Addressing Healthcare Disparities in Autoimmune Disease: A Focus on Systemic Lupus Erythematosus in the USA

By Moncrieffe, Halima; Tillery, Dwight | Journal of Pan African Studies, April 2015 | Go to article overview

Addressing Healthcare Disparities in Autoimmune Disease: A Focus on Systemic Lupus Erythematosus in the USA


Moncrieffe, Halima, Tillery, Dwight, Journal of Pan African Studies


Introduction

Autoimmune Diseases

Autoimmune diseases encompass a wide range of conditions that include type 1 diabetes, systemic lupus erythematosus (SLE), multiple sclerosis, rheumatoid arthritis and Crohn's disease. Despite the diverse clinical presentations and symptoms all these diseases manifest because the immune system, which is essential in protecting the human body against bacteria and viruses, attacks healthy organs and cells. In type 1 diabetes, the autoimmune reaction leads to the targeted destruction of the pancreatic beta cells that produce insulin. By contrast in SLE, multiple organs throughout the body can be targeted including the skin, kidney, digestive tract and lungs leading to often debilitating disease flares. All these autoimmune conditions have a wide range of disease severity and can cause pain, reduced quality of life, and for some conditions, an increased risk of mortality and long term disability. There are a complex range of factors that contribute to development of autoimmune disease including inherited, that is genetic, as well as environmental influences. Scientific research has transformed the outcome for patients with autoimmune diseases with an increasing range of new therapies available. These treatments vary in their precise mechanism of action but suppress the effects of the immune system to reduce inflammation.

Healthcare Disparities: a Focus on SLE in the USA

It is long been characterized that the greatest rates of SLE occur in women and also in individuals of African descent [1]. The prevalence rates for SLE were recently refined in a study where over 45,000 patients in Georgia, USA were screened across hospitals and specialist clinics including rheumatology, dermatology and nephrology [2]. When adjusted for age, the prevalence rates of SLE were over 9 times higher in women than men (127.6 cases per 100,000 in the population compared to 14.7 cases per 100,000). Black women had the highest rates, at 196.2 cases, with women between the ages of 30 and 59 at highest risk of developing SLE. Furthermore, there was a higher incidence of the more serious clinical manifestations of SLE among black patients, including severe kidney disease where there was a 7-fold greater incidence of end-stage renal disease [2].

The reasons for this are complex. Inherited genetic variations, as well as environmental and social factors are under investigation to reveal causes of these severe complications of SLE. Firstly, there is a higher risk of SLE patients of African ethnicity developing lupus nephritis--an earlier stage of renal disease [3]. A recent study of the genetics of end-stage renal disease in African Americans revealed the gene apolipoprotein L1 strongly impacted the risk of lupus nephritis [4]. The genetic variants that increased risk were nearly absent in European Americans. This exemplifies the role of inherited factors in disparities in SLE severity. When disease was severe enough to require kidney transplantation there were further differences in outcome: patients of African ancestry had a higher transplantation failure rate.

A recent study investigated the reason for this in a large cohort of American patients who received kidney transplants for SLE [5]. Transplanted kidneys that have longer cold storage and more incompatibilities between donor and recipient are more likely to be rejected. This study showed that when known risk factors that predict poor outcome are matched, then there is a similar rate of kidney transplantation failure between patients of European and African ancestry. The authors discuss that in the US population, patients of African ancestry have a higher rate of kidney transplantation from donors of European ancestry resulting in greater organ rejection and that improvement of kidney matching and organ donation among African ancestry patients would be beneficial.

A national study published in 2013, analyzed 23. …

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