Epidemiology of systemic lupus erythematosus in Korea

Jung-Yong Han; Soo-Kyung Cho; Yoon-Kyoung Sung

doi:10.4078/jrd.2023.0037

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J Rheum Dis 2023; 30(4): 211-219

Published online October 1, 2023

Epidemiology of systemic lupus erythematosus in Korea

Jung-Yong Han, M.D., M.S.^1,2, Soo-Kyung Cho, M.D., Ph.D.^1,2, Yoon-Kyoung Sung, M.D., Ph.D., MPH^1,2

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¹Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, ²Hanyang University Institute for Rheumatology Research, Seoul, Korea

Correspondence to : Yoon-Kyoung Sung, https://orcid.org/0000-0001-6691-8939
Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, 222-1 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea. E-mail: sungyk@hanyang.ac.kr

Received: June 23, 2023; Revised: August 10, 2023; Accepted: August 10, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

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Abstract
INTRODUCTION
MAIN SUBJECTS
CONCLUSION
ACKNOWLEDGMENTS
FUNDING
CONFLICT OF INTEREST
AUTHOR CONTRIBUTIONS
REFERENCES

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by diverse organ system disabilities, predominantly affecting young females. The clinical manifestations of SLE encompass various organs, including the kidney, cardiovascular system, and central nervous system. Young females with SLE experience higher mortality rates than the general population, making it imperative to gain insights into the disease patterns and associated factors. The current review examines the epidemiological studies to analyze the prevalence, incidence, and mortality trends of SLE in Korea and compares them with the findings from other countries. We aim to identify potential similarities, differences, and factors contributing to the burden of SLE in different populations by exploring the comparative epidemiological aspects. The knowledge derived from this comparison would aid in advancing the overall management of SLE in Korea.

Keywords Systemic lupus erythematosus, Epidemiology, Mortality

INTRODUCTION

Go to

Abstract
INTRODUCTION
MAIN SUBJECTS
CONCLUSION
ACKNOWLEDGMENTS
FUNDING
CONFLICT OF INTEREST
AUTHOR CONTRIBUTIONS
REFERENCES

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that manifests with a wide range of organ system disabilities, predominantly affecting young female [1-3]. The clinical manifestations of SLE involve various organs, such as the kidney, cardiovascular system, and central nervous system [4-6]. SLE poses a significant mortality risk among young female, with a mortality rate of 2.6 to 5.0 times higher compared with that in the general population [7-9].

In this review, we scrutinize the prevalence, incidence, and mortality trends of SLE in Korea to gain valuable insights into the dynamic nature of the disease in this population. Additionally, we explore the association of comorbidities like cardiovascular disease (CVD), malignancy, and infection with increased mortality rates among SLE patients. We sought to identify potential similarities, differences, and factors contributing to the burden of SLE in diverse populations worldwide by delving into the comparative epidemiological aspects.

The knowledge derived from this comprehensive analysis holds the potential to advance the overall management of SLE on a global scale. Furthermore, this review’s findings would deepen the understanding of SLE, leading to improved treatment outcomes for affected individuals. Altogether, the insights garnered may serve as valuable guidance for the development of a tailored national healthcare system, addressing the specific needs of SLE patients in Korea and beyond.

MAIN SUBJECTS

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Abstract
INTRODUCTION
MAIN SUBJECTS
CONCLUSION
ACKNOWLEDGMENTS
FUNDING
CONFLICT OF INTEREST
AUTHOR CONTRIBUTIONS
REFERENCES

Prevalence and incidence of SLE

The prevalence and incidence rates of SLE vary depending on race and ethnicity. Over the past years, several epidemiological studies have been conducted specifically focusing on SLE patients in Korea [10-14]. Table 1 provides an overview of the prevalence and incidence of SLE among Korean patients. A population-based cohort study, which utilized the Korean National Health Insurance (NHI) database and employed an operational definition of SLE based on diagnostic codes, medications, and laboratory tests, reported a prevalence rate ranging from 20.6 to 26.5 per 100,000 person-years (PY), with an incidence rate ranging from 2.5 to 2.8 per 100,000 PY between 2006 and 2010 [13]. Another Korean study, using a definition of SLE based on diagnostic codes, revealed slightly increased prevalence and incidence rates of 28.02 per 100,000 PY and 3.72 per 100,000 PY, respectively, between 2005 and 2015 compared to those of previous studies [12]. Notably, among female SLE patients in Korea, the highest prevalence (77.07 per 100,000 PY) and incidence (8.18 per 100,000 PY) were observed during the childbearing ages [11].

