Study: Pediatric SLE Outcomes Improving, but Racial and Ethnic Disparities Remain

Outcomes have improved over the past decade and a half for children with pediatric-onset systemic lupus erythematosus (SLE), but a new report suggests more work is needed to address racial and ethnic disparities in outcomes.

The data come from a new study that was published this month in the journal Arthritis & Rheumatology. It showed that rates of adverse renal outcomes declined between 2006 and 2019, but that Black children remained at the highest risk of end-stage renal disease (ESRD) and other severe complications.

Corresponding author Joyce Chang, MD, MSCE, of Harvard Medical School, and colleagues, explained that the treatment of SLE has been transformed in recent decades as mycophenolate mofetil (CellCept) and B-cell-depleting therapies have become prominent parts of routine care and as consensus guidelines for pediatric SLE care have crystallized.

Still, Chang and colleagues wrote that investigators have yet to quantify how these advances have affected patient outcomes on a macro level.

“It is unclear what impact these advances have made on renal outcomes of pediatric lupus,” they wrote. “Moreover, treatment advances have potential to either decrease or exacerbate existing racial inequities.”

The authors set out to identify trends among hospitalized children with SLE and discover how those changes affected documented racial and ethnic disparities in pediatric SLE outcomes.

To do so, Chang and colleagues consulted the Pediatric Health Information System, a database of deidentified patient and demographic data from 50 pediatric hospitals in the United States. They pulled data from the years 2006 through 2019. As of 2006, Black children made up approximately half of children in the US with ESRD due to lupus, they noted.

The database search yielded 20,893 hospital admissions, representing 7434 patients. Most of the patients were racial or ethnic minorities, led by Black patients (32%), White Hispanic patients (16%) and non-White Hispanics (12%).

Overall, the investigators noted positive trends. As a proportion of total hospital admissions, SLE admissions decreased from 0.29% of admissions in 2006 to 0.26% in 2019. Six percent of patients in the study had at least 1 diagnosis of ESRD, 8% had at least 1 procedure code for dialysis, and 2% underwent renal transplant.

The investigators said the proportion of SLE admissions per year that were associated with adverse renal outcomes decreased over time, and the proportion of admissions for a first occurrence of an adverse renal outcome for any particular patient dropped from 7% to 3.1% over the study period.

Still, Black children had the highest risk of adverse renal outcomes at any hospital admission (OR, 2.5; 95% CI, 1.8-3.5) vs. non-Hispanic White patients), and Black and Asian children had the highest risk of adverse renal outcome incidents, the authors said.

Chang and colleagues said it makes sense that outcomes improved overall, but they wrote that advances in patient care do not explain the persistence in racial disparities. Adjustments for household income and health insurance status also do not fully explain the racial and ethnic gap, they said.

“Our data suggests that while advances in pediatric lupus care may have reached groups that have been historically marginalized, they have not achieved greater benefit for Black children with lupus,” Chang and colleagues wrote.

They concluded that more attention should be paid to figure out how to narrow and eliminate the disparities, and to identify processes and interventions that can particularly improve outcomes in groups that have historically had inferior outcomes.

Reference

Chang JC, Sears C, Torres V, Son MB. Racial disparities in renal outcomes over time among hospitalized children with systemic lupus erythematosus. Published online April 5, 2022. Arthritis Rheumatol. doi:10.1002/art.42127