Refining Prognostic Assessment in SLE : A Call for Severity Stratification of Thrombocytopenia

Al-Adhoubi et al. [1] report thrombocytopenia in 22.5% of 1160 Omani patients with systemic lupus erythematosus, with striking associations to antiphospholipid antibodies, renal involvement (5.3% vs. 0.6%, p = 0.000), neuropsychiatric disease (30.9% vs. 17.9%, p = 0.000), and nearly fourfold higher mortality (11.1% vs. 2.9%, p = 0.000). Sepsis dominates deaths among thrombocytopenic cases (7.3% vs. 1.7%). Although the study uses the 2019 ACR-EULAR threshold of < 100 × 109/L, it treats thrombocytopenia as a single entity, leaving the prognostic impact of platelet nadir depth unexplored. This binary approach may mask a clinically meaningful severity gradient. Platelet counts of 90 × 109/L and 15 × 109/L differ sharply in bleeding risk, immune dysregulation intensity, and infection susceptibility. Recent large cohorts confirm that severe thrombocytopenia independently predicts higher mortality and faster irreversible organ damage accrual compared with milder forms [2-4]. In the Oman data, where prevalence is similar across pediatric (20.2%) and adult (22.8%) onset (p = 0.490), stratifying the 262 events by nadir could reveal whether moderate cytopenias preferentially accompany respiratory complications (25.6% vs. 16.4%, p = 0.001). At the same time, severe thrombocytopenia drives sepsis-related deaths and greater long-term damage. We respectfully suggest three immediate, low-effort steps using existing records. First, classify the 262 thrombocytopenia episodes by nadir into mild (50–99 × 109/L), moderate (20–49 × 109/L), and severe (< 20 × 109/L) categories, then redraw Kaplan–Meier curves with log-rank testing across strata. Second, perform cause-specific Cox regression to estimate sepsis hazard ratios per severity grade, adjusting for antiphospholipid antibody status and concurrent hemolytic anemia or leukopenia. Third, integrate these grades into the published multivariable model alongside age, sex, and organ involvement to derive a refined prognostic index directly comparable to international benchmarks. These additions require no new data collection yet would transform a valuable prevalence study into a precise risk-stratification tool, helping clinicians identify the highest-risk subset within the 22.5% affected group and potentially informing future iterations of classification criteria. The Oman Lupus Cohort is uniquely positioned to provide this insight for patients in the Middle East. Wei Wei and Xuechun Gu drafted the manuscript; Jingjing Liu provided critical revisions. This study was supported by Yangming Hospital Affiliated to Ningbo University. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.