Region: The Whole Patient
Base article: Uribe AG, McGwin G Jr, Reveille JD, Alarcón GS. What have we learned from a 10-year experience with the LUMINA (Lupus in Minorities; Nature vs. nurture) cohort? Where are we heading? Autoimmun Rev. 2004 Jun;3(4):321-9. doi: 10.1016/j.autrev.2003.11.005. PMID: 15246029.
Authors: Northwestern University Rheumatology Fellowship Program. Lakshmi Jayaram, MBBS, second year rheumatology fellow, Brian Jaros, MD, first year rheumatology fellow, Laura Arneson, MD, first year rheumatology fellow, Anisha Dua, MD, MPH, Associate Professor, Fellowship Program Director.
The LUMINA cohort was one of the first sources of prospective data highlighting the associations between ethnicity, social determinants of health, and SLE morbidity and mortality in the United States. Previous studies had demonstrated racial disparities in the prevalence and severity of SLE, though prior investigation had focused on genetic and behavioral factors underlying these disparities, and involved smaller cohorts with fewer racial groups (Ward 1990, Petri 1991, McCarty 1995, Jordan 2002, Petri 1991). This paper summarizes the findings from the first 10 years of the LUMINA (Lupus in Minorities: Nature vs. Nurture) cohort, which began enrolling patients with SLE of <5 years duration at the University of Alabama – Birmingham and the University of Texas – Houston in 1994; a site in Puerto Rico was added in 2001. At the time of this publication, the cohort included 587 patients with a mean follow-up time 40 months. Overall the study demonstrated higher disease activity and damage accrual among patients of African American or Texas Hispanic ethnicity, compared to patients of Caucasian or Puerto Rican Hispanic ethnicity, in association with both socioeconomic and genetic factors. Specifically, factors associated with higher disease activity on the SLAM (Systemic Lupus Activity Measure) at enrollment included African American ethnicity, lack of private health insurance, and particular HLA alleles. Damage measured by the SDI (SLICC/ACR Damage Index) was highest at enrollment among African American patients and accrued most rapidly among Texas Hispanic patients; it was also associated with education, poverty, and the HLA DR8 allele. Compared to Caucasian and Puerto Rican Hispanic patients, Texas Hispanic and African American patients were less likely to be on hydroxychloroquine at enrollment, were more likely to require corticosteroids and cyclophosphamide, and had a higher cumulative prevalence of lupus nephritis. In multivariate analysis, early mortality was predicted by disease activity, damage, and most strongly by poverty.
Impact on Rheumatology
The root of the word LUMINA is light. Much like its name, this landmark study has been shedding light on the importance of interplay between biologic and non-biologic factors in rheumatologic disease processes like SLE.
To start with, the LUMINA trial ignited an awareness amongst scientists in rheumatology to be cognizant of the importance of diversity and inclusion in their study samples. It earmarked the start of individualized care to rheumatology patients with consideration of immunogenetic, clinical, sociodemographic, and psychosocial factors.
There are multiple important nested case control studies that resulted from the parent study LUMINA. Fifty years ago, we learned about mortality in SLE related to atherosclerosis. Twenty-five years ago, we learned about increased myocardial infarctions in women with SLE. Now, thanks to LUMINA, we have learned that cardiovascular disease in SLE is multifactorial and related to age, gender, inflammatory marker levels, and baseline disease activity. The role of hydroxychloroquine in preventing damage accrual and reducing mortality in lupus patients is a major contribution of LUMINA. LUMINA also proved the factors contributing to adverse pregnancy outcomes ranged from renal involvement to African American ethnicity and fewer years of education- which in turn changed the landscape of counseling pregnant women with SLE. Disease burden aside, this paper also led to us to begin to understand socioeconomic barriers to accessing health care for underprivileged populations. In terms of tangible outcomes, the above studies resulted in development of multiple CDC (Centers for Disease Control)-funded SLE education and outreach programs to help increase awareness in vulnerable populations who have data indicating worse outcomes with disease.
Listed above are just a few of the many impactful advances that were derived from the LUMINA study- with the promise of many more such relevant studies. In the words of Dr. Suzanne Serrate-Sztein from NIAMS, the LUMINA cohort database can be considered “a national resource”.
Chances in the Tournament
While many of the competitor articles outline significant diagnostic, pathophysiologic or therapeutic advancements, only LUMINA summates components of each of these core domains into one landmark study. Beyond this, LUMINA demonstrates how these advancements are ultimately subject to various genetic and social determinants of health. In 20 years, the landscape of the tournament bracket will be filled with new pharmaceutical agents that have transcended these listed in 2023. However, the interaction of ethnicity, social determinants of health, and rheumatologic disease will continue to be a durable mainstay of conversation due to its lasting and pervasive effects on the way we care for patients. LUMINA represents a first major step in the initiation of this conversation, and for this reason we believe it will shoot the lights out in this year’s Rheum Madness competition.
Next scouting report: HAQ
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See the Q&A on theMednet.org for The Whole Patient region: What target do you utilize in clinical practice for defining disease remission in RA?
- Uribe AG, McGwin G Jr, Reveille JD, Alarcón GS. What have we learned from a 10-year experience with the LUMINA (Lupus in Minorities; Nature vs. nurture) cohort? Where are we heading? Autoimmun Rev. 2004 Jun;3(4):321-9. doi: 10.1016/j.autrev.2003.11.005. PMID: 15246029.