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2009 SLICC修改的ACR系统性红斑狼疮分类标准

2012-12-10 16:46| 发布者: night_jia| 查看: 7052| 评论: 0|原作者: Petri, Michelle, Systemic Lupus International Collaborating Clinic (SLICC)

摘要: SLICC Revision of the ACR Classification Criteria for SLEPetri, Michelle, Systemic Lupus International Collaborating Clinic (SLICC)参考网址:1. http://acr.confex.com/acr/2009/webprogram/Paper13266.htm ...

SLICC Revision of the ACR Classification Criteria for SLE

Petri, Michelle, Systemic Lupus International Collaborating Clinic (SLICC)
参考网址:1. http://acr.confex.com/acr/2009/webprogram/Paper13266.html
2. http://www.blackwellpublishing.com/acrmeeting/abstract.asp?MeetingID=761&id=80525
Purpose:
The ACR Classification Criteria for SLE date from 1982 with a 1997 revision that was not validated. Because of new knowledge of autoantibodies, neuropsychiatric lupus, the importance of low complement and the need for lupus nephritis to be a "stand alone" criterion, the SLICC group undertook a revision.
Method:
An initial set of relevant variables was determined. Real patient scenarios (n=716) of SLE and non-SLE controls were submitted by SLICC centers. A consensus diagnosis was arrived at for each scenario. The consensus diagnoses were used to identify the variables that were most predictive of SLE. Recursive partitioning was employed to derive a classification rule based on multiple candidates predictor variables. This preliminary classification rule was discussed at three SLICC meetings, independently validated by a SLICC steering comittee and further refined.
Results:

Classify a patient as having SLE if: The patient has biopsy-proven lupus nephritis with ANA or anti-dsDNA OR the patient satisfies four of the criteria, including at least one clinical and one immunologic criterion.

Clinical Criteria

1. Acute or subacute cutaneous lupus
2. Chronic cutaneous lupus
3. Oral/Nasal ulcers
4. Nonscarring alopecia
5. Inflammatory synovitis with physician-observed swelling of two or more joints OR tender joints with morning stiffness
6. Serositis
7. Renal: Urine protein/creatinine (or 24 hr urine protein) representing at least 500 mg of protein/24 hr or red blood cell casts
8. Neurologic: seizures, psychosis, mononeuritis multiplex, myelitis, peripheral or cranial neuropathy, cerebritis (acute confusional state)
9. Hemolytic anemia
10. Leukopenia (<4000/mm3 at least once)
OR
Lymphopenia (<1000/mm3 at least once)
11. Thrombocytopenia (<100,000/mm3) at least once

Immunologic Criteria

1. ANA above laboratory reference range
2. Anti-dsDNA above laboratory reference range (except ELISA: twice above laboratory reference range)
3. Anti-Sm
4. Antiphospholipid antibody
lupus anticoagulant
false-positive test for syphilis
anticardiolipin–at least twice normal or medium-high titer
anti-b2 glycoprotein 1
5. Low complement
low C3
low C4
low CH50
6. Direct Coombs test in absence of hemolytic anemia

When applied to our patient scenarios, this classification rule had better sensitivity than the ACR 11 (94% vs. 86%), and roughly equal specificity (92% vs. 93%), and resulted in significantly fewer misclassifications (p=.0082).
Conclusion:
The SLICC SLE classification criteria address the major deficiencies of the ACR. Currently, ongoing validation will determine if they perform better than the ACR criteria.

To cite this abstract, please use the following information:
Petri, Michelle, Systemic Lupus International Collaborating Clinic (SLICC), ; SLICC Revision of the ACR Classification Criteria for SLE [abstract]. Arthritis Rheum 2009;60 Suppl 10 :895
DOI: 10.1002/art.25975
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中文版
========================================================================

2009 SLICC
修改的ACR系统性红斑狼疮分类标准


临床标准
1.
急性或亚急性皮肤狼疮
2.
慢性皮肤狼疮
3.
口腔/鼻溃疡
4.
不留瘢痕的脱发
5.
炎症性滑膜炎,内科医生观察到的两个或两个以上关节肿胀或伴晨僵的关节触痛
6.
浆膜炎
7.
肾脏:用尿蛋白/肌酐比值(或24小时尿蛋白)算,至少500mg蛋白/24小时,或有红细胞管型
8.
神经系统:癜痫发作,精神病,多发性单神经炎,脊髓炎,外周或颅神经病变,脑炎(急性精神混乱状态
9.
溶血性贫血
10.
白细胞减少(至少一次< 4000/mm3 或淋巴细胞减少(至少一次< 1000/mm3
11.
至少一次血小板减少(<100,000/mm3)
免疫学标准
1.ANA
高于实验室参考值范围
2.
ds-DNA高于实验室参考值范围(ELISA法另外,用此法检测,需两次高于实验室参考值范围)
3.
sm阳性
4.
抗磷脂抗体
狼疮抗凝物阳性
梅毒血清学试验假阳性
抗心磷脂抗体-至少两倍正常值或中高滴度
b2 糖蛋白1阳性
5.
低补体
C3
C4
CH50
6.
在无溶血性贫血者,直接coombs试验阳性