Table 1 . The studies of prevalence and incidence of SLE patients in Korea

Study	Database	Prevalence (/100,000 PYs)	Number of prevalent cases of SLE	Incidence (/100,000 PYs)	Number of incident cases of SLE	Female/male ratio	Age (yr)	Study period
Ju et al. [10]	HIRA	18.8-21.7	2,000	-	-	8.4	All age group	2004~2006
Chung et al. [11]	NHI	77.07	12,756	8.18	4,487	Female	20~44	2009~2016
Bae et al. [12]	NHI	28.02	14,049	3.72	1,849	9.9	All age group	2005~2015
Shim et al. [13]	NHI	20.6-26.5	10,080-13,316	2.5-2.8	1,260-1,398	6.5	All age group	2006~2010
Kim et al. [14]	NHI	30.4-38.0	15,287-19,441	-	-	10	All age group	2012~2016

SLE: systemic lupus erythematosus, HIRA: Health Insurance Review and Assessment, PYs: person-years, NHI: National Health Insurance.

A recent systematic review of epidemiological studies on SLE patients demonstrated that the highest estimates of prevalence (241 per 100,000 PY) and incidence (23.2 per 100,000 PY) were reported in North America. The lowest prevalence was observed in Northern Australia (0 cases in a sample of 847 individuals), and the lowest incidence was reported in Africa and Ukraine (0.3 per 100,000 PY) [15]. There were notable variations in the published studies across different countries. Most studies comparing ethnic differences indicated higher SLE incidence and prevalence rates in Black populations, lower rates in White populations, and intermediate rates in Hispanic and Asian populations [16]. Among Asian ethnicity, the prevalence of SLE in Korea was lower than that in China (30 per 100,000 PY) [17] or Taiwan (67.4 per 100,000 PY) [18]. However, a comprehensive data comparison should be conducted cautiously because most reports from Asia used information from hospital records or community surveys, except for Taiwan.

Major organ involvement in patients with SLE

Major organ involvement in SLE typically includes the kidney, cardiovascular system, and central nervous system, while minor organ involvement may affect the skin, joints, and hematopoietic system. Race and ethnicity play a significant role in the manifestation and outcomes of SLE, with Black, Asian, and Hispanic individuals having more severe disease and poorer outcomes [19]. Black individuals have the highest risk of developing SLE, followed by South Asians, East Asians, and other non-White groups compared to White individuals. Moreover, non-White populations tend to experience more severe disease and faster damage accumulation.

1) Renal involvement

Studies have reported that approximately 40% to 60% of SLE patients could develop signs and symptoms of kidney disease during the course of their illness [20,21]. Renal manifestation and prognosis of SLE may be influenced by various factors such as age, gender, ethnicity, and high disease activity [22]. Renal involvement in SLE is more common in female and younger patients [21]. In Korea, the risk of chronic kidney disease (CKD) and mortality rate were increased in patients aged over 50 years [23]. Otherwise, the nationwide cohort study in Taiwan reported that those with juvenile-onset SLE had the highest mortality risk, whereas SLE patients aged under 50 years had a higher risk of end-stage renal disease [24]. Thus far, the renal involvement or renal outcome of patients with SLE has been found to vary depending on their ethnicity and country. In Korea, approximately 15.5% of patients diagnosed with lupus nephritis developed CKD within 10 years [25]. A cohort study using the NHI database in 2000~2008 unraveled that the adjusted hazard ratio of end-stage renal disease for Korean SLE patients was 18.2 (95% CI 5.7~58.2) compared to the non-SLE group [26]. African American and Hispanic patients are known to have worse renal outcomes and mortality than Caucasian patients [27,28], while Asians, including Korean SLE patients [29], have shown higher rates of renal involvement than Caucasians.

