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Shrestha S, Wiener HW, Chowdhury S, Kajimoto H, Srinivasasainagendra V, Mamaeva OA, Brahmbhatt UN, Ledee D, Lau YR, Padilla LA, Chen JY, Dahdah N, Tiwari HK, Portman MA. Pharmacogenomics of coronary artery response to intravenous gamma globulin in kawasaki disease. NPJ Genom Med 2024; 9:34. [PMID: 38816462 PMCID: PMC11139870 DOI: 10.1038/s41525-024-00419-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/09/2024] [Indexed: 06/01/2024] Open
Abstract
Kawasaki disease (KD) is a multisystem inflammatory illness of infants and young children that can result in acute vasculitis. The mechanism of coronary artery aneurysms (CAA) in KD despite intravenous gamma globulin (IVIG) treatment is not known. We performed a Whole Genome Sequencing (WGS) association analysis in a racially diverse cohort of KD patients treated with IVIG, both using AHA guidelines. We defined coronary aneurysm (CAA) (N = 234) as coronary z ≥ 2.5 and large coronary aneurysm (CAA/L) (N = 92) as z ≥ 5.0. We conducted logistic regression models to examine the association of genetic variants with CAA/L during acute KD and with persistence >6 weeks using an additive model between cases and 238 controls with no CAA. We adjusted for age, gender and three principal components of genetic ancestry. The top significant variants associated with CAA/L were in the intergenic regions (rs62154092 p < 6.32E-08 most significant). Variants in SMAT4, LOC100127, PTPRD, TCAF2 and KLRC2 were the most significant non-intergenic SNPs. Functional mapping and annotation (FUMA) analysis identified 12 genomic risk loci with eQTL or chromatin interactions mapped to 48 genes. Of these NDUFA5 has been implicated in KD CAA and MICU and ZMAT4 has potential functional implications. Genetic risk score using these 12 genomic risk loci yielded an area under the receiver operating characteristic curve (AUC) of 0.86. This pharmacogenomics study provides insights into the pathogenesis of CAA/L in IVIG-treated KD and shows that genomics can help define the cause of CAA/L to guide management and improve risk stratification of KD patients.
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Affiliation(s)
- Sadeep Shrestha
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Howard W Wiener
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sabrina Chowdhury
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hidemi Kajimoto
- Division of Cardiology, Seattle Children's and University of Washington Department of Pediatrics, Seattle, WA, USA
| | - Vinodh Srinivasasainagendra
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Olga A Mamaeva
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ujval N Brahmbhatt
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dolena Ledee
- Division of Cardiology, Seattle Children's and University of Washington Department of Pediatrics, Seattle, WA, USA
| | - Yung R Lau
- Division of Pediatric Cardiology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luz A Padilla
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jake Y Chen
- Department of Biomedical Informatics and Data Science, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nagib Dahdah
- Division of Pediatric Cardiology, CHU Ste-Justine, Universite de Montreal, Montreal, QC, Canada
| | - Hemant K Tiwari
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael A Portman
- Division of Cardiology, Seattle Children's and University of Washington Department of Pediatrics, Seattle, WA, USA
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Shrestha S, Wiener HW, Chowdhury S, Kajimoto H, Srinivasasainagendra V, Mamaeva OA, Brahmbhatt UN, Ledee D, Lau Y, Padilla LA, Chen J, Dahdah N, Tiwari HK, Portman MA. Pharmacogenomics of Coronary Artery Response to Intravenous Gamma Globulin in Kawasaki Disease. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.30.24301800. [PMID: 38352371 PMCID: PMC10862995 DOI: 10.1101/2024.01.30.24301800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Background Kawasaki disease (KD) is a multisystem inflammatory illness of infants and young children that can result in acute vasculitis. The pathological walls of afflicted coronary arteries show propensity for forming thrombosis and aneurysms. The mechanism of coronary artery aneurysms (CAA) despite intravenous gamma globulin (IVIG) treatment is not known. Methods We performed a Whole Genome Sequencing (WGS) association analysis in a racially diverse cohort of KD patients treated with IVIG, both using AHA guidelines. We defined coronary aneurysm (CAA) (N = 234) as coronary z>2.5 and large coronary aneurysm (CAA/L) (N = 92) as z>5.0. We conducted logistic regression models to examine the association of genetic variants with CAA/L during acute KD and with persistence >6 weeks using an additive model between cases and 238 controls with no CAA. We adjusted for age, gender and three principal components of genetic ancestry. We performed functional mapping and annotation (FUMA) analysis and further assessed the predictive risk score of genomic risk loci using the area under the receiver operating characteristic curve (AUC). Results The top significant variants associated with CAA/L were in the intergenic regions (rs62154092 p<6.32E-08 most significant). Variants in SMAT4, LOC100127 , PTPRD, TCAF2 and KLRC2 were the most significant non-intergenic SNPs. FUMA identified 12 genomic risk loci with eQTL or chromatin interactions mapped to 48 genes. Of these NDUFA5 has been implicated in KD CAA and MICU and ZMAT4 has potential functional implications. Genetic risk score using these 12 genomic risk loci yielded an AUC of 0.86. Conclusions This pharmacogenomics study provides insights into the pathogenesis of CAA/L in IVIG-treated KD patients. We have identified multiple novel SNPs associated with CAA/L and related genes with potential functional implications. The study shows that genomics can help define the cause of CAA/L to guide management and improve risk stratification of KD patients.
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Hattori S, Nozawa T, Nishimura K, Hara R, Murase A, Ohara A, Ohnishi A, Ohya T, Ito S. Characteristics of persistent arthritis with refractory Kawasaki disease: a single-center retrospective study. Sci Rep 2023; 13:9890. [PMID: 37336934 DOI: 10.1038/s41598-023-36308-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 05/31/2023] [Indexed: 06/21/2023] Open
Abstract
Arthritis is one complication of Kawasaki disease (KD); however, the clinical features of arthritis in KD have not been well clarified. We retrospectively investigated the characteristics of persistent arthritis beyond the subacute phase of KD. In this cohort, 49 of 243 patients (20%) developed arthritis, with 33 patients (14%) experiencing persistent arthritis. Among these 33 patients, 31 (94%) had complete KD. Thirty (91%) were resistant to first intravenous immunoglobulin, and 15 (45%) required additional infliximab. Five patients (15%) developed coronary artery lesions, and 24 (73%) had oligoarthritis, mainly in large lower-extremity joints. Twenty-four patients (73%) complained of arthralgia. At arthritis onset, 16 patients (48%) presented with fever, including recurrent fever in 10 patients. Serum C-reactive protein concentration in patients with active arthritis significantly increased compared with after acute KD treatment (2.4 vs. 0.7 mg/dL, p < 0.001). Serum matrix metalloproteinase-3, a biomarker of arthritis, was significantly higher in patients with active arthritis than in remission (93.7 vs. 20.3 ng/mL, p < 0.001). Thirty (91%) and 14 (42%) patients, respectively, were treated with non-steroidal anti-inflammatory drugs and prednisolone, and they completely recovered. To summarize, persistent arthritis is a common complication in refractory KD, and adequate diagnosis and treatment are necessary.
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Affiliation(s)
- Seira Hattori
- Department of Paediatrics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Tomo Nozawa
- Department of Paediatrics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Kenichi Nishimura
- Department of Paediatrics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Ryoki Hara
- Department of Paediatrics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Ayako Murase
- Department of Paediatrics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Asami Ohara
- Department of Paediatrics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Ai Ohnishi
- Department of Paediatrics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
- Department of Paediatrics, Nagasaki University Hospital, Nagasaki, Japan
| | - Takashi Ohya
- Department of Paediatrics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Shuichi Ito
- Department of Paediatrics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan.