患者如果满足下列条件至少一条,则归类于系统性红斑狼疮:1.有活检证实的狼疮肾炎,伴有ANA阳性或抗ds-DNA阳性;2.患者满足分类标准中的4条,其中包括至少一条临床标准和一条免疫学标准
在入选的患者中应用此标准,较ACR标准有更好的敏感性(94% vs. 86%),并与ACR标准有大致相同的特异性(92% vs. 93%),同时明显减少误分类(p=0.0082)

 

 

其实,就是因为看到之前网上的很多翻译过来的标准内容比较含糊,我才贴上英文原文和自己的翻译。我觉得要获得正确的认识还是最好看原文。
1.
临床标准第四条Nonscarring alopecia
alopecia
译为脱发为好,秃发是什么意思啊?有点莫名奇妙,中文里面说秃头,哪有说秃发的呢。

2.
关节炎的问题:
这个新标准中的关节炎定义有两个,一个就是医生观察到的两个或两个以上的关节肿胀,另一个是伴晨僵的触痛。符合任何一个都可以算关节炎了。不是说关节痛就不算的问题。有关节触痛如果同时伴关节晨僵也算炎症性滑膜炎的。

3.
几种类型的皮肤狼疮的问题:有一段话,可以参考,借鉴下:

50
年代采用的BundickEllis分类法为:局限性盘状红斑狼疮;播散性红斑狼疮,其下又分急性、亚急性和慢性播散性红斑狼疮,(播散性盘状红斑狼疮)。随着对本病的研究日趋广泛和深入,其后出现了不少分类方法。北村根据皮损性质不同将本病分成:不全型(顿挫型);慢性盘状干燥型;慢性盘状渗出液;色素增生型;慢性播散型;急性播散型。Martin将本病分成:隐性红斑狼疮;有特异性皮损而无系统性症状者;有特异性皮损亦有系统性症状者;有系统性症状而无特异性皮损者。Gilliam将患者皮损不论其有否皮损外病变分成:慢性皮肤红斑狼疮(CCLE),又可分为局限性盘状红斑狼疮、泛发性盘状红斑狼疮,肥厚性盘状红斑狼疮、深部红斑狼疮;亚急性皮肤型红斑狼疮(SCLE);急性红斑狼疮,可分为面()部红斑,面、头皮、颈、上胸、肩臂伸面和手背红斑,大疱性或中毒性表皮松解样损害。有人倾向只分盘状和系统型;前者又再分成:局限性盘状型和泛发生盘状型。又有人主张将盘状型改为皮肤型红斑狼疮。现认为红斑狼疮系一病谱性 疾病 ,局限性盘状和系统性红斑狼疮(SLE)为其二极端类型,中间有亚急性皮肤型红斑狼疮和深部红斑狼疮等。

看过这段话之后,相信思路就清晰得多,急性皮肤狼疮就是大疱性或中毒性表皮松解样损害的。亚急性的和慢性的在皮肤病学里面讲得比较多。

4.
关于免疫学标准中第6条:
原文为Direct Coombs test in absence of hemolytic anemia,这句中in absence of,意思是说缺乏,没有,缺席等之类的意思,缺乏,没有,缺席的是of后面的东东,不是in absence of前面的“Direct Coombs test ”,所以,其实意思很明白,就是说在无溶血性贫血者,直接coombs试验阳性。如果译为有溶血性贫血但Coombs试验阴性不仅翻译不正确,还跟前文以及跟狼疮这个病都是有矛盾的,常识上都不正确。

5.
关于ELISA法检测ANA ds-DNA方法的标准化问题:
我的粗浅理解是仅就当地实验室所采取的试剂对应的参考值而言的。不同实验室之间采用不同试剂公司的试剂不具可比性。可以继续讨论这个问题。

6.
关于分类条件的问题:
我的理解是符合两个方面的任何一个方面就可以分类为SLE了,而不是要去强调肾活检的重要性。仔细看英文原文Classify a patient as having SLE if: The patient has biopsy-proven lupus nephritis with ANA or anti-dsDNA OR the patient satisfies four of the criteria, including at least one clinical and one immunologic criterion.里面有or OR 连接,连接的部分是不同的,应理解为两个条件满足一个即可,不是两条都要具备才能分类为SLE。如:1.有活检证实的狼疮肾炎,伴有ANA阳性或抗ds-DNA阳性;2.患者满足分类标准中的4条,其中包括至少一条临床标准和一条免疫学标准 。满足一条即可分类为SLE。这实际上简化了诊断程序,比如第一个条件,活检证实后,只要有抗核抗体或ds-DNA阳性就可以分类为SLE了。


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