Mortality and survival in patients with systemic lupus erythematosus in the Middle East and North Africa: a systematic review and meta-analysis

Clinical Snapshot

Key Findings

• P Value: Not reported in abstract

• Effect Size: Pooled all-cause mortality rate: 9.9%; Survival: 93.9% at 5 years, 90.0% at 10 years, 85.5% at 15 years, 71.7% at 20 years

• Primary Outcome: Pooled all-cause mortality rate in adult SLE patients across MENA region (12 cohort studies, n=3,478)

• Nnt Or Sensitivity: Prognostic study: no NNT applicable. Key mortality predictors include renal involvement, cardiovascular disease, infections, hypertension, diabetes, haematologic abnormalities, and male sex. Hydroxychloroquine and azathioprine associated with reduced mortality; higher cumulative corticosteroids and cyclophosphamide associated with increased mortality. I² = 89.7% for primary pooled estimate.

• Confidence Interval: All-cause mortality 95% CI: 7.2%–14.0%; CIs for individual survival time points not reported in abstract

Clinical Application

The identified mortality predictors (renal involvement, cardiovascular risk, infection burden, male sex) are clinically actionable using existing monitoring frameworks. Optimisation of hydroxychloroquine use and minimisation of cumulative corticosteroid exposure are feasible within current rheumatology practice. Establishment of multicenter MENA registries, as recommended by the authors, would require significant infrastructure investment. Australia has a growing MENA-origin population, and SLE prevalence and severity may differ from the predominantly European cohorts underpinning current RACGP and Australian Rheumatology Association guidelines. Hydroxychloroquine is PBS-listed for SLE (PBS item 5261K) and its protective association reinforces current prescribing practice. Azathioprine is also PBS-listed as a steroid-sparing agent. The finding that infection is the leading cause of death aligns with Australian immunosuppression stewardship priorities. Clinicians managing MENA-background SLE patients should be alert to potentially higher renal involvement rates and ensure nephrology co-management pathways are in place. The TGA-approved biologics (belimumab) for SLE are not addressed in this review. RACGP chronic disease management plans should incorporate cardiovascular risk reduction given the identified cardiovascular mortality burden. Adult patients with SLE, particularly those of Middle Eastern, North African, or broadly non-European ethnic backgrounds. Findings are most directly applicable to patients from Türkiye, Iran, Egypt, Israel, and Tunisia. Caution is warranted in extrapolating to other MENA populations not represented in the included studies.

Abstract

Systemic lupus erythematosus (SLE) is associated with increased mortality compared with the general population, with outcomes influenced by ethnicity and organ involvement. Data from the Middle East and North Africa (MENA) remain limited, particularly regarding long-term survival and mortality predictors. To estimate and compare all-cause mortality and survival rates among adult patients with SLE in the MENA region and identify predictors of mortality. A systematic review and meta-analysis of cohort studies reporting survival and mortality in patients with SLE in the MENA region was conducted. Eligible studies were identified through a comprehensive database search and screened according to PRISMA guidelines. Data on treatment exposures and clinical predictors of mortality were extracted. Twelve cohort studies, including 3,478 adults with SLE from five MENA countries (Türkiye, Iran, Egypt, Israel, and Tunisia), were analyzed. The pooled all-cause mortality rate was 9.9% (95% CI: 7.2%-14.0%; I² = 89.7%). Survival remained high at 5 years (93.9%) and 10 years (90.0%), but declined at 15 years (85.5%) and 20 years (71.7%), with long-term estimates highly sensitive to single-study exclusion. Leave-one-out analysis slightly increased survival estimates and reduced heterogeneity. Major mortality predictors included renal involvement, cardiovascular disease, infections, hypertension, diabetes, hematologic abnormalities, and male sex. Higher cumulative corticosteroid and cyclophosphamide exposure was linked to increased mortality, whereas hydroxychloroquine and azathioprine appeared protective. Infection was the leading cause of death, followed by active disease, renal failure, and cardiovascular complications. Patients with SLE in the MENA region show high short-term survival, but long-term outcomes remain variable. Mortality is mainly driven by renal, cardiovascular, and infectious complications, with treatment exposure contributing to risk. These findings highlight the need for multicenter registries, standardized reporting, and strategies to reduce infection burden and optimize nephritis care.

References

1. 1.Alharbi, S., & Aljohani, R. (2026). Mortality and survival in patients with systemic lupus erythematosus in the Middle East and North Africa: a systematic review and meta-analysis. Rheumatology International. https://doi.org/10.1007/s00296-019-04484-9