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Refractory Kawasaki disease: modified methylprednisolone regimen decreases coronary artery dilatation. Pediatr Res 2022; 91:1542-1550. [PMID: 34021270 DOI: 10.1038/s41390-021-01576-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/14/2021] [Accepted: 04/22/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND The use of corticosteroids in Kawasaki disease (KD) is still controversial. The aim of this study was to investigate the safety and effectiveness of modified methylprednisolone (mPSL) regimen as an initial treatment for refractory KD. METHODS This is a real-world observational study. We identified refractory KD with a self-developed scoring system. Patients were divided into the intravenous immunoglobulin (IVIG) + mPSL group and the IVIG group. Clinical outcomes and changes in coronary arteries after the treatment during a 12-week period were observed. Propensity-score matching was used to analyze those patients with similar baseline characteristics. RESULTS Of a total of 168 patients, 104 patients were assigned into the IVIG group and 64 patients into the IVIG + mPSL group. The therapeutic response rate of the IVIG + mPSL group was significantly higher than that of the IVIG group (98.4 vs 76.0%, P < 0.05). The IVIG + mPSL group had a shorter duration of fever and a higher rate of C-reactive protein decline than the IVIG group (1.17 ± 0.64 vs 1.81 ± 1.16 days; 88.1 vs 83.5%; P < 0.05). The luminal diameter and Z-score of the left circumflex coronary artery (LCX) were significantly smaller and lower in the IVIG + mPSL group than that in the IVIG group at weeks 2 and 12. CONCLUSIONS Modified mPSL regimen has minimal side effects. It might improve the initial response to IVIG and decrease the dilation of LCX for refractory KD. IMPACT Modified mPSL regimen (2-4 mg/kg/day, divided into 2-3 doses for 3-5 days, then 1 mg/kg/day, once a day for 3-5 days, then oral prednisone was tapered over 3-5 weeks in 5-7 days steps) as an intensive initial treatment can decrease LCX dilation in high-risk IVIG-resistant KD patients. Our self-developed scoring system has been proven validated and can be used to identify high-risk IVIG-resistant KD patients in North China. The present study provides an alternative therapeutic regimen for high-risk refractory KD patients.
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Takura T, Horiuchi S. Cost-effectiveness analysis of infliximab for the treatment of Kawasaki disease refractory to the initial treatment: A retrospective cohort study. J Cardiol 2022; 80:172-178. [PMID: 35341683 DOI: 10.1016/j.jjcc.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/04/2022] [Accepted: 03/07/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Infliximab (IFX) treatment is approved in Japan for health insurance coverage in patients with Kawasaki disease (KD). This study aimed to compare the cost-effectiveness of IFX and other therapeutic strategies for KD refractory to initial treatment, including intravenous immunoglobulin (IVIG), steroids, immunosuppressants, and plasma exchange therapy. METHODS This multicenter, retrospective cohort study utilized data from the public medical insurance system of Japan. The target population included those who received treatment for KD between April 2012 and March 2019. Eligibility criteria were as follows: 1) initial onset of KD, 2) age < 15 years at onset, and 3) administration of 3rd line treatment if the 1st line treatment was IVIG alone or 2nd line treatment if the 1st line treatment was a combination of IVIG and steroids, in accordance with Japanese guidelines (2012). Those with KD-related cardiovascular complications before admission and those with congenital cardiac disease were excluded. The primary outcome was cost-effectiveness, which was calculated based on the number of admission events per annum divided by medical expenses per annum (times/10,000 US dollars). The Wilcoxon test was applied to analyze the difference in cost-effectiveness between patients who had received IFX and those who had not. RESULTS Among 1267 patients with KD, 25 received IFX treatment, while 206 received another treatment after the disease was designated refractory to initial treatment. The frequency of steroid use during initial IVIG treatment (a predictor of severity) was higher in the non-IFX group than in the IFX group (70.4% vs. 32.0%, p < 0.001) but became comparable after propensity-score matching. Our analysis indicated that IFX was more cost-effective than other treatments [1.04 (0.86, 1.34) vs. 1.38 (1.03, 1.79) (times/10,000 US dollars), p = 0.006]. CONCLUSIONS IFX treatment may be more cost-effective than non-IFX treatment for patients with KD that is refractory to initial treatment.
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Affiliation(s)
- Tomoyuki Takura
- Department of Healthcare Economics and Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sayaka Horiuchi
- Department of Healthcare Economics and Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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Mazahir FA, Al Saqqa A, Magzoub A, Al Sabbah MA. Rethinking the Typical Diagnostic and Therapeutic Challenges of Kawasaki Disease. DUBAI MEDICAL JOURNAL 2022. [DOI: 10.1159/000521334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
This report presents a case of a 9-month-old male subject, with an initial presentation of a viral-like illness progressing rapidly to multiple deep neck abscesses involving the bilateral submandibular, parapharyngeal, retropharyngeal, and anterior mediastinal spaces subsequently confirmed with contrast-enhanced computed tomography of the neck. Additionally, the subject developed mucocutaneous signs of generalized erythematous rash, with red, fissured lips along with edema of the extremities. Initial lab parameters were suggestive of high inflammatory markers, low albumin, and deranged coagulation profile. Treatment with broad-spectrum intravenous antibiotics, albumin, and fresh frozen plasma infusions was commenced. Echocardiography revealed dilatation of the left main coronary artery with mild mitral valvular regurgitation. Based on the clinical criteria, a diagnosis of typical Kawasaki disease (KD) on day 5 of illness was made, and the subject received intravenous immunoglobulin (IVIg) and aspirin. The clinical course was complicated by IVIg resistance, for which a second dose of IVIg and pulse systemic corticosteroid therapy was required. Post defervescence, an isolated elevation of activated thromboplastin time, partially corrected with mixing studies and a positive circulating lupus anticoagulant was noted. The patient did not develop any bleeding or thromboembolic complications during his hospital stay. Surgical drainage of the neck abscesses did not yield any pus or fluid collection. After a stormy course of 31 days, the subject was discharged with an improving trend of inflammatory markers and no progression of coronary artery dilatation. Gradual resolution to baseline health was noted upon follow-up, 18 months postdischarge from the hospital. Despite being one of the most common cause of childhood acquired cardiac disease, KD still poses a significant diagnostic and treatment challenge to physicians. This requires physicians to be vigilant for timely diagnosis and appropriate management to prevent significant cardiac comorbidities and be aware of the possible complications that might arise during the treatment.
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Abrams JY, Ae R, Maddox RA, Schonberger LB, Nakamura Y, Belay ED. First-line corticosteroids for Kawasaki disease: Pulse versus multiple dose. Pediatr Int 2022; 64:e15112. [PMID: 35468260 DOI: 10.1111/ped.15112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 10/27/2021] [Accepted: 12/03/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Kawasaki disease (KD) can result in severe coronary artery abnormalities (CAAs). Corticosteroids added to initial standard intravenous immunoglobulin (IVIG) treatment may decrease the risk for these complications. Different corticosteroid regimens (single-day high dose pulse vs multiple lower doses) may contribute to the discrepant results of prior studies. METHODS Using data from the 22nd, 23rd , and 24th Japanese nationwide KD surveys (2011-2016), we identified KD patients who did not have CAAs at first presentation and who were treated with either pulse or multiple-dose corticosteroids as part of their initial treatment. Occurrence of subsequent CAAs and treatment failure were compared between the treatment regimens and adjusted odds ratios were calculated controlling for sex, age group, illness day at first treatment, survey, and recurrent KD. RESULTS There were 782 KD patients who received pulse corticosteroid treatment and 4,817 who received multiple dose treatment. Patients receiving multiple dose treatment were less likely to develop CAAs (5.5% vs 8.3%, OR 0.64; 95% CI: 0.48-0.85) or treatment failure (21.4% vs 41.6%; OR: 0.38; 95% CI: 0.33-0.45). Adjusted analyses showed similar protective effects of multiple-dose treatment against CAAs (OR: 0.67, 95% CI: 0.51-0.90) and treatment failure (OR: 0.39, 95% CI: 0.33-0.46). CONCLUSIONS Multiple-dose corticosteroid combination treatment resulted in substantially improved outcomes in KD patients compared to pulse treatment. For patients who may be at elevated risk of treatment failure or CAA, use of multiple-dose corticosteroids in conjunction with IVIG is likely to provide considerable clinical benefit.
