Cell adhesion molecule expression in coronary artery aneurysms in acute Kawasaki disease

Epigenetics in Kawasaki Disease

Kawasaki disease (KD) is a common febrile multisystemic inflammatory illness in children that preferentially affects coronary arteries. Children with KD who develop coronary artery aneurysms have a life-long risk of premature coronary artery disease. Hypothesis of inherent predisposition to KD is supported by epidemiological evidence that suggests increased risk of development of disease in certain ethnicities and in children with a previous history of KD in siblings or parents. However, occurrence of cases in clusters, seasonal variation, and very low risk of recurrence suggests an acquired trigger (such as infections) for the development of illness. Epigenetic mechanisms that modulate gene expression can plausibly explain the link between genetic and acquired predisposing factors in KD. Analysis of epigenetic factors can also be used to derive biomarkers for diagnosis and prognostication in KD. Moreover, epigenetic mechanisms can also help in pharmacogenomics with the development of targeted therapies. In this review, we analysed the available literature on epigenetic factors such as methylation, micro-RNAs, and long non-coding RNAs in KD and discuss how these mechanisms can help us better understand the disease pathogenesis and advance the development of new biomarkers in KD.

Oxidative Phosphorylation-Mediated E-Selectin Upregulation Is Associated With Endothelia-Monocyte Adhesion in Human Coronary Artery Endothelial Cells Treated With Sera From Patients With Kawasaki Disease

Background and aims: E-selectin is a cell adhesion molecule of the vascular endothelium that mediates leukocyte rolling in the early inflammatory responses in many diseases including Kawasaki disease (KD). Previous studies have demonstrated that the expression levels of E-selectin was significantly increased in the sera of KD patients and in endothelial cells of KD patient's autopsy. In this study, we aimed to examine E-selectin levels in endothelial cells treated with sera from KD patients and explore the underlying mechanisms. Methods: Human coronary artery endothelial cells (HCAECs) were randomly incubated with sera from either healthy children [healthy control (HC group)] or pediatric KD patients [assigned as KD with coronary artery lesion (KD-CAL+ group) and KD without coronary artery lesion (KD-CAL- group)]. E-selectin levels were determined by RT-qPCR, Western blotting, and immunofluorescence. Cell adhesion assay was performed to quantify the role of E-selectin in intercellular adhesion. High-throughput cell RNA sequencing followed by functional validation was performed to explore the underlying mechanism. Results: E-selectin levels were significantly increased in KD-CAL+ group vs. HC group and KD-CAL- group. Compared with the KD-CAL- group, endothelia-monocyte adhesion was increased in the KD-CAL+ group, while E-selectin-specific siRNA could significantly rescue it. High-throughput cell RNA sequencing analysis also found a significant difference in oxidative phosphorylation (OXPHOS) levels between KD-CAL+ group and KD-CAL- group. Functional validation results further confirmed that the OXPHOS was upregulated in the KD-CAL+ group and KD-CAL- group compared to that in the HC group, while the KD-CAL+ group exhibited a higher OXPHOS than the KD-CAL- group. We also found that the E-selectin levels and endothelia-monocyte adhesion were significantly decreased by OXPHOS inhibitor oligomycin in the KD-CAL+ group and KD-CAL- group, respectively. Conclusion: Sera from KD patients stimulate OXPHOS levels and enhance E-selectin expression in HCAECs, which may contribute to the development of CAL in KD patients.

Kawasaki Disease and Allergic Diseases

Background: Kawasaki disease (KD) is an inflammatory disorder with an unknown etiology. It is the leading cause of acquired heart disease, which leads to coronary vasculitis among children. Studies of frequent manifestation of allergic diseases in children with KD have been the subject of mounting clinical interest. However, evidence supporting the association between KD and allergies has yet to be systematically reviewed. Methods: In this article, we reviewed current literature regarding the association between KD and allergic diseases. References for this review were identified through searches of PubMed, Cochrane, and Embase through the end of August 2020. Results: The results of the analyses of immune repertoire, clinical, and epidemiological studies have indicated some of the characteristics of infectious disease for KD. Although some allergic disorders, such as asthma, may be exacerbated by viral infections, allergies are typically caused by an allergen that triggers an immune response, with the potential involvement of type 2 inflammation and immune disturbances leading to tissue remodeling in genetically susceptible hosts. The effect of intravenous immunoglobulin is multi-faceted and results in a decrease in activating Fc gamma receptor IIA and an increase in anti-inflammatory eosinophils. The findings from this review demonstrate that children who have suffered from KD are more likely to have allergic rhinitis than the general population and their siblings, a condition that lasts until the age of 17. When followed up as teenagers and adults, children with KD are more likely to develop urticaria. Conclusions: This review supports that allergic diseases, such as allergic rhinitis, have been demonstrated to increase following KD. Therefore, the importance of allergic diseases in patients with KD should be emphasized in long-term care. Interventions that include strategies for managing allergies in children with KD would be beneficial.