2) Neuropsychiatric involvement

Neuropsychiatric systemic lupus erythematosus (NPSLE) is a complex manifestation of SLE that affects the central nervous system, leading to various neurological and psychiatric symptoms. These manifestations vary widely, including cognitive dysfunction, seizures, psychosis, mood disorders, and cerebrovascular events [30]. In addition, previous studies have reported varying prevalence rates of NPSLE due to differences in study populations, diagnostic criteria, and disease heterogeneity [31,32]. The neuropsychiatric manifestations differed from the age of SLE onset. Late-onset SLE showed lower frequencies of neuropsychiatric SLE, seizures, and psychosis but a higher prevalence of peripheral neuropathy than early-onset SLE [33]. A study in Korea observed NPSLE in a significant portion (38.3%) of SLE patients with an increased risk of mortality (HR 3.09, 95% CI 1.03~9.21) [34]. The Swiss SLE cohort study showed that the prevalence rate of NPSLE was 28.1% [35]. Otherwise, a single-center study in the UK reported that approximately 60% of SLE patients developed neuropsychiatric manifestations [36]. Large-scale multi-center studies were crucial to process large and diverse sample sizes and increasing generalizability. In this regard, an international prospective study conducted by the Systemic Lupus International Collaborating Clinics reported that 52% of SLE patients developed neuropsychiatric events, indicating the substantial burden of NPSLE within the SLE population [37]. These studies provide critical insights into the prevalence, clinical course, and outcomes of NPSLE.

3) Diffuse alveolar hemorrhage and pulmonary hypertension

Diffuse alveolar hemorrhage (DAH) and pulmonary hypertension (PH) are potential complications in SLE patients that contribute to life-threatening conditions [38]. DAH refers to bleeding within the lungs, especially in the small blood vessels, and PH refers to elevated blood pressure in the pulmonary arteries of the lungs [39]. They could be developed as a consequence of chronic inflammation, immune dysregulation, and vascular damage [40]. The incidence rates of DAH in SLE patients vary from 0.5% to 5% [41,42]. In previous studies involving Asian populations, the reported incidence rates were 0.52% in Taiwan [43] and 2.0% in China [44], while Korean SLE patients exhibited a lower incidence rate (1.38%) of DAH compared to the Chinese population [45]. The prognosis of SLE patients with DAH depends on various factors, such as thrombocytopenia, renal failure, and mechanical ventilation [46]. In a previous multivariable analysis, a severe condition requiring mechanical ventilation was maintained as an independent risk factor [47].

Although the exact incidence rate of PH in SLE is difficult to determine, incidence rates have been reported to range from 2% to 14% [48,49]. The incidence of PH depend on the diagnostic tool, as well as disease duration and severity [50,51]. Two studies demonstrated varying incidence rates of PH in SLE patients, ranging from 3.8% among Chinese patients [52] to 14% among Korean patients [53]. Another study involving Korean SLE patients reported that the prevalence of PH was 4.3%, with a higher mortality rate [54]. Understanding the epidemiology of PH in SLE patients can support early detection and treatment strategies to improve patient prognosis.

Comorbidities of SLE patients

SLE patients have an increased risk of comorbidities, such as CVD and cancers [55]. They could affect the long-term outcomes and all-cause mortality of SLE patients. Therefore, several epidemiologic studies on comorbidities in SLE have been conducted.

1) Cardiovascular disease in SLE

CVD remains the leading cause of death among SLE patients [56]. Recent studies have reported an increased risk of ischemic heart disease, heart failure, and stroke in SLE patients [57,58]. Previous research conducted in the US, Sweden, and Canada has consistently shown a 2- to 3-fold higher incidence of CVD in individuals with SLE than in the general population (Table 2) [58-65]. A Korean cohort study that utilized the NHI database also reported similar findings, with SLE patients exhibiting an increased risk of myocardial infarction (MI) (HR 2.74, 95% CI 2.28~3.37), stroke (HR 3.31, 95% CI 2.84~3.86), and heart failure (HR 4.60, 95% CI 3.96~5.35) [64]. In addition, another study evaluating newly diagnosed SLE patients indicated a significantly higher risk of MI (IRR 2.19, 95% CI 1.30~3.68) and ischemic stroke (2.41, 95% CI 1.84~3.15) compared to the general population [66]. Furthermore, incident SLE patients aged over 40 years had a substantially higher CVD risk (HR 1.99, 95% CI 1.66~2.38) compared with that of patients with diabetes mellitus (DM) (HR 1.39, 95% CI 1.22~1.58) [67].

