Adverse outcomes after major surgery in patients with systemic lupus erythematosus: a nationwide population-based study

Abstract

SLE significantly increased the risks of surgical patients for overall major complications and mortality after major surgery. Our findings demonstrated the need for integrated care and revised protocols for perioperative management to improve outcomes for surgical patients with SLE.

Perioperative medical management for patients with RA, SPA, and SLE undergoing total hip and total knee replacement: a narrative review

“…The age standardized rate of TKA infection was 1.26% for recipients with RA, compared to 0.84% for recipients with OA, with an adjusted Hazard Ratio (HR) of 1.47, P = 0.03, confirmed in a recent meta-analysis demonstrating a relative risk of 1.7 for patients with RA [11,29]. For patients with SLE whose disease was severe enough to warrant hospitalization within 6 months of surgery, a large study based on Taiwan's National Health Insurance Research Database found the risk of septicaemia to be markedly increased after surgeries including orthopedic procedures (OR = 3.43, 95% CI 2.48 to 4.74) [14]. Immunosuppressant medications including biologics and DMARDs used to treat RA, SPA, and SLE are recognized to increase the risk of infection [30].…”

“…Increased in-hospital mortality for patients with SLE has been confirmed using discharge data from seven states, comprising 8 million discharges, with a higher risk of in-hospital mortality(OR (99% CI) of 1.27 (1.11, 1.47); P < .001), although no increase in in-hospital cardiac events were reported [67]. Similarly, 30 day post-operative mortality risk is increased in patients with SLE in a report using the Taiwan national insurance database (OR = 2.39, 95% CI 1.28 to 4.45) [14]. For patients with AS, the risk of in-patient cardiac events after THA was significantly higher than in controls [21].…”

“…However, a recent study that used billing data to specify the timing of infliximab infusions in relation to surgery found no clear increase in risk of infection when infliximab was infused within 4 weeks of surgery compared to longer periods of drug withholding [34]. Disease activity and severity may contribute to the risk of peri-operative infection for RA, SPA, and SLE, and might confound the reported association with medication use [14,37]. Use of glucocorticoids, however, has been consistently associated with an increased risk of infection in multiple settings-including surgery -at dosages above 15 mg./day, yet supraphysiologic doses of glucocorticoids ("stress dose steroids") are routinely administered on the day of surgery out of concern for hemodynamic instability [38,39].…”

“…Among lupus patients, VTE risk factors include smoking, obesity, hemolytic anemia and anti-phospholipid antibodies, while Asian race is protective [89,90]. Lupus patients who have received inpatient care for their lupus in the 6 months prior to surgery are five times more likely to experience postoperative PE [14] reinforcing the concept that it is disease activity that increases thrombotic risk. Lupus patients are also more likely than other individuals to have antiphospholipid antibodies, a well-established risk factor for VTE [89,91].…”

“…The increased utilization of potent disease modifying anti-rheumatic drugs (DMARDs) and biologics like the tumor necrosis factor inhibitors (TNFi) has had a clear impact on quality of life for patients with RA, SPA, and SLE, medication use has not been shown to decrease the incidence of large joint arthroplasty for RA, and most RA, PSA, and SLE patients are receiving these immunosuppressant medications at the time of surgery [6][7][8]. While improvements in pain and function outcomes measured pre and post-operatively are excellent after THA and TKA for patients with RA, SPA, and SLE, adverse events, in particular infection, are increased [9][10][11][12][13][14][15][16][17]. Ninety day readmission, most commonly for infection, is also increased for patients with RA [18].…”