Increased levels of circulating fibroblast growth factor 21 in children with Kawasaki disease

The purpose of this study was to examine the serum levels of fibroblast growth factor 21 (FGF21) in children with acute Kawasaki disease (KD) and to investigate its relationship with coronary artery lesions (CALs). Blood samples from 58 children with KD before intravenous immunoglobulin treatment and from 28 healthy children as control group were collected. Serum FGF21 levels in all participants were measured using enzyme-linked immunosorbent assay, and clinical parameters were tested in all KD patients. Serum FGF21 levels were significantly increased in acute KD patients as compared to the control group. Serum levels of FGF21 were substantially higher in the group of KD patients with CALs (KD-CALs) than in KD patients without CALs (KD-NCALs). Positive relationships between serum levels of FGF21 and percentage of leukomonocytes (L %), C-reactive protein, activated partial thromboplastin time and D-dimer were observed in KD patients. Furthermore, serum FGF21 levels were negatively correlated with red blood cell counts, hemoglobin (Hb), percentage of neutrophils (N %) and albumin. Serum level of FGF21 is associated with inflammation and coagulation. The paradoxical increase in serum FGF21 in acute KD patients may indicate a protective compensatory response.

Monocyte-Derived Interleukin-1β As the Driver of S100A12-Induced Sterile Inflammatory Activation of Human Coronary Artery Endothelial Cells: Implications for the Pathogenesis of Kawasaki Disease

OBJECTIVE

Kawasaki disease (KD) is an acute vasculitis of childhood, predominantly affecting the coronary arteries. S100A12, a granulocyte-derived agonist of both the receptor for advanced glycation end products (RAGE) and Toll-like receptor 4 (TLR-4), is strongly up-regulated in KD. This study was undertaken to investigate the potential contributions of S100A12 to the pathogenesis of KD.

METHODS

Serum samples from patients with KD (n = 30) at different stages pre- and post-intravenous immunoglobulin (IVIG) treatment were analyzed for the expression of S100A12, cytokines, chemokines, and soluble markers of endothelial cell activation. Primary human coronary artery endothelial cells (HCAECs) were analyzed for responsiveness to direct stimulation with S100A12 or lipopolysaccharide (LPS), as assessed by real-time quantitative reverse transcription-polymerase chain reaction analysis of cytokine and endothelial cell adhesion molecule messenger RNA expression. Alternatively, HCAECs were cultured in conditioned medium obtained from primary human monocytes that were stimulated with LPS or S100A12 in the absence or presence of IVIG or cytokine antagonists.

RESULTS

In the serum of patients with KD, pretreatment S100A12 levels were associated with soluble vascular cell adhesion molecule 1 titers in the course of IVIG therapy (r_s = -0.6, P = 0.0003). Yet, HCAECs were not responsive to direct S100A12 stimulation, despite the presence of appropriate receptors (RAGE, TLR-4). HCAECs did, however, respond to supernatants obtained from S100A12-stimulated primary human monocytes, as evidenced by the gene expression of inflammatory cytokines and adhesion molecules. This response was strictly dependent on interleukin-1β (IL-1β) signaling (P < 0.001).

CONCLUSION

In its role as a highly expressed mediator of sterile inflammation in KD, S100A12 appears to activate HCAECs in an IL-1β-dependent manner. These data provide new mechanistic insights into the contributions of S100A12 and IL-1β to disease pathogenesis, and may therefore support current IL-1-targeting studies in the treatment of patients with KD.

Disruption of vascular homeostasis in patients with Kawasaki disease: involvement of vascular endothelial growth factor and angiopoietins

OBJECTIVE

In Kawasaki disease (KD), a pediatric vasculitis of medium-sized arteries, the coronary arteries are most commonly affected. Angiopoietins and vascular endothelial growth factor (VEGF) play an important role in maintaining vascular homeostasis. Recently, we identified ANGPT1 and VEGFA as susceptibility loci for KD. This study was undertaken to fine-map these associations and to gain further insight into their role in this vasculitis of unknown etiology to further the search for improved diagnostic and therapeutic options.

METHODS

A total of 292 single-nucleotide polymorphisms (SNPs) located in VEGF and ANGPT and their receptors were genotyped in 574 families, including 462 trios. For replication, 123 cases and 171 controls were genotyped.