Table 2 . The studies of cardiovascular disease in SLE patients

Study	Database	Hazard ratio (95% CI)	Outcomes	Study population	Comparator	Country	Study period
Tornvall et al. [58]	Swedish NPR, CDR, and SCAAR	1.6 (1.4, 1.7)	MI	Prevalent SLE patient	General population	Sweden	1996~2015
Bartels et al. [59]	MESA	1.8	CVD combined MI, stroke and heart failure	Incident SLE patient	Matched population	United States	1991~2008
Barbhaiya et al. [60]	US MAX	2.67	CVD combined MI and stroke	Prevalent SLE patient	General population	United States	2007~2010
Bengtsson et al. [61]	Multi-center	1.27 (0.82, 1.87)	CVD combined MI and stroke	Prevalent SLE patient	General population	Northern Sweden	2000~2007
Chen et al. [62]	US Medicaid	2.7 (2.3, 3.1)	Heart failure	Prevalent SLE patient	General population	United States	2007~2010
Magder et al. [63]	Hopkins Lupus Cohort	2.66	CVD combined MI, thrombotic stroke, clinically definite angina, percutaneous coronary intervention, a coronary bypass procedure, or claudication	Prevalent SLE patient	General population	Unites State	1987~2010
Lim et al. [64]	NHI	2.74 (2.28, 3.37) 3.31 (2.84, 3.86) 4.60 (3.96, 5.35) 3.98 (3.61, 4.39)	MI Stroke Heart failure Cardiac death	Prevalent SLE patient	General population	Korea	2008~2015
Yafasova et al. [65]	Danish administrative registries	1.93 (1.46, 2.55) 3.53 (1.82, 6.84) 6.88 (3.53, 13.4)	MI Ischemic stroke HF	Prevalent SLE patient	General population	Denmark	1996~2018
Han et al. [66]	NHI	2.40 (1.88, 3.05) 2.19 (1.30, 3.68) 2.41 (1.84, 3.15)	MACE combined MI and stroke MI Stroke	Incident SLE patient	General population	Korea	2008~2018
Han et al. [67]	NHI	1.39 (1.22, 1.58)	CVD combined MI, stroke, and cardiac arrest	Incident SLE patient	General population	Korea	2008~2018

SLE: systemic lupus erythematosus, CI: confidence interval, MESA: Marshfield Epidemiologic Study Area, MI: myocardial infarction, MAX: Medicaid Analytic eXtract, NHI: National Health Insurance, NIR: National Inpatient Register, CDR: cause of death register, SCAAR: Swedish Coronary Angiography and Angioplasty Register.

Importantly, differences in definitions across studies should be carefully considered while comparing epidemiological studies on CVD. For example, the risk of heart failure was reported to be 1.7 times higher in Korean SLE patients than in US patients [61,64]. However, this difference may be attributed to variations in the heart failure definition. In the US study, heart failure was defined based on diagnostic codes with hospitalization, whereas the Korean study included diagnostic codes with both hospitalization and outpatient visits.

2) Cancer in SLE

It is well known that SLE can be associated with specific types of cancer. Table 3 depicts a few studies on cancer risk in SLE patients [68-75]. A recent study reported that the standardized incidence ratio (SIR) of overall cancer in SLE patients was 1.14 (95% CI 1.05~1.23) [76]. A meta-analysis identified SLE as a risk factor for most cancers, except for prostate cancer and cutaneous melanoma [77]. In a previous study involving female SLE patients, the increased rate of cervical intraepithelial neoplasia was documented in SLE patients treated with intravenous cyclophosphamide [78]. However, there has been no clear explanation for the etiology and pathogenesis of cancer development in SLE patients. Immunosuppressive drugs, chronic inflammation and damage, and genetic susceptibility could be related to an increased risk of cancer development in SLE [79,80].

