Global prevalence, site-specific patterns, and key risk factors for osteoporosis and bone loss in systemic lupus erythematosus: a systematic review and meta-analysis

Background: Systemic lupus erythematosus (SLE) is a complex autoimmune disease in which patients have a significantly increased risk of developing osteoporosis (OP) and osteopenia. Despite numerous studies, the global burden of SLE-related OP, its regional distribution patterns and its major risk factors remain poorly quantified and subject to controversy due to heterogeneity in sample sizes, diagnostic criteria and methodologies. To address these gaps in the evidence, we conducted a systematic assessment of the prevalence and risk factors for OP and osteopenia in patients with SLE. Methods: We conducted a systematic review and meta-analysis. We performed a comprehensive search of Chinese and English databases, including PubMed, Embase, the Cochrane Library, Web of Science, CNKI and WANFANG, up to 26 September 2025. We included observational studies that met the diagnostic criteria for SLE and reported the prevalence of OP or reduced bone mass, as well as associated risk factors. Two reviewers independently conducted literature screening, data extraction and quality assessment. Statistical analysis was performed using Stata 12.0 software; random-effects or fixed-effects models were employed to pool prevalence rates and odds ratios, and subgroup analysis, meta-regression and sensitivity analysis were used to explore sources of heterogeneity. Results: A total of 59 studies were included. Meta-analysis revealed an overall prevalence of osteoporosis in SLE patients of 16.70% (95% CI: 14.2%, 19.3%) and a prevalence of osteopenia of 39.50% (95% CI: 35.5%, 43.5%). Site-specific analysis indicated that the lumbar spine was the site with the highest prevalence of osteoporosis (10.0%), whilst the femoral neck was the site most commonly affected by osteopenia (44.1%). Subgroup analysis identified several high-risk populations; the prevalence of osteoporosis in postmenopausal women (34.0%) was significantly higher than in premenopausal women (11.6%). Risk factor analysis indicated that advanced age (>50 years, OR = 21.92), long-term glucocorticoid use (OR = 1.63) and prolonged duration of SLE (OR = 1.05) were significant risk factors for OP. Glucocorticoid dosage was positively correlated with risk, with a significant increase in risk observed at daily doses >10 mg. Conclusion: Patients with SLE are at high risk of osteoporosis and osteopenia; postmenopausal women, Asian patients and those on long-term glucocorticoid therapy should be prioritized for screening and intervention. This study has revealed site-specific patterns of skeletal involvement and quantified the impact of key risk factors. In clinical practice, priority should be given to combined bone density monitoring, focusing on the lumbar spine and femoral neck, in high-risk populations. Furthermore, risk-stratified, proactive bone health management strategies should be implemented, with the aim of shifting the focus from 'treating fractures' to 'preventing fractures', thereby improving long-term patient outcomes. Systematic Review Registration: https://inplasy.com/inplasy-2025-12-0043/, identifier INPLASY2025120043.