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Affiliation(s)
- Joseph Y Abrams
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ryusuke Ae
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.,Division of Public Health, Center for Community Medicine, Jichi Medical University, Simotsuke, Tochigi, Japan
| | - Ryan A Maddox
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lawrence B Schonberger
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yosikazu Nakamura
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Simotsuke, Tochigi, Japan
| | - Ermias D Belay
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Lin Y, Wang L, Li A, Zhang H, Shi L. Eyelid ptosis and muscle weakness in a child with Kawasaki disease: a case report. BMC Pediatr 2021; 21:526. [PMID: 34837997 PMCID: PMC8626717 DOI: 10.1186/s12887-021-02979-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/28/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Kawasaki disease (KD) is an acute febrile vasculitis that often occurs in children under 5 years. Ptosis and muscle weakness associated with KD are rarely documented. CASE PRESENTATION We present a case of KD with eyelid ptosis and muscle weakness in a 3-year-old boy. At admission, grade IV and grade III muscle strength were recorded for upper and lower limbs, respectively. Diminished patellar tendon reflex was noted. Laboratory evaluation showed hypokalemia with the serum potassium concentration of 2.62 mmol/L. Intravenous immunoglobulin (IVIG) and aspirin were initiated immediately accompanied with methylprednisolone for adjunctive therapy. Potassium supplement was administered at the same time, which resulted in the correction of hypokalemia on the 2nd day of admission but no improvement in ptosis and muscle weakness. Neostigmine testing, lumber puncture, electromyography, and cerebral and full spine MRI were performed, which, however, did not find evidence for neural and muscle diseases. On the 5th day, the fever was resolved. On the 6th day, eyelid ptosis disappeared. And on the 14th day, the muscle strength and muscle tension returned to normal, patellar tendon reflex could be drawn out normally, and the boy regained full ambulatory ability. CONCLUSIONS KD might affect the neural and muscular systems, and KD complicated with eyelid ptosis and muscle weakness is responsive to the standard anti-inflammatory treatment plus adjunctive corticosteroid therapy.
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Affiliation(s)
- Yao Lin
- Department of Pediatric Cardiology, Children's Hospital, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Lijun Wang
- Department of Pediatric Cardiology, Children's Hospital, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Aijie Li
- Department of Pediatric Cardiology, Children's Hospital, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Hongwei Zhang
- Department of Pediatric Cardiology, Children's Hospital, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Lin Shi
- Department of Pediatric Cardiology, Children's Hospital, Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, China.
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Inoue T, Murakami S, Matsumoto K, Matsuda A. Functional benefits of corticosteroid and IVIG combination therapy in a coronary artery endothelial cell model of Kawasaki disease. Pediatr Rheumatol Online J 2020; 18:76. [PMID: 33023630 PMCID: PMC7539408 DOI: 10.1186/s12969-020-00461-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 09/03/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Kawasaki disease (KD) is the most common pediatric systemic vasculitides of unknown etiology. Recent clinical studies led to reappraisal of the usefulness of initial combination therapy of intravenous immunoglobulin (IVIG) plus a corticosteroid for patients with severe KD. However, the molecular mechanisms underlying the clinical benefits of that combination therapy remain unclear. Here, we used cultured human coronary artery endothelial cells (HCAECs), as a mimic of KD, to study the possible mechanisms responsible for the clinical benefits of adding a corticosteroid to standard IVIG therapy for patients with severe KD. METHODS HCAECs were stimulated with TNF-α, IL-1α or IL-1β in the presence and absence of high-dose IgG and/or dexamethasone (DEX). The mRNA and protein concentrations for high-mobility group box-1 (HMGB1), IL-1α, IL-6 and granulocyte-colony stimulating factor (G-CSF) in the culture supernatants were measured by quantitative PCR (qPCR) and ELISA, respectively. Apoptosis was evaluated by the caspase 3/7 activities. RESULTS DEX, but not IgG, significantly inhibited apoptosis caused by inflammatory stimuli, resulting in effective reduction of HMGB1 and IL-1α protein release by HCAECs. As previously reported, DEX or IgG alone significantly suppressed TNF-α-induced production of IL-6 and G-CSF and mRNA expression, but induction of those cytokines by IL-1 s (IL-1α and IL-1β) was resistant to high-dose IgG. CONCLUSIONS A corticosteroid can effectively inhibit the release of HMGB1 and IL-1α, which may be involved in IVIG resistance in KD. Since high-dose IgG does not have such beneficial anti-cytotoxic effects, adding a corticosteroid to standard IVIG therapy may help prevent the progression of IVIG resistance in KD.
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Affiliation(s)
- Takashi Inoue
- grid.63906.3a0000 0004 0377 2305Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535 Japan ,grid.411898.d0000 0001 0661 2073Department of Pediatrics, Jikei University School of Medicine, Tokyo, Japan
| | - Shokei Murakami
- grid.63906.3a0000 0004 0377 2305Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535 Japan ,grid.267346.20000 0001 2171 836XDepartment of Pediatrics, Toyama University School of Medicine, Toyama, Japan
| | - Kenji Matsumoto
- grid.63906.3a0000 0004 0377 2305Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535 Japan
| | - Akio Matsuda
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
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Okubo Y, Miura M, Kobayashi T, Morisaki N, Michihata N, Matsui H, Fushimi K, Yasunaga H. The Impact of Changes in Clinical Guideline on Practice Patterns and Healthcare Utilizations for Kawasaki Disease in Japan. Front Pediatr 2020; 8:114. [PMID: 32266191 PMCID: PMC7105796 DOI: 10.3389/fped.2020.00114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 03/05/2020] [Indexed: 12/19/2022] Open
Abstract
Objective: Previous studies showed the efficacy of glucocorticoids on prevention of coronary artery lesions (CAL) among Kawasaki disease (KD) patients, and clinical guideline for KD in Japan was changed regarding glucocorticoid use in 2012. However, little is known regarding how the guideline change had impacts on healthcare utilizations and clinical outcomes. Methods: We conducted a retrospective observational study using national inpatient database in Japan among KD patients aged under 18 years during 2010-2015. Recent trends in practice patterns were analyzed, and we divided the hospitals into four groups based on glucocorticoid use: (1) consistently using hospital, (2) started using hospital, (3) stopped using hospital, and (4) never using hospital. Then, we compared healthcare utilizations and risks of coronary artery lesions before and after the guideline change. Results: We identified 24,517 inpatients with KD. From 2010 to 2014, use of glucocorticoid increased from 8.9 to 17.4% of KD inpatients. All types of hospitals showed reduction in coronary artery lesions, but the reduction was the most prominent in hospitals that started using glucocorticoid therapy after clinical guideline change in 2012 (adjusted OR, 0.22; 95%CI, 0.07-0.68). Also, Glucocorticoid consistently using hospitals, started using hospitals, and never using hospitals showed reductions in hospitalization costs, whereas hospitals that stopped using glucocorticoids after clinical guideline change had elevated healthcare costs as opposed to natural trends observed in other groups. Guideline complying hospitals had the greatest reductions in healthcare costs. Conclusions: The early stage glucocorticoid use could be a cost-saving strategy for treatment for KD patients without increasing risks of CAL.
