease severity should be further evaluated, but with the added recommendation to develop an index with conditions more indicative of active SLE.

Introduction

Systemic lupus erythematosus (SLE) is the prototypical autoimmune disease, with prevalence in the United States ranging from 1 to 2 million.1, 2 This chronic disease can affect any organ system of the body, but initial manifestation is often vague symptomatology (eg, fatigue, low grade fever, joint pain) that may delay accurate diagnosis. However, treatment and detection of SLE have improved significantly over the last several decades, thus improving the lifespan of patients.3 As a consequence of improved treatment, a greater number of comorbidities has been identified as a result of exposure to medications, as well as chronic inflammation attributed to SLE itself. For instance, non-Hodgkin lymphoma is the most common cancer observed among patients with SLE, and more aggressive subtypes occur in patients with SLE owing to the use of immunosuppressive medications.4

High disease severity, measured by the extent and number of comorbidities, is predictive of poorer prognosis and early mortality.5 Identification of gender-based differences in comorbidities and disease severity may assist health practitioners in providing optimum care for those living with SLE. Historically, the ratio of female to male patients with SLE has been 9:1; as such, it is difficult to obtain data on male patients to achieve adequate statistical power for comparison. Consequently, conflicting results have been presented regarding gender differences among SLE patients.

According to studies conducted by several researchers,6, 7, 8, 9, 10 no difference in organ involvement has been reported between female and male patients with SLE. However, Pande et al11 have reported less severe disease among male patients with SLE, whereas others have suggested poorer prognosis for male patients.12, 13, 14, 15 Given the equivocal findings for gender-based differences on disease severity, the present study used hospital discharge data collected during a 7-year period to garner a large SLE patient sample. The purpose of this study was to determine the effect of gender on SLE comorbidities and disease severity.

Section snippets

Methods

Hospital discharge data were obtained from the Dallas-Fort Worth Hospital Council. Patients for this study were hospitalized in the Dallas-Fort Worth metropolitan statistical area between 1999 and 2005 and had a diagnosis of SLE (International Classification of Diseases, Ninth Revision, Clinical Modification 710.0). Deterministic linkage was used to certify each case as unique, yielding a sample of 14,829 patients with SLE.

Descriptive analyses were performed to determine mean age, total

Results

The majority of patients with SLE were female (90.5%), which supports previous findings in the literature. As shown in Table I, the average age for SLE patients was 47 (16.26) years, and ages ranged from 18 to 96 years. The average length of stay was 6.56 (8.35) days, and length of stay ranged from 1 to 190 days. From 1999 to 2005, total hospitalization costs averaged $27,454 ($48,694), with a minimum recorded charge of $0 and a maximum charge of $1,253,662. Patients had an average of 1.17

Gender Effect on Individual Comorbidities

Overall, male patients with SLE were more likely to have cardiovascular and renal comorbidities. Although cardiomyopathy (13th) and venous embolism and thrombosis (16th) were among the most common comorbidities for male patients (Table II), these diagnoses were not among the most common diagnoses for female patients with SLE. Furthermore, the male patients were 84% more likely to have a diagnosis of cardiac arrhythmia, 69% more likely to have a diagnosis of coronary atherosclerosis, and 67%

Conclusions

In the population studied, this study indicated a significant effect by gender on SLE disease severity and individual comorbidities indicative of a more serious prognosis. The study used a larger sample of male patients (n = 1412) compared with other SLE gender studies and yielded some interesting findings. Some of the comorbidities on the SLE-CI are not considered to be associated with SLE (eg, severe liver disease, AIDS), whereas other commonly associated conditions of SLE severity (eg,

Conflicts of Interest

The authors have indicated that they have no conflicts of interest regarding the content of this article.

Acknowledgments

Drs. Crosslin and Wiginton designed and monitored the study. Dr. Wiginton performed the statistical analyses. Dr. Crosslin authored the Introduction, Methods, and Discussion sections; Dr. Wiginton authored the Results section.

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