Prospective Evaluation of Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio for Intravenous Immunoglobulin Resistance in a Large Cohort of Kawasaki Disease Patients

The Associations of Two Novel Inflammation Biomarkers, SIRI and SII, with Mortality Risk in Patients with Chronic Heart Failure

Background

The associations of two novel inflammation biomarkers, systemic inflammation response index (SIRI) and systemic immune inflammation index (SII), with mortality risk in patients with chronic heart failure (CHF) are not well-characterized.

Methods

This retrospective cohort study included patients with CHF in two medical centers of Chinese People's Liberation Army General Hospital, Beijing, China. The outcomes of this study included in-hospital mortality and long-term mortality. Associations of SIRI and SII with mortality were assessed using multivariable regressions and receiver operating characteristic (ROC) analyses.

Results

A total of 6232 patients with CHF were included in the present study. We documented 97 cases of in-hospital mortality and 1738 cases of long-term mortality during an average 5.01-year follow-up. Compared with patients in the lowest quartile of SIRI, those in the highest quartile exhibited 134% higher risk of in-hospital mortality (adjusted odds ratio, 2.34; 95% confidence interval [CI], 1.16-4.72) and 45% higher risk of long-term mortality (adjusted hazard ratio, 1.45; 95% CI, 1.25-1.67). Compared with patients in the lowest quartile of SII, those in the highest quartile exhibited 27% higher risk of long-term mortality (adjusted hazard ratio, 1.27; 95% CI, 1.11-1.46). In ROC analyses, SIRI showed better prognostic discrimination than C-reactive protein (area under the curve: 69.39 vs 60.91, P = 0.01, for in-hospital mortality; 61.82 vs 58.67, P = 0.03, for 3-year mortality), whereas SII showed similar prognostic value with C-reactive protein.

Conclusion

SIRI and SII were significantly associated with mortality risk in patients with CHF. SIRI may provide better prognostic discrimination than C-reactive protein.

Nomogram for predicting coronary artery lesions in patients with Kawasaki disease

BACKGROUND

Coronary artery lesions are the most important complications of Kawasaki disease. Approximately 25-30% of untreated patients develop coronary artery disease, which can lead to long-term cardiovascular sequelae.

AIM

The aim of this study is to evaluate the risk factors for coronary artery lesions in Kawasaki disease and to construct a nomogram for predicting the likelihood of developing such lesions.

METHODS

Data from 599 patients between January 2012 and June 2020 were reviewed retrospectively. Patients were randomly assigned to the training set (n = 450) and the validation set (n = 149). A comparison of clinical features and laboratory data was performed, followed by multivariate logistic regression analysis to identify independent risk factors and develop the nomogram. The predictive efficiency of the nomogram was evaluated using the calibration curve, area under the receiver operating characteristic curve (AUC), C-index, and decision curve analysis (DCA).

RESULTS

Intravenous immunoglobulin (IVIG) resistance, delayed IVIG treatment, C-reactive protein, and neutrophil/lymphocyte ratio were identified as independent risk factors for the development of coronary artery lesions. The nomogram was constructed based on these four variables. The calibration curve of the nomogram showed a high degree of agreement between the predicted probability and the actual probability. The AUC of the nomogram in the training and validation set was 0.790 and 0.711, respectively. In addition, DCA revealed that the nomogram provided a significant net benefit, further supporting its clinical utility.

CONCLUSIONS

The constructed nomogram demonstrates a strong and reliable performance in predicting coronary artery lesions, which enables clinicians to make timely and tailored clinical decisions.

Neutrophil-to-Lymphocyte Ratio as a Predictor of the Need for Surgical Treatment in Children's Intussusception

OBJECTIVE

 Neutrophil-to-lymphocyte ratio (NLR) is an emerging inflammatory marker in abdominal pathologies. Ileocolic intussusception (ICI) involves a progressive intestinal inflammation, and the effectiveness of nonsurgical treatment (enema) might be related to the inflammation degree, although no previous studies have investigated this relationship. Our aim is to identify predictors of the need for surgical treatment in ICI.

MATERIALS AND METHODS

 A single-center, retrospective, case-control study was performed in children with ICI, who were treated with initial nonsurgical management between 2005 and 2019. Patients were divided in two groups: A (effective enema) and B (need for surgery). Admission demographic and clinical and laboratory data were analyzed. Specificity and sensitivity of the different parameters as predictors of the need for surgical treatment were determined by receiver operating characteristic (ROC) curves.