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Affiliation(s)
- Yusuke Okubo
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, United States.,Department of Social Medicine, National Center for Child Health and Development, Tokyo, Japan.,Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Tohru Kobayashi
- Division of Clinical Research Planning, Department of Development Strategy, Center for Clinical Research and Development, National Center for Child Health and Development, Tokyo, Japan
| | - Naho Morisaki
- Department of Social Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Dionne A, Burns JC, Dahdah N, Tremoulet AH, Gauvreau K, de Ferranti SD, Baker AL, Son MB, Gould P, Fournier A, Newburger JW, Friedman KG. Treatment Intensification in Patients With Kawasaki Disease and Coronary Aneurysm at Diagnosis. Pediatrics 2019; 143:peds.2018-3341. [PMID: 31048414 DOI: 10.1542/peds.2018-3341] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Coronary artery aneurysms (CAA) are a serious complication of Kawasaki disease. Treatment with intravenous immunoglobulin (IVIg) within 10 days of fever onset reduces the risk of CAA from 25% to <5%. Corticosteroids and infliximab are often used in high-risk patients or those with CAA at diagnosis, but there are no data on their longer-term impact on CAA. METHODS Retrospective multicenter study including children who had CAA with a z score ≥2.5 and <10 at time of diagnosis and who received primary therapy with IVIg alone or in combination with either corticosteroids or infliximab within 10 days of onset of fever. RESULTS Of 121 children, with a median age of 2.8 (range 0.1-15.5) years, 30 (25%) received primary therapy with corticosteroids and IVIg, 58 (48%) received primary therapy with infliximab and IVIg, and 33 (27%) received primary therapy with IVIg only. Median coronary z scores at the time of diagnosis did not differ among treatment groups (P = .39). Primary treatment intensification with either corticosteroids or infliximab were independent protective factors against progression of coronary size on follow-up (coefficient: -1.31 [95% confidence interval: -2.33 to -0.29]; coefficient: -1.07 [95% confidence interval: -1.95 to -0.19], respectively). CONCLUSIONS Among a high-risk group of patients with Kawasaki disease with CAA on baseline echocardiography, those treated with corticosteroids or infliximab in addition to IVIg had less progression in CAA size compared with those treated with IVIg alone. Prospective randomized trials are needed to determine the best adjunctive treatment of patients who present with CAA.
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Affiliation(s)
- Audrey Dionne
- Department of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jane C Burns
- Department of Pediatrics, School of Medicine and Rady Children's Hospital, University of California, San Diego, La Jolla, California; and
| | - Nagib Dahdah
- Department of Cardiology, Centre Hospitalier Universitaire Sainte-Justine, Montreal University, Montreal, Canada
| | - Adriana H Tremoulet
- Department of Pediatrics, School of Medicine and Rady Children's Hospital, University of California, San Diego, La Jolla, California; and
| | - Kimberlee Gauvreau
- Department of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Sarah D de Ferranti
- Department of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Annette L Baker
- Department of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mary Beth Son
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Patrick Gould
- Department of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Anne Fournier
- Department of Cardiology, Centre Hospitalier Universitaire Sainte-Justine, Montreal University, Montreal, Canada
| | - Jane W Newburger
- Department of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Kevin G Friedman
- Department of Cardiology and .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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12
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Ebata R, Yasukawa K, Nagai K, Saito Y, Higashi K, Homma J, Takada N, Takechi F, Saito N, Kobayashi H, Okunushi K, Hamada H, Kohno Y, Hanaoka H, Shimojo N. Sivelestat sodium hydrate treatment for refractory Kawasaki disease. Pediatr Int 2019; 61:438-443. [PMID: 30916859 DOI: 10.1111/ped.13851] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 02/16/2019] [Accepted: 03/20/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is still no definite treatment for refractory Kawasaki disease (KD). In this pilot study, we evaluated the safety and efficacy of a new protocol consisting of sivelestat sodium hydrate (SSH) combined with additional i.v. immunoglobulin (IVIG) for KD resistant to initial IVIG therapy. METHODS This study is a prospective non-randomized, open-label and single-arm study undertaken in a population of refractory KD patients at Chiba University Hospital from December 2006 to March 2016. The subjects had KD resistant to initial IVIG (2 g/kg) and received SSH (0.2 mg/kg/h for 5 days) combined with additional IVIG (2 g/kg) as a second-line therapy. We evaluated the safety and efficacy of the treatment during the study period. RESULTS Forty-six KD patients were enrolled in this study and no serious adverse event was noted. Of these, 45 patients were evaluated for the incidence of coronary artery lesions, which occurred in one patient (2.2%; 95% CI: 0.5-15.2). Twenty-eight (62.2%) responded promptly and were afebrile after the therapy. The median total duration of fever was 8 days (range, 6-28 days). CONCLUSIONS Additional IVIG combined with SSH as a second-line therapy for KD refractory to initial IVIG therapy was safe and well tolerated and could be a promising option for severe KD. Further investigations are expected to clarify the safety and timing of SSH treatment for KD.
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Affiliation(s)
- Ryota Ebata
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Yachiyo, Japan
| | - Kumi Yasukawa
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Yachiyo, Japan
| | - Kazue Nagai
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yuko Saito
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Yachiyo, Japan
| | - Kouji Higashi
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Yachiyo, Japan
| | - Jun Homma
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Yachiyo, Japan
| | - Nobuyuki Takada
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Yachiyo, Japan
| | - Fumie Takechi
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Yachiyo, Japan
| | - Naoki Saito
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Yachiyo, Japan
| | - Hironobu Kobayashi
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Yachiyo, Japan
| | - Kentaro Okunushi
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Yachiyo, Japan
| | - Hiromichi Hamada
- Department of Pediatrics, Tokyo Women's Medical University, Yachiyo Medical Center, Yachiyo, Japan
| | - Yoichi Kohno
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Yachiyo, Japan
| | - Hideki Hanaoka
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Naoki Shimojo
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Yachiyo, Japan
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13
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Tomobe Y, Nomura O, Morikawa Y, Inoue N, Sakakibara H, Miura M. Coronary Lesions and Systemic Inflammatory Response Syndrome in Kawasaki Disease. JMA J 2018; 2:47-53. [PMID: 33681512 PMCID: PMC7930751 DOI: 10.31662/jmaj.2018-0013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/02/2018] [Indexed: 12/19/2022] Open
Abstract
Introduction: In patients with Kawasaki disease (KD), who later develop coronary artery lesions (CALs), several inflammatory cytokines are reportedly higher than in patients without CALs. Systemic inflammatory response syndrome (SIRS) is used as a clinical index of hypercytokinemia. The objective of this study was to determine whether SIRS is related to CAL formation. Methods: We conducted a retrospective cohort study of KD patients admitted to our hospital between July 2012 and July 2015. The subjects were classified into the SIRS or the non-SIRS group based on their vital signs and blood test results. Their initial treatment was determined by their Kobayashi score. We compared the incidence of CALs between the two groups. Results: Of 357 KD patients, 277 were included in this study and 175 (63.2%) met the SIRS criteria. The incidence of CAL formation at week 1 in the clinical course and at one month after the primary treatment was significantly higher in the SIRS group than in the non-SIRS group (17.7% vs. 7.8%, p = 0.03 and 10.9% vs. 3.9%, p = 0.03, respectively). Multivariate analyses showed that after adjusting for each variable of the Kobayashi score, SIRS was an independent risk factor for CAL formation at week 1 in the clinical course (odds ratio, 2.7; 95% confidence interval, 1.03–7.23; p = 0.04). Conclusions: SIRS can be a risk factor for CAL in the acute phase of KD.
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Affiliation(s)
- Yutaro Tomobe
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Osamu Nomura
- Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yoshihiko Morikawa
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Nobuaki Inoue
- Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Sakakibara
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masaru Miura
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Cardiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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14
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Arane K, Mendelsohn K, Mimouni M, Mimouni F, Koren Y, Brik Simon D, Bahat H, Hanna Helou M, Mendelson A, Hezkelo N, Glatstein M, Berkun Y, Eisenstein E, Butbul YA, Brik R, Hashkes PJ, Uziel Y, Harel L, Amarilyo G. Japanese scoring systems to predict resistance to intravenous immunoglobulin in Kawasaki disease were unreliable for Caucasian Israeli children. Acta Paediatr 2018; 107:2179-2184. [PMID: 29797463 DOI: 10.1111/apa.14418] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/13/2018] [Accepted: 05/21/2018] [Indexed: 11/29/2022]
Abstract
AIM This study assessed the validity of using established Japanese risk scoring methods to predict intravenous immunoglobulin (IVIG) resistance to Kawasaki disease in Israeli children. METHODS We reviewed the medical records of 282 patients (70% male) with Kawasaki disease from six Israeli medical centres between 2004 and 2013. Their mean age was 2.5 years. The risk scores were calculated using the Kobayashi, Sano and Egami scoring methods and analysed to determine whether a higher risk score predicted IVIG resistance in this population. Factors that predicted a lack of response to the initial IVIG dose were identified. RESULTS We found that 18% did not respond to the first IVIG dose. The three scoring methods were unable to reliably predict IVIG resistance, with sensitivities of 23%-32% and specificities of 67%-87%. Calculating a predictive score that was specific for this population was also unsuccessful. The factors that predicted a lacked of response to the first IVIG dose included low albumin, elevated total bilirubin and ethnicity. CONCLUSION The established risk scoring methods created for Japanese populations with Kawasaki disease were not suitable for predicting IVIG resistance in Caucasian Israeli children, and we were unable to create a specific scoring method that was able to do this.
