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Evaluating the properties of a frailty index and its association with mortality risk among patients with systemic lupus erythematosus


Legge A1, Kirkland S2, Rockwood K3, Andreou P2, Bae SC4, Gordon C5, Romero-Diaz J6, Sanchez-Guerrero J6, Wallace DJ7, Bernatsky S8, Clarke AE9, Merrill JT10, Ginzler EM11, Fortin P12, Gladman DD13, Urowitz MB13, Bruce IN14, Isenberg DA15, Rahman A15, Alarcón GS16, Petri M17, Khamashta MA18, Dooley MA19, Ramsey-Goldman R20, Manzi S21, Steinsson K22, Zoma AA23, Aranow C24, Mackay M24, Ruiz-Irastorza G25, Lim SS26, Inanc M27, van Vollenhoven RF28, Jonsen A29, Nived O29, Ramos-Casals M30, Kamen DL31, Kalunian KC32, Jacobsen S33, Peschken CA34, Askanase A35, Hanly JG36. Arthritis Rheumatol. 2019 Feb 16. doi: 10.1002/art.40859. 

Author Information

1 Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.

2 Department of Community Health& Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.

3 Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.

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

5 Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.

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

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

8 Divisions of Rheumatology and Clinical Epidemiology, Department of Medicine, McGill University, Montreal, Quebec, Canada.

9 Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

10 Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA.

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

12 Division of Rheumatology, CHU de Québec et Université Laval, Quebec City, Canada.

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

14 Arthritis Research UK Epidemiology Unit, Faculty of Biology Medicine and Health, Manchester Academic Health Sciences Center, The University of Manchester, and NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Center Manchester, UK.

15 Center for Rheumatology, Department of Medicine, University College London, UK.

16 Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.

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

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

19 Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA.

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

21 Lupus Center of Excellence, Allegheny Health Network, Pittsburgh, PA, USA.

22 Center for Rheumatology Research, Landspitali University hospital, Reykjavik, Iceland.

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

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

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

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

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

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

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

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

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

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

33 Copenhagen Lupus and Vasculitis Clinic, 4242, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.

34 University of Manitoba, Winnipeg, Manitoba, Canada.

35 Hospital for Joint Diseases, NYU, Seligman Center for Advanced Therapeutics, New York, NY.

36 Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canad



To evaluate the properties of a frailty index (FI), constructed using data from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort, as a novel health measure in SLE.


For this secondary analysis, the baseline visit was defined as the first study visit at which both organ damage (SLICC/ACR Damage Index [SDI]) and health-related quality of life (Short-Form 36 [SF-36]) were assessed. The SLICC-FI was constructed using baseline data. The SLICC-FI comprises 48 health deficits, including items related to organ damage, disease activity, comorbidities, and functional status. Content, construct, and criterion validity of the SLICC-FI were assessed. Multivariable Cox regression was used to estimate the association between baseline SLICC-FI values and mortality risk, adjusting for demographic and clinical factors.


The 1683 SLE patients in the baseline dataset were 89% female with mean (SD) age 35.7 (13.4) years and mean (SD) disease duration 18.8 (15.7) months. At baseline, the mean (SD) SLICC-FI score was 0.17 (0.08) with a range from 0 to 0.51. Baseline SLICC-FI values exhibited the expected measurement properties and were weakly correlated with baseline SDI scores (r=0.262; p<0.0001). Higher baseline SLICC-FI values (per 0.05 increment) were associated with increased mortality risk (Hazard Ratio 1.59; 95%CI 1.35-1.87), after adjusting for age, sex, steroid use, ethnicity/region, and baseline SDI scores.


The SLICC-FI demonstrates internal validity as a health measure in SLE and predicts future mortality risk. The SLICC-FI is potentially valuable for quantifying vulnerability among patients with SLE, and adds to existing prognostic scores.