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Economic evaluation of lupus nephritis in the Systemic Lupus International Collaborating Clinics inception cohort using a multistate model approach

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Barber MRW1, Hanly JG2, Su L3, Urowitz MB4, Pierre YS5, Romero-Diaz J6, Gordon C7, Bae SC8, Bernatsky S9, Wallace DJ10, Isenberg DA11, Rahman A11, Ginzler EM12, Petri M13, Bruce IN14,15, Fortin PR16, Gladman DD4, Sanchez-Guerrero J4, Ramsey-Goldman R17, Khamashta MA18, Aranow C19, Mackay M19, Alarcón GS20, Manzi S21, Nived O22, Jönsen A22, Zoma AA23, van Vollenhoven RF24, Ramos-Casals M25, Ruiz-Irastorza G26, Sam Lim S27, Kalunian KC28, Inanc M29, Kamen DL30, Peschken CA31, Jacobsen S32, Askanase A33, Theriault C34, Farewell V3, Clarke AE35. Arthritis Care Res (Hoboken). 2017 Nov 28. doi: 10.1002/acr.23480. [Epub ahead of print]


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1 Department of Medicine, University of Calgary, AB, Canada.

2 Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.

3 MRC Biostatistics Unit, University of Cambridge, Cambridge, UK.

4 Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, ON, Canada.

5 Division of Clinical Epidemiology, Research Institute, of the McGill University Health Center, Montreal, Canada.

6 Instituto Nacional de Ciencias Medicas y Nutrición, Mexico City, Mexico.

7 Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.

8 Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea.

9 Divisions of Rheumatology and Clinical Epidemiology, McGill University Health Centre.

10 Cedars-Sinai/David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

11 Centre for Rheumatology, Department of Medicine, University College London, UK.

12 Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA.

13 Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

14 Arthritis Research UK Epidemiology Unit, Institute of Inflammation and Repair, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK.

15 NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre.

16 Division of Rheumatology, CHU de Québec - Université Laval, Quebec City, Canada.

17 Northwestern University, and Feinberg School of Medicine, Chicago, IL, USA.

18 Lupus Research Unit, The Rayne Institute, St Thomas' Hospital, King's College London School of Medicine, London, UK.

19 Feinstein Institute for Medical Research, Manhasset, NY, USA.

20 Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.

21 Division of Rheumatology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

22 Department of Clinical Sciences, Rheumatology Lund University, Lund, Sweden.

23 Lanarkshire Centre for Rheumatology, Hairmyres Hospital, East Kilbride, Scotland, UK.

24 Unit for clinical therapy research (ClinTRID), Karolinska Institute, Stockholm, Sweden.

25 Josep Font Autoimmune Diseases Laboratory, IDIBAPS, Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain.

26 Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain.

27 Emory University School of Medicine, Division of Rheumatology, Atlanta, Georgia, USA.

28 UCSD School of Medicine, La Jolla, CA, USA.

29 Division of Rheumatology, Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.

30 Medical University of South Carolina, Charleston, South Carolina, USA.

31 University of Manitoba, Winnipeg, Manitoba, Canada.

32 Copenhagen Lupus and Vasculitis ClinicRigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.

33 Hospital for Joint Diseases, NYU, Seligman Centre for Advanced Therapeutics, New York, NY.

34 Department of Medicine, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.

35 Division of Rheumatology, University of Calgary, AB, Canada.


OBJECTIVE: Little is known about the long-term costs of lupus nephritis (LN). These were compared between patients with and without LN based on multistate modelling.

METHODS: Patients from 32 centres in 11 countries were enrolled in the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort within 15 months of diagnosis and provided annual data on renal function, hospitalizations, medications, dialysis, and selected procedures. LN was diagnosed by renal biopsy or the American College of Rheumatology classification criteria. Renal function was assessed annually using estimated glomerular filtration rate (eGFR) or proteinuria (ePrU). A multistate model was used to predict 10-year cumulative costs by multiplying annual costs associated with each renal state by the expected state duration.

RESULTS: 1,545 patients participated, 89.3% female, mean age at diagnosis 35.2 years (SD 13.4), 49.0% Caucasian, and mean follow up 6.3 years (SD 3.3). LN developed in 39.4% by the end of follow up. Ten-year cumulative costs were greater in those with LN and an eGFR < 30 ml/min ($310 579 2015 Canadian dollars versus $19 987 if no LN and eGFR > 60 ml/min) or with LN and ePrU > 3 g/d ($84 040 versus $20 499 if no LN and ePrU < 0.25 g/d).

CONCLUSION: Patients with eGFR < 30 ml/min incurred 10-year costs 15-fold higher than those with normal eGFR. By estimating the expected duration in each renal state and incorporating associated annual costs, disease severity at presentation can be used to anticipate future healthcare costs. This is critical knowledge for cost-effectiveness evaluations of novel therapies.