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Affiliation(s)
- Karen Arane
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Kerry Mendelsohn
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | | | | | - Yael Koren
- Tel Aviv Sourasky Medical Center; Tel Aviv Israel
| | - Dafna Brik Simon
- Schneider Children's Medical Center of Israel; Petach Tikva Israel
| | - Hilla Bahat
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Assaf Harofeh Medical Center; Zerifin Israel
| | | | | | - Nofar Hezkelo
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Miguel Glatstein
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Tel Aviv Sourasky Medical Center; Tel Aviv Israel
| | - Yackov Berkun
- Hadassah Hebrew University Medical Center; Jerusalem Israel
| | - Eli Eisenstein
- Hadassah Hebrew University Medical Center; Jerusalem Israel
| | | | - Riva Brik
- Rambam Health Care Campus; Haifa Israel
| | | | - Yosef Uziel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Meir Medical Center; Kfar Saba Israel
| | - Liora Harel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Schneider Children's Medical Center of Israel; Petach Tikva Israel
| | - Gil Amarilyo
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Schneider Children's Medical Center of Israel; Petach Tikva Israel
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15
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Miyakoshi C, Yamamoto Y, Yamakawa M, Fukuhara S. Heart Rate, Responsiveness to Intravenous Immunoglobulin, and Coronary Artery Aneurysms in Kawasaki Disease. J Pediatr 2018; 200:160-165.e5. [PMID: 29793867 DOI: 10.1016/j.jpeds.2018.04.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 04/02/2018] [Accepted: 04/17/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate whether heart rate (HR) was associated with intravenous immunoglobulin (IVIG) responsiveness or development of coronary artery lesions (CALs) in patients with Kawasaki disease. STUDY DESIGN We conducted a retrospective cohort study using data from in patients with Kawasaki disease who were hospitalized in our institution from 2006 to 2016. The patients were divided into 5 groups according to the age- and temperature-adjusted HR z score (HRZage/temp) just before IVIG administration. The ORs of outcomes were estimated by using logistic regression models, with the middle group set as the reference. RESULTS Of the 322 patients, a total of 98 patients (30%) were refractory to initial IVIG treatment. The patients whose HRZage/temp belonged to the lowest group were at the highest risk of being refractory to the initial IVIG treatment (OR 2.10 [95% CI 1.01-4.37]). Multivariable analyses showed the same trend, though this was not statistically significant. The patients with the highest HRZage/temp were most likely to develop CALs (OR 2.61 [95%CI 0.86-7.92]). CONCLUSIONS In patients with Kawasaki disease , HRs has a different relationship with IVIG responsiveness and CALs. Low HRZage/temp might be associated with high risk of being refractory to the initial IVIG treatment, while the risk of developing CALs increased among those whose HRs were high. Further studies are necessary to investigate the mechanisms regarding HR and these outcomes in Kawasaki disease.
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Affiliation(s)
- Chisato Miyakoshi
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Pediatrics, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Masaru Yamakawa
- Department of Pediatrics, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan; Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Fukushima, Japan
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16
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Failure to Predict High-risk Kawasaki Disease Patients in a Population-based Study Cohort in Germany. Pediatr Infect Dis J 2018; 37:850-855. [PMID: 29406464 DOI: 10.1097/inf.0000000000001923] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Diverse scores on high-risk Kawasaki disease (KD) patients have proven a good prognostic validity in the Japanese population. However, data on non-Japanese have been inconclusive. Do the Kobayashi, Egami and Sano scores or application of up-to-date statistical methods (Random Forest) predict response to standard intravenous immunoglobulin (IVIG) therapy and the risk of persistent coronary artery aneurysm (CAA) in patients with KD in a mainly Caucasian population in Germany? METHODS Data on 442 children (German population-based survey, 2013 and 2014) were used to assess the prognostic validity of the Kobayashi, Egami and Sano scores for being refractory to IVIG treatment and for predicting the risk of persistent CAA. Additionally, an up-to-date statistical approach (Random Forest) was applied to identify a potentially more valid score. RESULTS A total of 301 children were eligible for assessment of their response to IVIG treatment. Among those, 177 children were followed-up for 1 year to identify persistent CAA. Although all scores were significantly associated with being refractory to IVIG (relative risk range between 2.32 and 3.73), the prognostic properties were low (likelihood ratio positive: 1.83-4.57; sensitivity in the range of 0.28-0.53). None of the scores was a significant predictor of CAA 1 year after acute illness. Application of statistical analysis such as Random Forest did not yield a more valid score. CONCLUSIONS None of the available scores appears to be appropriate for identifying high-risk Caucasian children with KD who might need intensified therapy.
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17
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Yang TJ, Lin MT, Lu CY, Chen JM, Lee PI, Huang LM, Wu MH, Chang LY. The prevention of coronary arterial abnormalities in Kawasaki disease: A meta-analysis of the corticosteroid effectiveness. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 51:321-331. [DOI: 10.1016/j.jmii.2017.08.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 08/31/2017] [Accepted: 08/31/2017] [Indexed: 01/28/2023]
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18
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Okubo Y, Michihata N, Morisaki N, Sundel RP, Matsui H, Fushimi K, Yasunaga H. Association Between Dose of Glucocorticoids and Coronary Artery Lesions in Kawasaki Disease. Arthritis Care Res (Hoboken) 2018; 70:1052-1057. [DOI: 10.1002/acr.23456] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 10/17/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Yusuke Okubo
- National Center for Child Health and Development, School of Public Health; University of Tokyo, Tokyo, Japan, and Fielding School of Public Health, University of California; Los Angeles
| | | | - Naho Morisaki
- National Center for Child Health and Development, School of Public Health; University of Tokyo; Tokyo Japan
| | | | - Hiroki Matsui
- School of Public Health; University of Tokyo; Tokyo Japan
| | - Kiyohide Fushimi
- Tokyo Medical and Dental University Graduate School of Medicine; Tokyo Japan
| | - Hideo Yasunaga
- School of Public Health; University of Tokyo; Tokyo Japan
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19
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Li X, Chen Y, Tang Y, Ding Y, Xu Q, Sun L, Qian W, Qian G, Qin L, Lv H. Predictors of intravenous immunoglobulin-resistant Kawasaki disease in children: a meta-analysis of 4442 cases. Eur J Pediatr 2018; 177:1279-1292. [PMID: 29948255 PMCID: PMC6061038 DOI: 10.1007/s00431-018-3182-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/15/2018] [Accepted: 05/23/2018] [Indexed: 12/21/2022]
Abstract
UNLABELLED The purpose of this study was to identify the clinical features and laboratory factors that are predictive of intravenous immunoglobulin (IVIG)-resistant Kawasaki disease. Multiple databases were searched for relevant studies on IVIG-resistant Kawasaki disease published from January 2002 to April 2017. Eligible studies were retrieved by manual review of the references. Stata 12 was used for the meta-analysis. Weighted mean differences and odds ratios with 95% confidence intervals were calculated for several indices. Twenty-eight studies involving 26,260 patients comprising 4442 IVIG-resistant Kawasaki disease patients and 21,818 IVIG-sensitive Kawasaki disease patients were included. The meta-analysis showed that the erythrocyte sedimentation rate (ESR) in the IVIG-resistant group was significantly higher than that in the IVIG-sensitive group, and that platelet count and hemoglobin levels were significantly lower in the IVIG-resistant group. The patients with oral mucosa alterations, cervical lymphadenopathy, swelling of the extremities, polymorphous rash, and initial administration of IVIG ≤ 4.0 days after the onset of symptoms were more likely to be IVIG resistant. CONCLUSION The initial administration of IVIG ≤ 4.0 days after the onset of symptoms increased ESR and decreased hemoglobin and platelet counts, oral mucosa alterations, cervical lymphadenopathy, swelling of the extremities, and polymorphous rash and are the risk factors for IVIG-resistant Kawasaki disease. What is Known: • Recent reports on this topic are about aspartate aminotransferase (AST), alanine aminotransferase (ALT), gammaglutamyl transferase, total bilirubin, white blood cells, platelets, erythrocyte sedimentation rate (ESR), polymorphonuclear leukocytes (PMN), C-reactive protein (CRP), pro-brain natriuretic peptide (BNP), albumin, and sodium as the risk factors in the IVIG-resistant Kawasaki disease; however, no studies have been published on clinical features as predictors of IVIG resistance. What is New: • This meta-analysis identified the clinical features, the initial administration of IVIG ≤ 4.0 days after the onset of symptoms, and much more comprehensive laboratory indicators, such as hemoglobin, as predictors of IVIG-resistant Kawasaki disease.