Table 3 . The studies of malignancies in SLE patients

Study	Database	Overall SIR (95% CI)	Site-specific cancer	Study population	Country	Study period
Hsu et al. [68]	NHI	-	Breast, haematological, colorectal, lung, and hepatobiliary	Prevalent SLE patient	Taiwan	2001~2013
Chen et al. [69]	NHI	1.76 (1.74, 1.79)	Haematological, vagina/vulva, nasopharynx, and kidney	Prevalent SLE patient	Taiwan	1996~2007
Han et al. [70]	NHI	1.75 (1.63, 1.87)	Haematological, head and neck, larynx, bladder, and liver	Prevalent SLE patient	Korea	2012~2014
Bae et al. [71]	NHI	1.44 (1.33, 1.56)	Haematological, cervical, ovarian, oral, thyroid	Prevalent SLE patient	Korea	2008~2014
Kang et al. [72]	Korea National Cancer Registry	1.45 (0.74, 2.16)	Haematological, cervical, and bladder	Prevalent SLE patient	Korea	1997~2007
Björnådal et al. [73]	National Swedish Cancer Register	1.25 (1.14, 1.37)	Haematological, lung, and squamous cell skin	Prevalent SLE patient	Sweden	1964~1995
Westermann et al. [74]	Danish Cancer Registry	1.45 (1.30, 1.62)	Haematologic, hepatobiliary, and nasopharynx	Prevalent SLE patient	Denmark	1995~2014
Dey et al. [75]	UCLH Lupus Clinic	1.05 (0.52, 1.56)	Cervical, prostate, and pancreatic	Prevalent SLE patient	UK	1978~2010

SLE: systemic lupus erythematosus, SIR: standardized incidence ratio, CI: confidence interval, NHI: National Health Insurance, UCLH: University College London Hospital.

Several studies have been performed in Korea to determine the risk of cancer in SLE. A nationwide cohort study performed in Korea using NHI data demonstrated an increased risk of overall cancer (SIR 1.75, 95% CI 1.63~1.87), solid cancer (SIR 1.65, 95% CI 1.53~1.77), and hematologic cancer (SIR 5.85, 95% CI 4.48~7.27) [70]. In another Korean study based on the NHI database, Korean patients with SLE showed an increased risk of overall cancer (SIR 1.44, 95% CI 1.33~1.56) [71]. For Asian ethnicity, SLE patients in Taiwan had similar incidence rates of cancer development [69]. The cohort study identified an increased risk of overall cancer (SIR 1.76, 95% CI 1.74~1.79), vulva/vagina cancer (SIR 4.76, 95% CI 4.24~5.33), kidney cancer (SIR 3.99, 95% CI 3.74~4.27), nasopharyngeal cancer (SIR 4.18, 95% CI 3.93~4.45), and hematologic cancer (SIR 4.96, 95% CI 4.79~5.14). It is important to conduct multiple studies to provide valid and generalizable information to physicians and patients. Therefore, further studies should be focused on verifying the heterogeneity of a cancer type and preventable risk factors for cancer.

3) Serious infection in SLE

SLE patients have a higher risk of experiencing severe infections, including the first infection requiring hospitalization, a greater total number of severe infections, and infection-related mortality compared to the healthy individuals [81]. A study in Korea revealed that 11.2% of SLE patients experienced frequent hospitalizations, and major cause was disease flare (71.2%) and infection (17.1%) [82]. Another study revealed that infection was one of the major causes of death among SLE patients, highlighting the importance of managing infection risk in this population [83]. And, a population-based study in British reported that SLE patients had an increased risk of severe infection (HR 1.82, 95% CI 1.66~1.99) and infection-related mortality (HR 1.61, 95% CI 1.24~2.08) [84].

It was recognized that the infection risk in SLE patients was associated with various factors, such as immunosuppressive agents, comorbidities, and disease activity [85]. A cohort study in Japan suggested that the above 5 mg of prednisolone could pose an infection risk in SLE patients [86]. In Spain, incident SLE patients showed a 2~4 folds risk of severe infection, especially with azathioprine initiators [87]. In another study, the difference in infection risk based on SLE patients’ treatment was not evident. A few factors, including prednisolone dose, hypogammaglobulinemia, and comorbidities, significantly impacted serious infections [88]. While the heterogeneity of study design, patient population, and varying definition of infection makes direct comparison challenging, SLE patients experience a substantially higher risk of infections compared to the general population.