RESULTS

 A total of 511 patients were included (410: group A; 101: group B), without statistically significant demographic differences. Group B presented significantly higher frequency of vomiting, bloody stools, and longer median time since symptoms onset (24 vs. 8 hours; p < 0.001). Group B presented higher median laboratory inflammatory markers than group A: NLR (6.8 vs. 1.8; p < 0.001), neutrophils (10,148 vs. 7,468; p < 0.001), and C-reactive protein (CRP; 28.2 vs. 4.7; p < 0.001). In ROC curve analysis, NLR had an area under the curve of 0.925, higher than neutrophil count (0.776; p = 0.001), CRP (0.670; p = 0.001), and time since symptoms onset (0.673; p = 0.001). It was estimated a cut-off point of NLR greater than 4.52 (sensitivity: 73.2%; specificity: 94.5%).

CONCLUSION

 High NLR values imply a high degree of bowel inflammation and might anticipate the need for surgical treatment in ICI in children.

LEVEL OF EVIDENCE

 III.

The role of neutrophil-to-lymphocyte ratio as a predictor of testicular torsion in children

INTRODUCTION

Doppler ultrasound constitutes the gold standard for the diagnosis of testicular torsion (TT), although sometimes the spermatic cord twisting and absence of testicular flow are difficult to visualize. To date, no laboratory markers have been shown to be useful for preoperative TT diagnosis.

OBJECTIVE

Our aim is to analyze the role of the neutrophil-to-lymphocyte ratio (NLR) as a predictor of pediatric TT.

STUDY DESIGN

A retrospective single-center case-control study was performed in patients with ultrasound suspicion of TT, in whom surgical testicular examination was performed between 2016 and 2020. Patients were divided into two groups according to the intraoperative findings: TT group (testicular torsion), defined as spermatic cord twisting on itself around its longitudinal axis at least 360°, and non-TT group (no torsion). Demographics, clinical, ultrasound and laboratory features at admission were analyzed. Sensitivity and specificity were determined by the area under the curve (AUC) represented on the receiver operating characteristic (ROC) curves.

RESULTS

A total of 159 patients were included (117 TT group; 42 non-TT group), with no demographic or clinical differences. TT group patients presented significantly shorter median time since symptoms onset (4 vs. 8 h; p < 0.012). Laboratory inflammatory test were significantly higher in TT group: Leukocytes (10,900 × 10³/μl vs. 7,980 × 10³/μl; p < 0.001), neutrophils (8,050 × 10³/μl vs. 3,350 × 10³/μl; p < 0.001) and NLR (4.6 vs. 1.1; p < 0.001). In ROC curve analysis, NLR presented the highest AUC (0.903), significantly higher than all other laboratory and ultrasound parameters. NLR of 2.3 was the cut-off point with maximum sensitivity (86.9%) and specificity (94.8%).

DISCUSSION

This is, to the best of our knowledge, the first study to analyze the usefulness of NLR in predicting the diagnosis of TT in patients with clinical and ultrasound suspicion. The limitations are mainly derived from being a single-center retrospective study. For this reason, multicenter studies with a higher number of patients and prospective design may be useful to minimize these biases. The sample size of our study, although not large, has allowed us to identify significant differences between the distinct parameters analyzed as predictors of TT. However, the absence of other similar studies in pediatric patients has hindered the comparison of our results.

CONCLUSION

NLR should be considered as a predictor of pediatric TT in cases with nuclear ultrasound suspicion that may help to anticipate the urgent surgical treatment in these patients.

Establishment and Validation of a Multivariate Predictive Scoring Model for Intravenous Immunoglobulin-Resistant Kawasaki Disease: A Study of Children From Two Centers in China

Background

Early identification of intravenous immunoglobulin (IVIG)-resistant Kawasaki disease (KD) is important for making a suitable therapeutic strategy for children with KD.

Methods

This study included a training set and an external validation set. The training set included 635 children (588 IVIG-sensitive and 47 IVIG-resistant KD) hospitalized in Wuhan Children’s Hospital, Hubei, China. Univariate analyses and binary logistic regression equation was incorporated to find the associated variables of the IVIG-resistant KD. A scoring model for predicting IVIG-resistant KD was established according to odds ratio (OR) values and receiver operating characteristic curves. The external validation set consisted of 391 children (358 IVIG-sensitive and 33 IVIG-resistant KD) hospitalized in Peking University First Hospital, Beijing, China. The predictive ability of the model of IVIG-resistant KD were externally validated by the real clinically diagnosed KD cases.