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Affiliation(s)
- Xuan Li
- Department of Cardiology, Children’s Hospital of Soochow University, Suzhou, 215003 China
| | - Ye Chen
- Department of Cardiology, Children’s Hospital of Soochow University, Suzhou, 215003 China
| | - Yunjia Tang
- Department of Cardiology, Children’s Hospital of Soochow University, Suzhou, 215003 China
| | - Yueyue Ding
- Department of Cardiology, Children’s Hospital of Soochow University, Suzhou, 215003 China
| | - Qiuqin Xu
- Department of Cardiology, Children’s Hospital of Soochow University, Suzhou, 215003 China
| | - Lin Sun
- Department of Cardiology, Children’s Hospital of Soochow University, Suzhou, 215003 China
| | - Weiguo Qian
- Department of Cardiology, Children’s Hospital of Soochow University, Suzhou, 215003 China
| | - Guanghui Qian
- Institute of Pediatric Research, Children’s Hospital of Soochow University, Suzhou, China
| | - Liqiang Qin
- Department of Nutrition and Food Hygiene, School of Public Health, Soochow University, Suzhou, China
| | - Haitao Lv
- Department of Cardiology, Children's Hospital of Soochow University, Suzhou, 215003, China.
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20
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Abstract
The term vasculitis covers heterogeneous disorders that share the presence of inflammation of blood vessel walls. Immune cell infiltrates can vary significantly and involve granulocytes or mononuclear cells. Vasculitis can be a symptom of other underlying disorders or the underlying cause of organ specific or systemic disease. Classification of childhood vasculitis is based on clinic, the size of predominantly affected vessels, and the histopathology of inflammatory infiltrates. Timely and accurate diagnosis and (where necessary) treatment initiation determine disease progression and outcomes. In light of new developments and the identification of autoinflammatory conditions with vasculitis, new classification tools may be discussed.
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Affiliation(s)
- Anja Schnabel
- Pädiatrische Rheumatologie, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Christian M Hedrich
- Pädiatrische Rheumatologie, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany.,Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom
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21
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Role of the Egami Score in Predicting Intravenous Immunoglobulin Resistance in Kawasaki Disease Among Different Ethnicities. Am J Ther 2017; 23:e1293-e1299. [PMID: 25611359 DOI: 10.1097/mjt.0000000000000045] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Early treatment with intravenous immunoglobulin (IVIG) is necessary to help reduce the risk of coronary artery abnormalities, such as coronary artery aneurysms and to help alleviate symptoms, in Kawasaki disease. Some patients, however, do not respond to an initial dose of IVIG and require additional doses. Prediction of these IVIG nonresponders may be of assistance in altering initial therapy to make it more effective. The Egami score has been validated in the Japanese population to predict IVIG nonresponders but has shown to be ineffective in US populations. This study evaluates the Egami score in a Midwest US population, subdividing patients by race and the diagnosis of typical or atypical type of Kawasaki disease. Patients were included in the study if they met criteria for Kawasaki disease and received IVIG in the inpatient setting. A total of 182 patients were studied, and in all studied groups, the Egami score had poor sensitivity at predicting IVIG nonresponders. Sensitivity of the score differed between races and differed between typical and atypical Kawasaki disease. The Egami score, as well as other systems, have been validated to predict IVIG nonresponders. These, however, lack sensitivity in the US population. Other scores developed in the United States have also lacked sensitivity, likely due to the absence of race or Kawasaki disease classification as variables. The development of a sensitive scoring system to predict IVIG nonresponders in US populations will require the incorporation of race and Kawasaki disease classification, factors that seem to alter IVIG response.
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22
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Perez EE, Orange JS, Bonilla F, Chinen J, Chinn IK, Dorsey M, El-Gamal Y, Harville TO, Hossny E, Mazer B, Nelson R, Secord E, Jordan SC, Stiehm ER, Vo AA, Ballow M. Update on the use of immunoglobulin in human disease: A review of evidence. J Allergy Clin Immunol 2016; 139:S1-S46. [PMID: 28041678 DOI: 10.1016/j.jaci.2016.09.023] [Citation(s) in RCA: 376] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 09/12/2016] [Accepted: 09/23/2016] [Indexed: 12/20/2022]
Abstract
Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.
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Affiliation(s)
- Elena E Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, Fla.
| | - Jordan S Orange
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Francisco Bonilla
- Department of Pediatrics, Clinical Immunology Program, Children's Hospital Boston and Harvard Medical School, Boston, Mass
| | - Javier Chinen
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Ivan K Chinn
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Morna Dorsey
- Department of Pediatrics, Allergy, Immunology and BMT Division, Benioff Children's Hospital and University of California, San Francisco, Calif
| | - Yehia El-Gamal
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Terry O Harville
- Departments of Pathology and Laboratory Services and Pediatrics, University of Arkansas, Little Rock, Ark
| | - Elham Hossny
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Bruce Mazer
- Department of Pediatrics, Allergy and Immunology, Montreal Children's Hospital and McGill University, Montreal, Quebec, Canada
| | - Robert Nelson
- Department of Medicine and Pediatrics, Division of Hematology and Oncology and Stem Cell Transplantation, Riley Hospital, Indiana University School of Medicine and the IU Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Elizabeth Secord
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Mich
| | - Stanley C Jordan
- Nephrology & Transplant Immunology, Kidney Transplant Program, David Geffen School of Medicine at UCLA and Cedars-Sinai Medical Center, Los Angeles, Calif
| | - E Richard Stiehm
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Ashley A Vo
- Transplant Immunotherapy Program, Comprehensive Transplant Center, Kidney Transplant Program, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Mark Ballow
- Department of Pediatrics, Division of Allergy & Immunology, University of South Florida, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Fla
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23
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Erratum zu: Kawasaki-Syndrom. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0107-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Kanamitsu K, Kakimoto H, Shimada A, Nakata Y, Ochi H, Watanabe H, Iwasaki Y, Tokorodani C, Kanazawa A, Maruyama H, Miyazawa M, Nishiuchi R, Kikkawa K. Verification of risk scores to predict i.v. immunoglobulin resistance in incomplete Kawasaki disease. Pediatr Int 2016; 58:146-51. [PMID: 26190225 DOI: 10.1111/ped.12755] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 06/29/2015] [Accepted: 07/10/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND A recent study indicated the efficacy of the addition of prednisolone to i.v. immunoglobulin (IVIG) as initial treatment in patients with higher risk of IVIG resistance. Several different risk scores for predicting IVIG resistance have been proposed, mainly based on typical Kawasaki disease (KD) patients. We investigated the utility of the risk scores to predict IVIG resistance in incomplete KD. METHODS Clinical records of incomplete KD patients who received a single dose of IVIG between 2005 and 2012 at Kochi Health Sciences Center were retrospectively reviewed. Patients were classified into an IVIG-responsive group and an IVIG-resistant group. The Kobayashi, Egami, and Sano risk scores were calculated for each patient and the proportion of high-risk patients was compared between the two groups for each risk score. RESULTS For 51 incomplete KD patients, Kobayashi (66.7% vs 47.6%, P = 0.253), Egami (55.6% vs 38.1%, P = 0.274), and Sano (57.1% vs 10.8%, P = 0.068) risk scores identified a higher proportion of high-risk patients in the IVIG-resistant group compared with the IVIG-responsive group, but significant difference was not observed. Sano risk score had the highest OR (6.19; 95%CI: 1.00-38.26). CONCLUSIONS The proportion of patients identified as being at high risk for IVIG resistance using the Kobayashi, Egami, and Sano risk scores, respectively, was not significantly different between the IVIG-responsive group and the IVIG-resistant group for incomplete KD. Among the three risk scores, the Sano risk score has the best ability to predict IVIG resistance in incomplete KD.