Mortality of SLE patients

The prognosis of SLE patients has shown significant improvement compared to previous years, with the persistence of low disease activity. However, due to various contributing factors, their mortality rate is still higher than the general population [89]. Mortality among SLE patients is high across all racial and ethnic groups; nevertheless, it is especially pronounced in Asian populations. In Korea, Chun et al. [90] showed that SLE patients had an increased death risk with a crude mortality rate of 596.0 per 100,000 PY and a standardized mortality ratio (SMR) of 3.02. This was slightly lower than the SMR of 3.8 in Asian groups from a US registry (CLSP), and it was higher than the SMR of white (2.3) and black (2.0) individuals [91]. Another multi-center retrospective cohort study reported that the cumulative 5-year survival rate was 96% among Korean SLE patients [83]. A cohort of SLE patients in a single center in China showed a 5-year survival rate of 93.8% [92], and an Egyptian study reported that the overall cumulative survival rate was 82.9% at 5 years after SLE diagnosis [93], which were lower than that in Korea. Further information on mortality and causes for 20, 30, and 40 years would be helpful to ensure a higher quality of life in patients.

CONCLUSION

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Abstract
INTRODUCTION
MAIN SUBJECTS
CONCLUSION
ACKNOWLEDGMENTS
FUNDING
CONFLICT OF INTEREST
AUTHOR CONTRIBUTIONS
REFERENCES

The overall prevalence and incidence of SLE have increased in Korea. Several studies have been conducted on SLE patients to assess it as an independent risk factor for cancer, CVD, and other diseases, which may affect the mortality rate. In addition, it is worth noting that variations in population structure, study design, and diagnostic criteria across different studies could contribute to result variations. Recent population-based studies conducted in Korea using the NHI database have significantly contributed to our understanding of SLE. These findings can potentially establish guidelines for diagnosing and treating Korean patients with SLE.

ACKNOWLEDGMENTS

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Abstract
INTRODUCTION
MAIN SUBJECTS
CONCLUSION
ACKNOWLEDGMENTS
FUNDING
CONFLICT OF INTEREST
AUTHOR CONTRIBUTIONS
REFERENCES

None.

FUNDING

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Abstract
INTRODUCTION
MAIN SUBJECTS
CONCLUSION
ACKNOWLEDGMENTS
FUNDING
CONFLICT OF INTEREST
AUTHOR CONTRIBUTIONS
REFERENCES

None.

CONFLICT OF INTEREST

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Abstract
INTRODUCTION
MAIN SUBJECTS
CONCLUSION
ACKNOWLEDGMENTS
FUNDING
CONFLICT OF INTEREST
AUTHOR CONTRIBUTIONS
REFERENCES

S.K.C. has been an editorial board member since June 2020, but has no role in the decision to publish this article.

AUTHOR CONTRIBUTIONS

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Abstract
INTRODUCTION
MAIN SUBJECTS
CONCLUSION
ACKNOWLEDGMENTS
FUNDING
CONFLICT OF INTEREST
AUTHOR CONTRIBUTIONS
REFERENCES

Y.K.S. and J.Y.H. were involved in the conception and study design. Y.K.S., S.K.C., and J.Y.H. were responsible for the data acquisition, analysis, and interpretation processes. Y.K.S., S.K.C., and J.Y.H were involved in revision of submitted manuscript. All authors approved the final version of submitted manuscript.

REFERENCES

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Abstract
INTRODUCTION
MAIN SUBJECTS
CONCLUSION
ACKNOWLEDGMENTS
FUNDING
CONFLICT OF INTEREST
AUTHOR CONTRIBUTIONS
REFERENCES

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Article

Review Article

J Rheum Dis 2023; 30(4): 211-219

Published online October 1, 2023 https://doi.org/10.4078/jrd.2023.0037

Epidemiology of systemic lupus erythematosus in Korea

Jung-Yong Han, M.D., M.S.^1,2, Soo-Kyung Cho, M.D., Ph.D.^1,2, Yoon-Kyoung Sung, M.D., Ph.D., MPH^1,2

¹Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, ²Hanyang University Institute for Rheumatology Research, Seoul, Korea

Correspondence to:Yoon-Kyoung Sung, https://orcid.org/0000-0001-6691-8939
Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, 222-1 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea. E-mail: sungyk@hanyang.ac.kr

Received: June 23, 2023; Revised: August 10, 2023; Accepted: August 10, 2023