RESULTS

A significant association with KD susceptibility was observed with 5 SNPs in the ANGPT1 gene (most significantly associated SNP +265037 C>T; Pcombined=2.3×10(-7) ) and 2 SNPs in VEGFA (most significantly associated SNP rs3025039; Pcombined=2.5×10(-4) ). Both ANGPT1 +265037 C>T and VEGFA rs3025039 are located in 3' regulatory regions at putative transcription factor binding sites. We observed significantly down-regulated transcript levels of angiopoietin 1 (Ang-1) in patients with acute KD compared to patients with convalescent KD. In patients with acute KD, high serum protein levels of VEGF and Ang-2 were observed compared to patients with convalescent KD and to both controls with and controls without fever. Immunohistochemistry demonstrated VEGF and angiopoietin expression in the coronary artery wall in autopsy tissue.

CONCLUSION

Our data support the hypothesis that dysregulation of VEGF and angiopoietins contributes to the disruption of vascular homeostasis in KD.

Long-term prognosis of Kawasaki disease: increased cardiovascular risk?

PURPOSE OF REVIEW

Whereas the cause of Kawasaki disease is still unknown, progress in treatment during its acute phase has decreased the incidence of coronary artery lesions from 25-30% to 3-5%. In addition to acute-phase coronary disturbances, sclerotic vascular changes are often observed in post-Kawasaki disease patients, including those without coronary lesions during the acute phase. Survivors of Kawasaki disease are now reaching the age of atherosclerosis and it is unknown if these individuals carry a higher risk of coronary disease. This review aims to report the current state of knowledge concerning the long-term prognosis of patients with Kawasaki disease.

RECENT FINDINGS

Histopathological studies prove the changes of Kawasaki disease to be distinctive from those of atherosclerosis. However, endothelial dysfunction and risk factors for the development of atherosclerosis, such as dyslipidemia, decreased vascular elasticity, increased C-reactive protein, oxidative stress, inflammatory cytokines, and reactive oxygen species, are known to be present in the late phase of Kawasaki disease. In addition, postarteritis coronary arteries in animal models are more prone to the development of atherosclerotic changes.

SUMMARY

Potential cardiovascular risks are present in survivors of Kawasaki disease. Epidemiological studies enrolling a large cohort of Kawasaki disease patients surviving to middle age are awaited.

Pathogenesis and management of Kawasaki disease

Kawasaki disease (KD) is an acute systemic inflammatory illness of young children that can result in coronary artery aneurysms, myocardial infarction and sudden death in previously healthy children. Clinical and epidemiologic features support an infectious cause, but the etiology remains unknown four decades after KD was first identified by Tomisaku Kawasaki. Finding the cause of KD is a pediatric research priority. We review the unique immunopathology of KD and describe the current treatment. New research has led to identification of viral-like cytoplasmic inclusion bodies in acute KD tissues; this finding could lead to identification of the elusive etiologic agent and result in significant advances in KD diagnosis and treatment. Current management of acute KD is based upon prospective, multicenter treatment trials of intravenous immunoglobulin (IVIG) with high-dose aspirin. Optimal therapy is 2 g/kg IVIG with high-dose aspirin as soon as possible after diagnosis during the acute febrile phase of illness, followed by low-dose aspirin until follow-up echocardiograms indicate a lack of coronary abnormalities. The addition of one dose of intravenous pulse steroid has not been shown to be beneficial. For the 10-15% of patients with refractory KD, few controlled data are available. Options include repeat IVIG (our preference), a 3-day course of intravenous pulse methylprednisolone, or infliximab (Remicade). Patients with mild-to-moderate coronary abnormalities should receive an antiplatelet agent such as low-dose aspirin (3-5 mg/kg/day) or clopidogrel (1 mg/kg/day up to 75 mg), and those with giant (approximately 8 mm diameter) or multiple coronary aneurysms should receive an antiplatelet agent with an anticoagulant such as warfarin or low-molecular-weight heparin. Acute coronary obstruction requires acute thrombolytic therapy with a surgical or percutaneous interventional procedure.

Long-term prognosis of patients with Kawasaki disease: at risk for future atherosclerosis?

