SLE缺血性骨坏死的发生率及危险因素

摘要：目的：本研究的目的是评估系统性红斑狼疮（SLE）缺血性骨坏死（AVN）的发生率及危险因素。

方法：搜索MEDLINE, CINAHL, Web ofScience, EMBASE 和Cochrane Library数据库截止2015.7的数据，应用随机效应模型分析发生率，应用STROBE评估研究质量。

结果：共纳入62篇研究的2041例数据。多数结果间有较高的异质性。SLE患者中症状性缺血性骨坏死占9%（0.8%-33%），无症状性缺血性骨坏死占29%。股骨头为最常受累部位（8.0%）。高剂量糖皮质激素（CS），糖皮质激素大剂量、高累积剂量、冲击治疗以及有其他糖皮质激素不良反应（高血压，Cushing貌）与发生缺血性骨坏死相关，但糖尿病及高脂血症与缺血性骨坏死无相关性。狼疮活动（皮肤血管炎、肾损害、神经精神症状、浆膜炎和血细胞减少）、干燥综合征、雷诺现象、关节炎、应用环磷酰胺以及更多器官损害（不包括肌肉骨骼损害）与缺血性骨坏死相关。而应用硫唑嘌呤、吗替麦考纷酯或甲氨蝶呤与缺血性骨坏死无关。抗疟药无保护作用。皮疹及口腔溃疡与缺血性骨坏死无关。每日糖皮质激素剂量及糖皮质激素应用时间与缺血性骨坏死无关。抗ACL-IgM与缺血性骨坏死相关。而其他自身抗体及其他免疫指标无法预测缺血性骨坏死。非洲裔美国人更易出现缺血性骨坏死(OR 1.8, p=0.04)。

结论：缺血性骨坏死可见于1/3的SLE患者，9%具有症状。狼疮活动及多器官受累（中枢神经系统、肾损害、皮肤血管炎、浆膜炎和血细胞减少）与缺血性骨坏死相关，应用糖皮质激素尤其是疾病早期应用及高剂量应用与缺血性骨坏死相关。早期即出现糖皮质激素其他不良反应的患者具有较高的罹患缺血性骨坏死的风险。

附原文：

Abstract：OBJECTIVES:To determine the prevalence of and riskfactors for avascularnecrosis(AVN) in systemic lupus erythematosus(SLE).

METHODS:MEDLINE, CINAHL, Web of Science, EMBASEand Cochrane Librarywere searched from inception to July, 2015 and a random effects modelwas used to combine frequencies; study quality was assessed using STROBE.

RESULTS:2,041 citations identified 62 articles.Many results had high heterogeneity. The prevalence of symptomatic AVN was 9%(range 0.8%-33%) in SLE and 29% for asymptomatic AVN;femoralheadwas the most common location (8.0%). High-dose corticosteroids (CS)any CS use, maximum and cumulative dose, pulsetherapy, and CSside-effects (hypertension, Cushings, but not diabetes mellitus orhyperlipidaemia) were associated with AVN, as was active SLE (cutaneousvasculitis, renal and neuropsychiatric manifestations, serositis, cytopenias)and Sjögren's, Raynaud's phenomenon, arthritis, cyclophosphamide (but notazathioprine mycophenolate mofetil, or methotrexate) and more damage (excludingmusculoskeletal system). Antimalarial drugs were not protective. Rashes andoral ulcers were not associated with AVN. Mean daily dose of CS and duration ofCS use had no impact on AVN occurence. Autoantibodies and other immunologicalmarkers did not predispose to AVN, except IgM anticardiolipin antibodies whichdoubled the risk. African Americans experienced more AVN (OR 1.8, p=0.04).

CONCLUSIONS:AVNmay occur in 1/3 of patients with SLE and 9% with symptoms. Features of activeorgan SLE (CNS, renal, cutaneous vasculitis, serositis, cytopenias) areassociated with AVN as are CS, especially early in disease and at high doses.Those with early CS side-effects seem to have the highest risk of AVN.

引自：Nevskaya T,GambleMP,PopeJE.A meta-analysisof avascularnecrosisin systemic lupus erythematosus: prevalence andrisk factors.Clin Exp Rheumatol.2017 Jul-Aug;35(4):700-710.