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Background: Lupus nephritis is one of the main causes of mortality along with cardiovascular diseases. Proteinuria is a clinical expression of lupus nephritis and has recently been established as a cardiovascular risk factor.
Objectives: To associate echocardiographic abnormalities in patients with systemic lupus erythematosus (SLE) and proteinuria.
Methods: Cross-sectional, observational, and comparative study of patients with SLE who met the classification criteria of ACR/EULAR 2019, aged 18 years or older. Patients with a diagnosis of overlapping syndromes, a history of major cardiovascular events (myocardial infarction, stroke, and heart failure), chronic kidney disease, and pregnant individuals were excluded. Patients were divided into three groups based on the mg/dl of proteinuria reported in a urinalysis: 10 mg/dl, 30 mg/dl, and 300 mg/dl. Transthoracic echocardiograms were performed on all study patients by a certified cardiologist who was blinded to clinical information. The evaluation included left ventricular mass index (LVMI), relative wall thickness (RWT), mitral deceleration time (MDT), E/E mitral, E/A mitral, tricuspid annular plane systolic excursion (TAPSE), left ventricular ejection fraction (LVEF). Left ventricular-Global Longitudinal Strain (GLS) was evaluated, and a value higher than -18% was classified as subclinical left ventricular systolic dysfunction. Statistical analysis was performed with JASP v.18.0. Group distribution was assessed using the Shapiro-Wilk test. Group comparisons were made using the chi-square test and the Kruskal-Wallis test. A p-value of ≤0.05 was considered statistically significant.
Results: Twenty patients with SLE and the presence of proteinuria in the urinalysis were included, most of whom were women (75.0%), with an average age of 32.3 ± 11.8 years. There was no difference between groups in the prevalence of traditional cardiovascular risk factors. The SLE Disease Activity Index (SLEDAI) was higher in patients with 300 mg/dl of proteinuria compared to those with 10 mg/dl or 30 mg/dl (6.0 vs 6.5 vs 16.0, p=0.026 ).
A significant difference was found in the LVEF between the groups, with a lower value reported in the 30 mg/dl group compared to 10 mg/dl and 300 mg/dl (61.0 52.0 vs 66.0, p=<0.001 ). Similarly, there was a significant difference in GLS value between the groups, where the mean value in the 30 mg/dl group fell into the category of subclinical left ventricular dysfunction (-20.6 vs -15.0 vs -19.1, p=0.039 ).
In a Post-Hoc subanalysis, a significant difference was reported in the GLS values between the group’s means of 10 mg/dl group and the mean of 30 mg/dl group (-5.61, Bonferroni p=0.036 ) and between the SLEDAI of 10 mg/dl group vs 300 mg/dl (-10.0, Bonferroni p=0.034 ) There was no significant difference in the rest of the echocardiographic parameters evaluated (Table 1).
Conclusion: Proteinuria stands out as a crucial indicator of cardiovascular dysfunction, paving the way for the commencement of cardiovascular screening in this demographic. The incorporation of echocardiography can significantly enhance the cardiovascular evaluation of individuals with SLE.
Demographic characteristics.
| Characteristics | 10 mg/dl
| 30 mg/dl
| 300 mg/dl
| P value |
|---|---|---|---|---|
| Age, years, mean ± SD | 32.6 ± 9.1 | 40.7 ± 18.5 | 27.0 ± 9.0 | NS |
| Women, n (%) | 7 (77.7) | 2 (50.0) | 6 (85.7) | NS |
| Diabetes, n (%) | 0 (0) | 0 (0) | 0 (0) | NS |
| Hypertension, n (%) | 2 (22.2) | 2 (50.0) | 2 (28.5) | NS |
| Dyslipidemia, n (%) | 2 (22.2) | 0 (0) | 1 (14.2) | NS |
| Active smoking, n (%) | 2 (22.2) | 0 (0) | 0 (0) | NS |
| Obesity, n (%) | 1 (11.1) | 1 (25.0) | 0 (0) | NS |
| Disease duration months, mean ± SD | 84.4 ± 48.4 | 75.0 ± 74.2 | 35.8 ± 38.5 | NS |
| SLEDAI, mean ± SD | 6.0 ± 4.7 | 6.5 ± 1.9 | 16.0 ± 10.2 | 0.026 |
| LVMI, mean ± SD | 59.2 ± 14.9 | 78.8 ± 5.8 | 70.5 ± 13.1 | NS |
| RWT, mean ± SD | 0.32 ± 0.06 | 0.36 ± 0.07 | 0.36 ± 0.10 | NS |
| MDT, mean ± SD | 194.5 ± 31.3 | 164.4 ± 35.0 | 150.7 ± 45.1 | NS |
| E/E, mean ± SD | 6.8 ± 2.2 | 9.8 ± 2.6 | 8.4 ± 3.0 | NS |
| E/A, mean ± SD | 1.4 ± 0.3 | 1.6 ± 0.9 | 1.3 ± 0.1 | NS |
| TAPSE, mean ± SD | 21.4 ± 2.7 | 23.7 ± 2.9 | 20.4 ± 1.9 | NS |
| LVEF, median (IQR) | 61.0 (59.0-63.0) | 52.0 (50.2-53.5) | 66.0 (65.0-66.0) | <0.001 |
| GLS, mean ± SD | -20.6 ± 3.6 | -15.0 ± 3.5 | -19.1 ± 2.7 | 0.039 |
REFERENCES: NIL.
Acknowledgements: NIL.
Disclosure of Interests: None declared.