Kawasaki disease causes coronary artery lesions, such as dilatation, aneurysms, stenosis, and even occlusion in young children, and is one of the most common acquired heart diseases in developed countries. More than 10,000 new cases are reported in Japan every year. In its acute phase, severe coronary arteritis induces morphological changes in coronary arteries. Treatments for Kawasaki disease aim to eliminate coronary artery inflammation as quickly as possible to reduce the chance of causing coronary lesions. Immunoglobulin therapy with aspirin has become the standard therapy of first choice and helps attenuate coronary lesions. In addition to coronary artery disturbances in the acute phase, sclerotic vascular changes were observed in post-Kawasaki disease patients who did not have coronary lesions in the acute phase. Recent studies have revealed peripheral vasculature endothelial dysfunction in post-Kawasaki disease patients with and without coronary lesions. The risk factors for the development of atherosclerosis in adults, such as C-reactive protein, oxidative stress, and inflammatory cytokines, are also increased in the remote phase of Kawasaki disease. This morphological and functional endothelial dysfunction as Kawasaki disease vascular sequelae may suggest the early development of atherosclerosis in patients with Kawasaki disease. However, no direct evidence for this early development has been found so far. Kawasaki disease was first reported slightly more than 40 years ago. The first documented post-Kawasaki disease patients are now becoming old enough to have atherosclerosis. Some case reports suggest myocardial infarction with atherosclerotic changes in young adults who are believed to have a history of Kawasaki disease. This paper reviews Kawasaki disease from the perspective of long-term prognosis.

Searching for the cause of Kawasaki disease--cytoplasmic inclusion bodies provide new insight

Although Kawasaki disease (KD) is the most common cause of acquired heart disease in children in the developed world, its aetiology remains unknown. In this Opinion, Anne Rowley and colleagues discuss evidence, including recently identified cytoplasmic inclusion bodies, which suggests that KD is caused by an infectious agent.

Kawasaki disease (KD) has emerged as the most common cause of acquired heart disease in children in the developed world. The cause of KD remains unknown, although an as-yet unidentified infectious agent might be responsible. By determining the causative agent, we can improve diagnosis, therapy and prevention of KD. Recently, identification of an antigen-driven IgA response that was directed at cytoplasmic inclusion bodies in KD tissues has provided new insights that could unlock the mysteries of KD.

Kawasaki disease: four case reports of cardiopathy with an institutional and literature review

Kawasaki disease (KD) is a systemic vasculitis condition with a relatively unknown etiology. First described in 1967 by Tomisaku Kawasaki in Japan, KD has come to be widely diagnosed in every region of the world. The disease has a high prevalence in children ages 6 months to 5 years, particularly in those of Japanese descent. Patients often present with a high fever, rash, lymphadenopathy, and conjunctival injections, but there is no diagnostic test for KD. This paper presents data from our Kawasaki registry including 99 patients with emphasis on Kawasaki cardiopathy. Three patients died from complications of KD, and 1 patient underwent heart transplant for massive aneurysmal dilatation. The 4 explanted hearts showed a spectrum of pathological findings (acute thrombosis, vasculitis, and myocarditis), and 1 patient showed the long-term sequelae of vasculitis in the form of massive aneurysmal dilatation. Among the survivors, 30% showed aneurysmal dilatation. This paper reviews the most recent information regarding Kawasaki cardiopathy and underlying molecular mechanisms.

Coronary artery aneurysm induced by Kawasaki disease in children show features typical senescence

BACKGROUND

Kawasaki disease (KD) causes coronary artery disease (CAD) in children. In addition, a history of KD is suspected to be a risk factor for the development of atherosclerotic heart disease in the future. Histological senescence changes are a common denominator in atherosclerotic lesions in adults, so the present study investigated whether histological senescence changes had already occurred in KD aneurysm.

METHODS AND RESULTS

KD coronary aneurysms and internal mammary arteries retrieved from 5 children with KD (3, 4, 5, 6, and 11 years old, respectively) who underwent coronary artery bypass grafting, as well as giant coronary aneurysm size-reducing operations, were analyzed. Senescence-associated strong beta-galactosidase activity was observed in KD aneurysms, but not in the internal mammary arteries. An immunohistochemical analysis of the KD aneurysm using anti-CD31, anti-endothelial nitric oxide synthetase (eNOS), anti-vascular adhesion molecule-1 (VCAM-1), and anti-monocyte chemoattractant protein-1 (MCP-1) showed vascular endothelium CD31 staining, decreased staining of eNOS and strong staining of MCP-1 and VCAM-1. cDNA microarray gene expression profiling revealed increased MCP-1 expression in the KD aneurysm, a finding confirmed by quantitative polymerase chain reaction.

CONCLUSIONS

Histological features of senescence and active remodeling gene expression show that the KD aneurysm is not a silent vasculitis terminal. The future fate of KD aneurysms, including atherosclerosis, should be monitored carefully.