Results

Fifteen variables in the training set were statistically different between IVIG-sensitive and IVIG-resistant KD children, including rash, duration of fever, peripheral blood neutrophil-to-lymphocyte ratio (NLR), prognostic nutritional index (PNI), percentage of monocytes and percentage of eosinophils, and serum alanine aminotransferase, aspartate aminotransferase, total bilirubin (TB), direct bilirubin, glutamyl transpeptidase, prealbumin, sodium ion, potassium ion and high-sensitivity C-reactive protein. According to logistic equation analysis, the final three independent correlates to IVIG-resistant KD were serum TB ≥ 12.8 μmol/L, peripheral blood NLR ≥ 5.0 and peripheral blood PNI ≤ 52.4. According to the OR values, three variables were assigned the points of 2, 2 and 1, respectively. When the score was ≥ 3 points, the sensitivity to predict IVIG-resistant KD was 80.9% and the specificity was 77.6%. In the validation set, the sensitivity, specificity and accuracy of the predictive model of IVIG-resistant KD were 72.7%, 84.9%, and 83.9%, respectively.

Conclusion

A scoring model was constructed to predict IVIG-resistant KD, which would greatly assist pediatricians in the early prediction of IVIG-resistant KD.

Value of blood inflammatory markers for predicting intravenous immunoglobulin resistance in Kawasaki disease: A systematic review and meta-analysis

BACKGROUND

Previous studies have assessed the diagnostic accuracy of blood inflammatory markers like neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP), and CRP to albumin ratio (CAR) to predict the resistant Kawasaki disease (KD). The aim of the current meta-analysis and systematic review is to compare the prognostic ability of these inflammatory markers to predict the resistance to IVIG in patients with Kawasaki disease.

METHODS

A systematic search of online academic databases and search engines such as EMBASE, PubMed Central, MEDLINE, Cochrane library, Google Scholar, and ScienceDirect was conducted for papers that report the diagnostic accuracy of inflammatory markers for resistant KD. Meta-analysis was performed using STATA software.

RESULTS

Twenty-two studies met the inclusion criteria. Pooled sensitivity and specificity of NLR as a predictor of resistant Kawasaki disease was 72% (95% CI: 62%, 80%) and 71% (95% CI: 63%, 78%), with AUC of 0.77 for PLR was 60% (95% CI: 50%, 69%) and 68% (95% CI: 61%, 75%), with area under the curve (AUC) of 0.69. Pooled sensitivity and specificity of CRP was 75% (95% CI: 68%, 81%) and 66% (95% CI: 55%, 76%), respectively, with an AUC value of 0.78. Pooled sensitivity and specificity of combined NLR and PLR was 58% (95% CI: 46%, 69%) and 73% (95% CI: 65%, 79%), respectively, with an AUC value of 0.72.

CONCLUSION

Our study found that NLR, CRP, PLR, and combined NLR/PLR have a good prognostic value in patients with resistant Kawasaki disease, with moderate to high sensitivity and specificity. More research on the accuracy of these indexes in multiple combinations is needed.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022322165].

Predictive value of Albumin-Bilirubin grade for intravenous immunoglobulin resistance in a large cohort of patients with Kawasaki disease: a prospective study

BACKGROUND

Intravenous immunoglobulin (IVIG) resistance prediction is one of the primary clinical issues and study hotspots in KD. This study aimed to prospectively investigate the value of albumin-bilirubin grade (ALBI) in predicting IVIG resistance in KD and to assess whether ALBI has more predictive value or accuracy than either ALB or TBil alone in predicting IVIG resistance.

METHODS

A total of 823 patients with KD were prospectively enrolled. The clinical and laboratory data were compared between the IVIG-response group (n = 708) and the IVIG-resistance group (n = 115). Multivariate logistic regression analysis was performed to identify the independent risk factors for IVIG resistance. Receiver operating characteristic (ROC) curves analysis was applied to assess the validity of ALBI, ALB, and TBil in predicting IVIG resistance.