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Affiliation(s)
- Kiichiro Kanamitsu
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, Japan.,Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Hisako Kakimoto
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, Japan.,Cardiovascular Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Akira Shimada
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Yusei Nakata
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, Japan
| | - Hiroaki Ochi
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, Japan.,Department of Pediatrics, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Japan
| | - Hirokazu Watanabe
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, Japan
| | - Yuka Iwasaki
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, Japan
| | - Chiho Tokorodani
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, Japan
| | - Akane Kanazawa
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, Japan
| | - Hidehiko Maruyama
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, Japan
| | - Mari Miyazawa
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, Japan
| | - Ritsuo Nishiuchi
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, Japan
| | - Kiyoshi Kikkawa
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, Japan
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Mansoor S, Sabella C, Auron M, Erenberg F, Zeft A. Weighing Evidence and Art: A Challenging Case of Early-Onset Atypical Kawasaki Disease. Hosp Pediatr 2015; 5:591-6. [PMID: 26526806 DOI: 10.1542/hpeds.2014-0228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Moises Auron
- Departments of Pediatrics, Pediatric Hospital Medicine
| | | | - Andrew Zeft
- Departments of Pediatrics, Pediatric Rheumatology, Cleveland Clinic Children's, Cleveland, Ohio
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26
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Fujino M, Hata T, Kuriki M, Horio K, Uchida H, Eryu Y, Boda H, Miyata M, Yoshikawa T. Inflammation aggravates heterogeneity of ventricular repolarization in children with Kawasaki disease. Pediatr Cardiol 2014; 35:1268-72. [PMID: 24823886 DOI: 10.1007/s00246-014-0926-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 04/25/2014] [Indexed: 02/07/2023]
Abstract
Kawasaki disease complicates with myocarditis and vasculitis. Even if myocarditis is asymptomatic, heterogeneity of ventricular repolarization may be increased in the acute phase. We evaluated whether the change in repolarization characteristics can be used as a predictor for myocarditis and coronary lesions. Enrolled 34 children who were treated with intravenous immunoglobulin therapy. There were no sequelae in the recovery phase in any subjects, including those who had transient coronary artery lesion. QT and the interval from the Tpeak to Tend (Tp-e) were determined. The Tp-e/QT ratios were compared between the acute and recovery phases and correlations with CRP level and body temperature were evaluated. A retrospective evaluation of Tp-e/QT as predictors of coronary dilation was also performed. Tp-e/QT in the acute phase correlated positively with body temperature and CRP level. In a comparison of patients with and without transient coronary artery lesion, Tp-e/QT was significantly higher in those with dilation. In conclusion, Tp-e/QT was strongly related to transient coronary dilation, in comparison with inflammatory indicators including fever and CRP level.
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Affiliation(s)
- Masayuki Fujino
- Department of Pediatrics, Fujita Health University, Toyoake, Japan,
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27
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Lim YJ, Jung JW. Clinical outcomes of initial dexamethasone treatment combined with a single high dose of intravenous immunoglobulin for primary treatment of Kawasaki disease. Yonsei Med J 2014; 55:1260-6. [PMID: 25048483 PMCID: PMC4108810 DOI: 10.3349/ymj.2014.55.5.1260] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To investigate the clinical effects of a single high dose intravenous immunoglobulin (IVIG) combined with initial dexamethasone as a primary treatment on Kawasaki disease (KD). MATERIALS AND METHODS Between January 2008 and December 2010, we reviewed the medical records of 216 patients with complete KD patients that were admitted to a single medical center. 106 patients were treated with a single high dose of IVIG (2 g/kg) alone and 110 patients received IVIG and dexamethasone (0.3 mg/kg per day for three days). RESULTS The combined IVIG plus dexamethasone patient group had a significantly shorter febrile period and duration of hospital stay (1.4±0.7 days vs. 2.0±1.2 days, p<0.001; 5.8±1.7 days vs. 6.9±2.5 days, p<0.001, respectively) than the IVIG alone group. The combined IVIG plus dexamethasone group required IVIG retreatment significantly less than the IVIG only group (12.7% vs. 32%, p=0.003). After completion of the initial IVIG, C-reactive protein levels in the combined IVIG plus dexamethasone group were significantly lower than those in the IVIG only group (2.7±4.0 mg/dL vs. 4.6±8.7 mg/dL, p=0.03). In the combined IVIG plus dexamethasone group, the incidence of coronary artery lesions tended to be lower without worse outcomes at admission after initial infusion of IVIG and in follow-up at two months; however, the differences were not significant (8.2% vs. 11.3%, p=0.22; 0.9% vs. 2.8%, p=0.29). CONCLUSION Initial combined therapy with dexamethasone and a single high-dose of IVIG resulted in an improved clinical course, in particular a shorter febrile period, less IVIG retreatment, and shorter hospital stay without worse coronary outcomes.
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Affiliation(s)
- Yun Ju Lim
- Department of Pediatrics, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Jo Won Jung
- Division of Pediatric Cardiology, Department of Pediatrics, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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28
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Fujimaru T, Ito S, Masuda H, Oana S, Kamei K, Ishiguro A, Kato H, Abe J. Decreased levels of inflammatory cytokines in immunoglobulin-resistant Kawasaki disease after plasma exchange. Cytokine 2014; 70:156-60. [PMID: 25082649 DOI: 10.1016/j.cyto.2014.07.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 06/26/2014] [Accepted: 07/07/2014] [Indexed: 11/27/2022]
Abstract
The pathogenesis of coronary artery aneurysm (CAA) formation in Kawasaki disease (KD) remains unknown. However, inflammatory cytokines are thought to play an important role in KD. Patients with intravenous immunoglobulin (IVIG)-resistant KD are more likely to develop CAA. For such refractory patients, steroids and emerging infliximab (IFX) are used; however, further verification is required for their efficacy and safety. Plasma exchange (PE), which removes various inflammatory cytokines, has been used in Japan for over 15 years to prevent CAA in IVIG-resistant KD patients. The sequential change in inflammatory cytokines during the time course of PE has yet to be investigated. In this study, we measured plasma levels of 13 cytokines in nine children with IVIG-resistant KD before the start of PE (day 0: D0), as well as at 1 or 2 days (D1/2), and 4 or 5 days (D4/5) after starting PE. The median age of onset was 8 months (range: 3-53 months). Before PE, patients were treated with IVIG (median dose: 4 g/kg, range: 3-4 g/kg). The median starting period of PE was 8 days after the onset of fever (range: 6-21 days), while its duration was 3 days (range: 2-5 days). Among the 13 cytokines, interleukin-6, tumor necrosis factor-α, tumor necrosis factor receptor I (TNFR1), TNFR2, granulocyte colony-stimulating factor, and IL-17 were significantly lower at D4/5 compared with D0 and/or D1/2, reflecting the potential central efficacy of PE. While three patients developed moderate CAA, their condition regressed within 1 year. The removal of inflammatory cytokines could be the central efficacy of PE against refractory KD.