Longitudinal course and clinical significance of TGF-beta1, sL- and sE-Selectins and sICAM-1 levels during severe acute stress in children

OBJECTIVES

To elucidate the potential role of circulating levels of transforming growth factor-beta1 (TGF-beta1), soluble intercellular adhesion molecule-1 (sICAM-1), soluble L- and sE-Selectins (sL- and sE-Selectins) in children with sepsis, traumatic brain injury (TBI) or acute respiratory distress syndrome (ARDS).

DESIGN AND METHODS

Levels of TGF-beta1, sICAM-1, L- and sE-Selectins were determined using solid-phase sandwich enzyme-linked immunosorbent assay in plasma of 10 patients with sepsis, 10 patients with TBI, 10 patients with ARDS, compared to 10 ventilated controls with chronic illness but not in acute stress, on days 1, 3, 5, 7 and 10.

RESULTS

The highest values of sICAM-1 were observed in patients with TBI (p<0.001) and those of sE-Selectin in patients with sepsis (p=0.0001). Patients in the control group did not show an elevation of sE-Selectin and sICAM-1 levels longitudinally. Increased levels of measured molecules (TGF-beta1, p<0.02, sE-Selectin, p<0.02, sL-Selectin, p=0.06, sICAM-1, p<0.03) were demonstrated among survivors in the sepsis and ARDS groups of patients and were positively correlated with length of stay (p<0.04) and mechanical ventilation (p<0.001).

CONCLUSIONS

A sustained increase of adhesion molecules occurs during acute stress in children which may contribute to morbidity in patients with sepsis (sE-Selectin) or traumatic brain injury (sICAM-1). Suppression of the expected response of sE-Selectins, s-ICAM-1 and TGF-beta1 is associated with poor outcome.

Family-based association analysis implicates IL-4 in susceptibility to Kawasaki disease

Several compelling lines of evidence suggest an important influence of genetic variation in susceptibility to Kawasaki disease (KD), an acute vasculitis that causes coronary artery aneurysms in children. We performed a family-based genotyping study to test for association between KD and 58 genes involved in cardiovascular disease and inflammation. By analysis of a cohort of 209 KD trios using the transmission disequilibrium test, we documented the asymmetric transmission of five alleles including the interleukin-4 (IL-4) C(-589)T allele (P=0.03). Asymmetric transmission of the IL-4 C(-589)T was replicated in a second, independent cohort of 60 trios (P=0.05, combined P=0.002). Haplotypes of alleles in IL-4, colony-stimulating factor 2 (CSF2), IL-13, and transcription factor 7 (TCF7), all located in the interleukin gene cluster on 5q31, were also asymmetrically transmitted. The reported associations of KD with atopic dermatitis and allergy, elevated serum IgE levels, eosinophilia, and increased circulating numbers of monocyte/macrophages expressing the low-affinity IgE receptor (FCepsilonR2) may be related to effects of IL-4. Thus, the largest family-based genotyping study of KD patients to date suggests that genetic variation in the IL-4 gene, or regions linked to IL-4, plays an important role in KD pathogenesis and disease susceptibility.

Pathogenesis and treatment of Kawasaki's disease

PURPOSE OF REVIEW

Coronary artery damage resulting from Kawasaki's disease is the leading cause of acquired heart disease in children in the developed world. This review highlights advances in our understanding of the etiology of Kawasaki's disease, the immune response leading to vascular damage, potential biomarkers, and insights into mechanisms of disease addressed by an animal model. Clinical dilemmas are discussed in the context of the new American Heart Association recommendations for the diagnosis and treatment of Kawasaki's disease.

RECENT FINDINGS

Improved understanding of the mechanisms of disease will assist in identifying predisposed individuals and in development of more effective therapy. Most investigators agree that an infectious trigger leads to massive activation of the immune system, resulting in a prolonged self-directed immune response at the coronary arteries. The etiology debate has centered on the nature of and mechanisms involved in immune activation. Genetic studies have not provided conclusive answers to these questions. Mechanistic studies done in animal models have pointed to specific biologic factors critical for coronary artery damage and together with studies in children may lead to more rationally conceived biologically based interventions. Increasingly, the questions regarding clinical management address timing of therapy and the management of children presenting with atypical Kawasaki's disease. New guidelines and management algorithms have been proposed by the American Heart Association to address these concerns.

SUMMARY

Biochemical and phenotypic characterization of Kawasaki's disease continues to improve. Answers are closer on etiology, reliable biomarkers, valid predictors of coronary outcome, and improved treatment of this syndrome.