Black children with lupus have higher disease activity, less likely to achieve low activity
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Key takeaways:
- Black children and those of more than one racial background were less likely to achieve LLDAS and had higher disease activity vs. white children.
- Living in high deprivation geographies did not impact LLDAS.
Black and multiracial children with systemic lupus erythematosus demonstrate higher disease activity and are less likely to achieve low disease activity compared with white children, according to data published in Arthritis Care & Research.
“Multiple studies have documented the presence of racial and ethnic disparities in patients with adult-onset SLE, including higher risk of incident SLE, younger age at disease onset and higher mortality,” William D. Soulsby, MD, of the University of California, San Francisco, and colleagues wrote. “However, the literature addressing this issue in [childhood-onset SLE (cSLE)] is sparse.
“The low lupus disease activity state (LLDAS) is a clinically relevant disease activity target associated with higher health-related quality of life and less disease damage and may be an important target for cSLE clinical care,” they added. “Whether racial disparities impact the achievement of LLDAS among pediatric patients with cSLE is not known.”
To investigate how race, ethnicity and social determinants of health combine to impact outcomes in childhood-onset SLE, Soulsby and colleagues conducted a cohort study of data from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. The researchers employed a “socioecological model” that examined insurance status for individual-level findings and, for neighborhood-level findings, used the Area Deprivation Index, which measures neighborhood-level social deprivation through a variety of census measures, including income, transportation and housing.
The study included 540 children (median age at diagnosis, 14 years), of whom 27% were Black, 25% were white, 23% were Latino/a, 11% were Asian and 9% identified as more than one race. The primary outcome was achievement of a modified version of low lupus disease activity state (LLDAS) that, due to lack of variation in the cohort, did not require standard doses of immunosuppressive medications, Soulsby and colleagues wrote.
According to the researchers, 41% of Black children vs. 16% of white children lived in neighborhoods within the highest quartile on the Area Deprivation Index, indicating the most deprivation. Black children (adjusted OR = 0.56; 95% CI, 0.38-0.82), as well as those reporting more than one race (adjusted OR = 0.51; 95% CI, 0.31-0.86), were significantly less likely to achieve LLDAS, compared with white children. In addition, Black children demonstrated higher disease activity (adjusted beta = 0.94; 95% CI, 0.11-1.78) vs. white children.
After adjusting for renal disease and insurance, living in neighborhoods within the highest quartile of the Area Deprivation Index showed no association with lower LLDAS achievement, according to the researchers.
In a causal mediation analysis, the presence of renal disease mediated 20% of the link between the highest deprivation quartile and cumulative prednisone exposure.
According to the researchers, these findings reveal a possible link between living in socioeconomically disadvantaged neighborhoods and lupus nephritis, potentially leading to higher prednisone use.
“In this cohort study of cSLE, we identified Black race as independently associated with lower rates of [modified LLDAS] achievement and higher disease activity,” Soulsby and colleagues wrote. “Additionally, we identified a significant mediating relationship between neighborhood-level deprivation and the presence of renal disease, which may in turn be related to higher cumulative prednisone exposure.
“The relationships underlying such associations are likely complex and require further study of the interplay among social variables; epigenetic phenomena may serve as an important mediator of such interactions between environment and disease outcomes, warranting further study,” they added. “Importantly, such associations occurring in the context of pediatric rheumatology care call for intervention. By leveraging systematic efforts with individual level interventions or practice changes, such as complex care coordination programs, the pediatric rheumatology can work toward achieving health equity for all patients with cSLE.”
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