RESULTS

ALBI was significantly higher in patients with IVIG resistance and was identified as an independent risk factor for IVIG resistance in KD. The parameter of ALBI ≥ - 2.57 (AUC: 0.705, 95 %CI: 0.672-0.736), ALB ≤ 33.0 g/L (AUC: 0.659, 95 %CI: 0.626-0.692), and TBil ≥ 16.0µmol/L (AUC: 0.626, 95 %CI: 0.592-0.659), produced a sensitivity, specificity, PPV, and NPV of 0.617, 0.657, 0.226 and 0.914; 0.374, 0.850, 0.289 and 0.893; 0.269, 0.941, 0.425 and 0.888, respectively.

CONCLUSIONS

A higher ALBI was an independent risk factor for IVIG resistance in KD. It yielded better predictive ability than ALB and TBil alone for initial IVIG resistance.

Predictive Value of the Systemic Immune-Inflammation Index for Intravenous Immunoglobulin Resistance and Cardiovascular Complications in Kawasaki Disease

Background: The prediction of intravenous immunoglobulin (IVIG) resistance and cardiovascular complications are critically clinical issues in Kawasaki disease (KD). This prospective study firstly aimed to determine the predictive ability of the systemic immune inflammation index (SII) for IVIG resistance and cardiovascular complications and compare the prognostic accuracy of SII with that of neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR).

Methods: Patients with KD were divided into different groups according to the presence of IVIG resistance or cardiovascular complications (coronary artery lesions, valve regurgitation, myocarditis, pericardial effusion, and Kawasaki disease shock syndrome [KDSS]). The clinical and laboratory parameters were compared. Further analysis stratified by platelet level was performed. Multivariate logistic regression analysis was used to identify predictors for IVIG resistance and cardiovascular complications. The receiver operating characteristic (ROC) curve was applied to assess and compare the ability of SII, NLR, and PLR for predicting IVIG resistance and cardiovascular complications.

Results: SII was significantly higher in KD patients with IVIG-resistance, myocarditis, valve regurgitation, and KDSS. It was identified as an independent risk factor for IVIG resistance, myocarditis, and valve regurgitation. For KD patients with thrombocytopenia, there were no significant differences in SII between KD patients with IVIG resistance/cardiovascular complications and those without. The best cutoff values of SII for IVIG resistance, myocarditis, valve regurgitation, and KDSS prediction in the whole cohort were 1331.4 × 10⁹, 1368.6 × 10⁹, 1002.4 × 10⁹, and 1485.4 × 10⁹, with a corresponding sensitivity of 0.525, 0.614, 0.754, and 0.670, a specificity of 0.711, 0.723, 0.584, and 0.730, respectively. The predictive value of SII for both IVIG resistance and cardiovascular complications were not superior to that of NLR.

Conclusion: Although the parameter of SII may predict IVIG resistance, myocarditis, valve regurgitation, and KDSS in KD as a single parameter, its predictive ability was not good enough and not superior to NLR. SII might not be applicable in patients with KD having thrombocytopenia.

Is there an association between intravenous immunoglobulin resistance and coronary artery lesion in Kawasaki disease?-Current evidence based on a meta-analysis

Background

Coronary artery lesion (CAL) caused by Kawasaki disease (KD) is a leading cause of acquired heart disease in children. Initial treatment of intravenous immunoglobulin (IVIG) can reduce the incidence of CAL. Although most of the current studies have shown a certain correlation between CAL and IVIG resistance, the conclusions are not completely consistent. Thus, we performed this meta-analysis to evaluate the association between IVIG resistance and CAL in KD.

Methods

PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and China National Knowledge Infrastructure through April 21, 2020 were searched to detect relevant studies. Data analysis was performed with STATA 15.1.

Results

A total of 53 relevant studies were eligible to this analysis, including 30312 KD patients, of which 4750 were IVIG resistance and 25562 were responders. There was a significant difference found between IVIG resistance and IVIG response groups in the incidence of CAL (P < 0.001, odds ratio (OR), 3.89; 95% confidence interval (CI) (3.18, 4.75)). The heterogeneity test results showed that the I² value was 74.8%. The meta-regression analysis showed that the study regions might be the sources of heterogeneity. The subgroup analysis suggested that the incidence of CAL in the IVIG resistance group was still higher than that in the IVIG response group under different regions, IVIG resistance diagnostic criteria, CAL diagnostic criteria, and study types. Meanwhile, the sensitivity analysis did not find any significant impact from every single study.

Conclusions

This is the first meta-analysis to reveal the incidence of CAL was associated with IVIG resistance in KD patients. Further well-designed studies with uniform criteria are needed to evaluate the incidence of CAL in IVIG resistant patients.

