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The biggest risks for organ damage for patients with systemic lupus erythematosus (SLE) come in the first year after diagnosis, analysis of a long-running registry indicated.

Among 1,274 members of a large Spanish SLE cohort, 20% were found during year 1 to have organ damage probably connected to the disease. As follow-up continued through as long as 20 years, progressively fewer patients developed new damage, according to Iñigo Rua-Figueroa, MD, of Hospital Universitario de Gran Canaria Dr Negrin in Las Palmas de Gran Canaria, Spain, and colleagues.

And although the damage was distributed among many organ systems, some were more affected than others, the researchers . As one might expect, musculoskeletal involvement was the most common, but -- perhaps surprisingly -- cardiovascular issues were the second most frequent, both initially and throughout the study's lengthy follow-up.

"[O]ur study highlights the importance of cardiovascular damage and the need for its prevention during the earliest stages of the disease," Rua-Figueroa's group emphasized.

In introducing the study, the researchers noted that the time course of lupus organ involvement hasn't been fully explored. "Although some reports describe damage occurring during the early stages of the disease, they involved small samples or short follow-up periods," they explained. "In addition, few data are available on the timing of damage manifestations across the different SDI [Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index] domains during the course of the disease."

To fill this gap, Rua-Figueroa and colleagues analyzed data in the Spanish Society of Rheumatology Lupus Registry. They focused on 1,274 (out of 4,219 consecutively enrolled) with organ damage whose records included dates for the first detection. More than 1,100 were followed for at least 10 years, and 601 had 20 years of follow-up.

During the second year after diagnosis, 11% had new organ damage recorded; in years 3 and 5, the proportions with new damage were 9% for both. From year 10 onward, for each year examined, just 5% had new damage.

Cardiovascular involvement as defined in the SDI excludes brain bleeds and claudication, even though both result from vascular abnormalities. Consequently, Rua-Figueroa and colleagues expanded their definition of cardiovascular damage to include both (with the proviso that claudication lasted at least 6 months).

In the first year, 20% of patients in the group developed arthritis or other musculoskeletal issues and 18% had newly diagnosed cardiovascular problems. Renal involvement was next at 15% of patients; 12% had new mucocutaneous damage.

Musculoskeletal involvement remained the most common domain to show new involvement, affecting from 22% to 30% of patients for each year examined out to year 20. (In fact, "80% of the [cohort] patients had arthritis at some point during the course of the disease," the investigators observed.) Cardiovascular damage was consistently second, at 11% to 25% of patients each year.

Although cardiovascular involvement in lupus has long been recognized, that it was this common may surprise those who haven't been following the latest research, the researchers said.

"Although this finding contrasts with the results of some seminal works, it is in line with other recent studies," they wrote, remarking that some had found evidence of cardiovascular damage occurring prior to SLE diagnosis. "Although, by definition, damage in SLE should occur after diagnosis, this concept is currently under review, as the persistent inflammation that can lead to early atherosclerosis could be present before the diagnosis of SLE or even before the patient meets the classification criteria for SLE."

Looking at the general pattern of organ involvement, and particularly the high rate of new damage seen early after lupus diagnosis, Rua-Figueroa and colleagues argued that two factors -- "higher lupus activity and need for more aggressive therapy including higher glucocorticoid doses" -- were likely to blame. SLE diagnosis usually occurs when symptoms can't be ignored, i.e., disease activity is substantial, and this is typically followed by intensive drug treatment. Steroid therapy comes with significant adverse effects in multiple organ systems, so this early occurrence of damage should not be unexpected, the researchers suggested.

Limitations to the study included its retrospective data collection and its reliance on medical records. Since the study included only patients from Spain whose records included dates for damage events, the sample might not be representative of the general lupus population.

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