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Construction of a frailty index as a novel health measure in systemic lupus erythematosus


Legge A1, Kirkland S1, Rockwood K1, Andreou P1, Bae SC1, Gordon C1, Romero-Diaz J1, Sanchez-Guerrero J1, Wallace DJ1, Bernatsky S1, Clarke AE1, Merrill JT1, Ginzler EM1, Fortin P1, Gladman DD1, Urowitz MB1, Bruce IN1, Isenberg DA1, Rahman A1, Alarcón GS1, Petri M1, Khamashta MA1, Dooley MA1, Ramsey-Goldman R1, Manzi S1, Zoma AA1, Aranow C1, Mackay M1, Ruiz-Irastorza G1, Lim SS1, Inanc M1, van Vollenhoven RF1, Jonsen A1, Nived O1, Ramos-Casals M1, Kamen DL1, Kalunian KC1, Jacobsen S1, Peschken CA1, Askanase A1, Hanly JG1. J Rheumatol. 2019 Apr 15. pii: jrheum.181338. doi: 10.3899/jrheum.181338. [Epub ahead of print]

Author Information

Department of Medicine, Division of Rheumatology, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada; Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea;Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Instituto Nacional de Ciencias Medicas y Nutrición, Mexico City, Mexico; Cedars-Sinai/David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Divisions of Rheumatology and Clinical Epidemiology, Department of Medicine, McGill University, Montreal, Quebec, Canada; Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA; Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA; Division of Rheumatology, CHU de Québec et Université Laval, Quebec City, Canada; Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, ON, Canada; 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; Center for Rheumatology, Department of Medicine, University College London, UK; Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Lupus Research Unit, The Rayne Institute, St Thomas' Hospital, King's College London School of Medicine, UK, London, UK; Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA; Northwestern University and Feinberg School of Medicine, Chicago, IL, USA; Lupus Center of Excellence, Allegheny Health Network, Pittsburgh, PA, USA; Lanarkshire Center for Rheumatology, Hairmyres Hospital, East Kilbride, Scotland UK; Feinstein Institute for Medical Research, Manhasset, NY, USA; Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain; Emory University School of Medicine, Division of Rheumatology, Atlanta, Georgia, USA Division of Rheumatology, Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey; Unit for clinical therapy research (ClinTRID), Karolinska Institute, Stockholm, Sweden; Department of Clinical Sciences Lund, Rheumatology, Lund University, Lund, Sweden. Josep Font Autoimmune Diseases Laboratory, IDIBAPS, Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain; Medical University of South Carolina, Charleston, South Carolina, USA; UCSD School of Medicine, La Jolla, CA, USA; Copenhagen Lupus and Vasculitis Clinic, 4242, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; University of Manitoba, Winnipeg, Manitoba, Canada; Hospital for Joint Diseases, NYU, Seligman Center for Advanced Therapeutics, New York NY; Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada. Funding for this work was provided by the Nova Scotia Health Authority Research Fund. Dr. Sang-Cheol Bae's work was supported in part by NRF-2017M3A9B4050335, Republic of Korea. Dr. Caroline Gordon's work was supported by Lupus UK and the NIHR /Wellcome Trust Clinical Research Facility. The Montreal General Hospital Lupus Clinic is partially supported by the Singer Family Fund for LupusResearch. Dr. Clarke holds The Arthritis Society Chair in Rheumatic Diseases at the University of Calgary. Dr. Paul R. Fortin presently holds a tier 1 Canada Research Chair on Systemic Autoimmune Rheumatic Diseases at Université Laval, and part of this work was done while he was still holding a Distinguished Senior Investigator of The Arthritis Society. Dr. Bruce is a National Institute for Health Research (NIHR) Senior Investigator and is supported by Arthritis Research UK, the NIHR Manchester Biomedical Centre and the NIHR/Wellcome Trust Manchester Clinical Research Facility. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. Dr Isenberg and Dr Rahman are supported by and supported by the National Institute for Health, Research University College London Hospitals Biomedical Research Center. The Hopkins Lupus Cohort is supported by the NIH (grant AR43727 and 69572). Dr. Mary Anne Dooley's work was supported by the NIH (grant RR00046). Dr. Ramsey-Goldman's work was supported by the NIH (grants 5UL1TR001422-02, formerly 8UL1TR000150 and UL-1RR-025741, K24-AR-02318, and P60AR064464 formerly P60-AR- 48098). Dr. Ruiz-Irastorza is supported by the Department of Education, Universities and Research of the Basque Government. Dr. Soren Jacobsen is supported by the Danish Rheumatism Association (A3865) and the Novo Nordisk Foundation (A05990). Dr. John G. Hanly is supported by the Canadian Institutes of Health Research (grant MOP-88526). Address Correspondence to: Dr. John G Hanly, Division of Rheumatology, Nova Scotia Rehabilitation Centre (2nd Floor), 1341 Summer Street, Halifax, Nova Scotia, Canada, B3H 4K4.Email: john.hanly@nshealth.ca.



To construct a frailty index (FI) as a measure of vulnerability to adverse outcomes among patients with SLE, using data from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort.


The SLICC inception cohort consists of recently diagnosed SLE patients followed annually with clinical and laboratory assessments. For this analysis, the baseline visit was defined as the first study visit at which sufficient information was available for construction of a frailty index. Following a standard procedure, variables from the SLICC database were evaluated as potential health deficits. Selected health deficits were then used to generate a SLICC frailty index (SLICC-FI). The prevalence of frailty in the baseline dataset was evaluated using established cut points for FI values.


The 1683 SLE patients (92.1% of the overall cohort) eligible for inclusion in the baseline dataset were mostly female (89%) with mean (SD) age 35.7 (13.4) years and mean (SD) disease duration 18.8 (15.7) months at baseline. Of 222 variables, 48 met criteria for inclusion in the SLICC-FI. Mean (SD) SLICC-FI was 0.17 (0.08) with a range from 0 to 0.51. At baseline, 27.1% (95% CI 25.0%-29.2%) of patients were classified as frail, based on SLICC-FI values greater than 0.21.


The SLICC inception cohort permits feasible construction of an FI for use in patients with SLE. Even in a relatively young cohort of SLE patients, frailty was common. The SLICC-FI may be a useful tool for identifying SLE patients who are most vulnerable to adverse outcomes but validation of this index is required prior to its use.