Predictive value of C-reactive protein to albumin ratio as a biomarker for initial and repeated intravenous immunoglobulin resistance in a large cohort of Kawasaki disease patients: a prospective cohort study

BACKGROUND

Intravenous immunoglobulin (IVIG) resistance prediction is one pivotal topic of interests in Kawasaki disease (KD). This study aimed to prospectively investigated the value of C-reactive protein-to-albumin (CAR) in predicting both initial and repeated IVIG resistance in patients with KD, and to test the hypothesis that CAR was more valuable or accurate than either C-reactive protein (CRP) or albumin (ALB) alone in IVIG resistance prediction.

METHOD

A prospective cohort study involving 550 patients with KD was conducted. The clinical and laboratory data were compared between IVIG-response group and IVIG-resistance group. Multivariate logistic regression analysis was performed to identify the independent risk factors of initial/repeated IVIG resistance. Receiver operating characteristic (ROC) curves analysis was applied to assess the validity of CAR, CRP and ALB in predicting both initial and repeated IVIG resistance.

RESULTS

CAR was significantly higher in IVIG non-responders and was identified as independent risk factor for both initial and repeated IVIG resistance in KD. The best cut-off value of CAR for initial and repeated IVIG resistance prediction was 2.07 and 3.34, with a corresponding sensitivity of 0.610 and 0.548, a specificity of 0.552 and 0.813, respectively. The value of CAR was not better than either CRP or ALB alone for both initial and repeated IVIG resistance prediction.

CONCLUSION

A higher CAR was an independent risk factor for both initial and repeated IVIG resistance. However, similar with that of CRP or ALB, the predictive value of CAR was not good enough for both initial and repeated IVIG resistance prediction in KD.

Prognostic value of pretreatment prognostic nutritional index in intravenous immunoglobulin-resistant Kawasaki disease

The aim of the present study was to investigate the potential predictive significance of pretreatment prognostic nutritional index (PNI) in intravenous immunoglobulin (IVIG) resistant Kawasaki disease (KD). The PNI, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) were analyzed in 1257 eligible patients with KD. Receiver operating curve analysis was used to explore the prediction accuracy for IVIG-resistant KD. The optimal cut-off values were identified as 49.5 for PNI, 3.58 for NLR and 164.00 for PLR, respectively. Lower pretreatment PNI (< 49.5) was demonstrated to be associated with lower age, serum sodium levels and platelet counts, and with a higher incidence of IVIG resistance and higher C-reactive protein levels. There was a significantly negative association between the PNI and NLR, and PLR. Univariate and multivariate analyses revealed that PNI, NLR and PLR were independent predictive factors for IVIG resistance. The discriminatory ability of PNI was not inferior to NLR, PLR and their combination (NLR > 3.58 and PLR > 164) for predicting IVIG resistance, respectively. Pretreatment PNI may serve as a novel surrogate independent predictor for IVIG-resistant KD.

The Expression of Glycoprotein Genes in the Inflammatory Process of Kawasaki Disease

Background: Kawasaki disease (KD) is the most common form of febrile coronary vasculitis disease to occur in children. Early diagnosis and proper therapy can prevent the complication of coronary artery lesions (CAL). The main pathogenesis of KD is an inflammatory process related to the host's genetic characteristics. In innate human immunity, the interaction of leukocytes and glycoprotein plays an important role against microbes. The purpose of our study was to understand the role of leukocytes' glycoprotein genes during the acute phase of KD. Materials and Methods: We enrolled a total of 97 subjects from a medical center. Of those, 24 subjects were healthy controls, and 24 subjects were fever controls; the other 49 subjects were KD patients who had had blood samples taken both before and after IVIG treatment. We collected the total RNA from leukocytes and performed a quantitative polymerase chain reaction for the HP, GRP84, and CLEC4D genes in real time. Results: Compared with both the healthy and fever controls, the upregulation of HP, GRP84, and CLEC4D genes was significant in peripheral leukocytes during acute-phase KD. The transcriptional level of these respective genes not only demonstrated a positive correlation with each other, but were also effective predictors for KD (all auROC >0.87) according to the ROC curve analysis. The hyper-expression of these three genes was significantly associated with IVIG resistance, but not CAL formation. Conclusions: Our study demonstrates that the expression of HP, GRP84, and CLEC4D genes of leukocytes play an important role in the pathogenesis and primary IVIG response during the acute inflammatory process of KD.