Understanding anemia in systemic lupus erythematosus with special emphasis to refractory Anemia: a prospective cohort

Background Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem involvement. Hematological manifestations, particularly anemia, represent common complications with diverse etiologies. Refractory anemia poses a significant clinical challenge due to its complex pathophysiology and limited therapeutic options. Objectives To assess the causes of anemia in SLE patients, identify the most prevalent etiologies in our locality, evaluate causes of refractory anemia, and correlate bone marrow abnormalities with anemia in SLE. Patients and methods This prospective observational study included 67 SLE patients diagnosed according to the 2019 American College of Rheumatology/European League Against Rheumatism classification criteria who presented with anemia. Patients were recruited from the Clinical Hematology and Rheumatology Units, Assiut University Hospital, between May 2023 and December 2024. All participants underwent thorough clinical assessment, including detailed medical history and physical examination. Laboratory investigations comprised complete blood count with red cell indices, reticulocyte count, iron profile, renal and liver function tests, inflammatory markers, and immunological parameters. Bone marrow examination was performed in patients with refractory anemia or when clinically indicated. Disease activity was evaluated using the Systemic Lupus Erythematosus Disease Activity Index 2000. Results The mean age was 28.4 ± 9.7 years with female predominance (88.1%). The mean hemoglobin was 6.8 ± 1.8 g/dl. Anemia of chronic disease was the most prevalent cause (22.4%), followed by autoimmune hemolytic anemia (16.4%) and iron deficiency anemia (14.9%). Bone marrow examination in 11 refractory cases revealed aplasia (45.5%), fibrosis (18.2%), and myelodysplastic syndrome (18.2%). Systemic Lupus Erythematosus Disease Activity Index score showed significant negative correlation with hemoglobin (r=–0.78, P <0.001). No significant predictors of refractory anemia were identified by regression analysis. Conclusion Anemia in SLE is highly heterogeneous with anemia of chronic disease and hemolytic etiologies predominating. Disease activity correlates strongly with anemia severity. Refractory anemia appears multifactorial and requires comprehensive bone marrow evaluation for appropriate management.