Factors associated with interstitial lung disease in patients with rheumatoid arthritis: A systematic review and meta-analysis

Abstract

Objectives: Interstitial lung disease (ILD) is frequent in patients with rheumatoid arthritis (RA) and is a potentially life-threatening complication with significant morbidity and mortality. This meta-analysis aims to systematically determine the factors associated with the development of rheumatoid arthritis-related interstitial lung disease (RA-ILD).

Materials and methods: All primary studies which reported the factors associated with of RA-ILD were eligible for the review except case reports. The Cochrane Library, PubMed, Embase, Web of Science, Chinese Biological Medicine Database (CBM), China National Knowledge Infrastructure (CNKI), and WANFANG electronic databases were searched through to December 30, 2022, for studies investigating the factors associated with RA-ILD. The methodological quality assessment of the eligible studies was performed using the Newcastle-Ottawa Scale (NOS). 2 reviewers extracted relevant data independently. Then, weighed mean differences (WMDs) or pooled odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were obtained for the relationships between the factors and RA-ILD. The statistical meta-analysis, subgroup and sensitivity analyses were performed using the Review Manager 5.3, and publication bias with Egger's test were performed using the Stata12.0 software.

Results: A total of 22 articles were screened for a meta-analysis which involved 1887 RA-ILD patients and 8066 RA without ILD patients. Some identified factors that were associated with an increased risk of RA-ILD included male sex (OR = 1.92, 95% CI: 1.54-2.39; P < 0.00001), older age (WMD = 5.77 years, 95% CI: 3.50-8.04; P < 0.00001), longer duration of RA (WMD = 0.80 years, 95% CI 0.12-1.47; P = 0.02), older age at onset of RA (WMD = 6.41 years, 95% CI: 3.17-9.64; P = 0.0001), smoking (OR = 1.69, 95% CI: 1.30-2.18; P < 0.0001). Five factors of laboratory items associated with the development of RA-ILD were evaluated in the meta-analysis. Compared with RA without ILD patients, positive rheumatoid factor (RF) (OR = 1.72, 95% CI: 1.47-2.01; P < 0.00001) and positive anti-citrullinated protein antibodies (ACPA) (OR = 1.58, 95% CI: 1.31-1.90; P < 0.00001) increased the risk of RA-ILD. Meanwhile, RF titer (WMD = 183.62 (IU/mL), 95% CI: 66.94-300.30; P = 0.002) and ACPA titer (WMD = 194.18 (IU/mL), 95% CI: 115.89-272.47; P < 0.00001) were significantly associated with increased risk of RA-ILD. Elevated erythrocyte sedimentation rate (ESR) (WMD = 7.41 (mm/h), 95% CI: 2.21-12.61; P = 0.005) and C-reactive protein (CRP) (WMD = 4.98 (mg/L), 95% CI: 0.76-9.20; P = 0.02) were also significantly associated with the development of the RA-ILD, whereas antinuclear antibody (ANA) positive status was not significantly associated with increased risk of RA-ILD (OR = 1.27, 95% CI: 1.00-1.60; P = 0.05).

Conclusions: This meta-analysis showed that male gender, older age, longer duration of RA, older age at onset of RA, smoking, positive RF, positive ACPA, elevated RF titer, elevated ACPA titer, higher ESR and higher CRP were associated with RA-ILD.

Fig 1. Flow diagram of selecting the literature and screening process.

Fig 2. Forest plot of the pooled ORs for correlation of male sex with RA-ILD.

Fig 3. Forest plot of the pooled WMDs about average age.

Fig 4. Forest plot of the pooled WMDs about duration of RA.

Fig 5. Forest plot of the pooled WMDs about age at onset of RA.

Fig 6. Forest plot of the pooled ORs for correlation of smoking with RA-ILD.

Fig 7

Forest plot of the pooled ORs for correlation of positive RF with RA-ILD. Data about positive RF was available for 72 RA-ILD patients and 1117 RA without ILD patients in Denis 2022 study.

Fig 8. Forest plot of the pooled ORs for correlation of positive ACPA with RA-ILD.

Data about positive ACPA was available for 67 RA-ILD patients and 1072 RA without ILD patients in Denis 2022 study.

Fig 9

Forest plot of the pooled WMDs for correlation of RF titer with RA-ILD.

Fig 10. Forest plot of the pooled WMDs for correlation of ACPA titer with RA-ILD.

Fig 11. Forest plot of the pooled WMDs for correlation of ESR level with RA-ILD.

Fig 12. Forest plot of the pooled WMDs for correlation of CRP level with RA-ILD.

Fig 13. Forest plot of the pooled ORs for correlation of positive ANA with RA-ILD.

Fig 14. Forest plot of subgroup analysis for the ACPA titer.