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Affiliation(s)
- Takuya Fujimaru
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Shuichi Ito
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan.
| | - Hiroshi Masuda
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Shinji Oana
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Akira Ishiguro
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hitoshi Kato
- Division of Cardiology, National Center for Child Health and Development, Tokyo, Japan
| | - Jun Abe
- Department of Allergy and Immunology, National Center for Child Health and Development, Tokyo, Japan
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29
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Kim SY, Han MY, Cha SH, Jeon YB. N-terminal pro-brain natriuretic peptide (NT proBNP) as a predictive indicator of initial intravenous immunoglobulin treatment failure in children with Kawasaki disease: a retrospective study. Pediatr Cardiol 2014; 34:1837-43. [PMID: 23744100 DOI: 10.1007/s00246-013-0724-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 05/20/2013] [Indexed: 10/26/2022]
Abstract
Intravenous immunoglobulin (IVIG) administered in the acute stage of Kawasaki disease (KD) is the standard therapy. Few reports describe nonresponders to initial treatment with IVIG in KD, which remains the most consistent risk factor for coronary artery lesions (CALs). This study aimed to investigate whether the serum level of N-terminal pro-brain natriuretic peptide (NT-proBNP) can be a predictive indicator for identifying patients with KD at higher risk of IVIG treatment failure. In this study, 135 patients with a diagnosis of KD admitted for IVIG treatment were retrospectively enrolled for analysis. Of these 135 patients, 22 were nonresponders who received additional rescue therapy because they had an elevated body temperature 36 h after completion of initial IVIG treatment. The NT-proBNP concentration was significantly higher in the nonresponder group (2,465.36 ± 3,293.24 pg/mL) than in the responder group (942.38 ± 1,293.48 pg/mL) (p < 0.05). The optimal sensitivity and specificity cutoff point for predicted nonresponders was 1,093.00 pg/mL or higher. The sensitivity and specificity for prediction of IVIG response were respectively 70.0 and 76.5 %. The findings show that NT-proBNP is a helpful marker in determining patients at risk for not responding to initial IVIG treatment. The authors suggest that patients with an NT-proBNP level of 1,093.00 pg/dL or higher are likely to fail initial IVIG and may require further rescue therapy.
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Affiliation(s)
- So Youn Kim
- Department of Pediatrics, Kyunghee University School of Medicine, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 130-701, South Korea
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30
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Guidelines for medical treatment of acute Kawasaki disease: report of the Research Committee of the Japanese Society of Pediatric Cardiology and Cardiac Surgery (2012 revised version). Pediatr Int 2014; 56:135-58. [PMID: 24730626 DOI: 10.1111/ped.12317] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 02/04/2014] [Indexed: 12/14/2022]
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Tremoulet AH, Pancoast P, Franco A, Bujold M, Shimizu C, Onouchi Y, Tamamoto A, Erdem G, Dodd D, Burns JC. Calcineurin inhibitor treatment of intravenous immunoglobulin-resistant Kawasaki disease. J Pediatr 2012; 161:506-512.e1. [PMID: 22484354 PMCID: PMC3613150 DOI: 10.1016/j.jpeds.2012.02.048] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 01/19/2012] [Accepted: 02/27/2012] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To describe the clinical course and outcome of 10 patients with Kawasaki disease (KD) treated with a calcineurin inhibitor after failing to respond to multiple therapies. STUDY DESIGN Demographic and clinical data were prospectively collected using standardized case report forms. T-cell phenotypes were determined by flow cytometry, and KD risk alleles in ITPKC (rs28493229), CASP3 (rs72689236), and FCGR2A (rs1801274) were genotyped. RESULTS Intravenous followed by oral therapy with cyclosporine (CSA) or oral tacrolimus was well tolerated and resulted in defervescence and resolution of inflammation in all 10 patients. There were no serious adverse events, and a standardized treatment protocol was developed based on our experiences with this patient population. Analysis of T-cell phenotype by flow cytometry in 2 subjects showed a decrease in circulating activated CD8(+) and CD4(+) T effector memory cells after treatment with CSA. However, suppression of regulatory T-cells was not seen, suggesting targeting of specific, proinflammatory T-cell compartments by CSA. CONCLUSION Treatment of refractory KD with a calcineurin inhibitor appears to be a safe and effective approach that achieves rapid control of inflammation associated with clinical improvement.
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Affiliation(s)
- Adriana H Tremoulet
- Department of Pediatrics, University of California at San Diego and Rady Children's Hospital, La Jolla, CA, USA
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33
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Shrestha S, Wiener H, Shendre A, Kaslow RA, Wu J, Olson A, Bowles NE, Patel H, Edberg JC, Portman MA. Role of activating FcγR gene polymorphisms in Kawasaki disease susceptibility and intravenous immunoglobulin response. ACTA ACUST UNITED AC 2012; 5:309-16. [PMID: 22565545 DOI: 10.1161/circgenetics.111.962464] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A functional polymorphism in the inhibitory IgG-Fc receptor gene FcγRIIB influences intravenous immunoglobulin (IVIG) response in Kawasaki disease (KD), a vasculitis preferentially affecting the coronary arteries in children. We tested the hypothesis that the polymorphisms in the activating receptors (FcγRIIA, FcγRIIIA, and FcγRIIIB) also influence susceptibility, IVIG treatment response, and coronary artery disease in patients with KD. METHODS AND RESULTS We genotyped polymorphisms in the activating FcγRIIA, FcγRIIIA, and FcγRIIIB using pyrosequencing in 443 patients with KD, including 266 trios and 150 single parent-child pairs, in northwest United States and genetically determined race with 155 ancestry informative markers. We used family-based association to test for transmission disequilibrium and further generated pseudosibling controls for comparisons with the cases. The FcγRIIA-131H variant showed an association with KD (P=0.001) with an additive odds ratio (OR) of 1.51 (95% CI, 1.16-1.96; P=0.002) for the primary combined population, which persisted in both white (P=0.04) and Asian (P=0.01) subgroups and is consistent with the recent genome-wide association study. We also identified overtransmission of the FcγRIIIB neutrophil antigen 1 (NA1) variant among IVIG nonresponders (P=0.0002) and specifically to white IVIG nonresponders (P=0.007). ORs for overall and white nonresponders were 3.67 (95% CI, 1.75-7.66; P=0.0006) and 3.60 (95% CI, 1.34-9.70; P=0.01), respectively. Excess NA1 transmission also occurred in patients with KD with coronary artery disease (OR(additive), 2.13; 95% CI, 1.11-4.0; P=0.02). CONCLUSIONS A common variation in FcγRIIA is associated with increased KD susceptibility. The FcγRIIIB-NA1 variant, which confers higher affinity for IgG than the NA2 variant, is a determining factor for treatment response. These activating FcγRs play an important role in KD pathogenesis and the IVIG antiinflammatory mechanism.
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Affiliation(s)
- Sadeep Shrestha
- Department of Epidemiology, University of Alabama at Birmingham, USA
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Kobayashi T, Saji T, Otani T, Takeuchi K, Nakamura T, Arakawa H, Kato T, Hara T, Hamaoka K, Ogawa S, Miura M, Nomura Y, Fuse S, Ichida F, Seki M, Fukazawa R, Ogawa C, Furuno K, Tokunaga H, Takatsuki S, Hara S, Morikawa A. Efficacy of immunoglobulin plus prednisolone for prevention of coronary artery abnormalities in severe Kawasaki disease (RAISE study): a randomised, open-label, blinded-endpoints trial. Lancet 2012; 379:1613-20. [PMID: 22405251 DOI: 10.1016/s0140-6736(11)61930-2] [Citation(s) in RCA: 423] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Evidence indicates that corticosteroid therapy might be beneficial for the primary treatment of severe Kawasaki disease. We assessed whether addition of prednisolone to intravenous immunoglobulin with aspirin would reduce the incidence of coronary artery abnormalities in patients with severe Kawasaki disease. METHODS We did a multicentre, prospective, randomised, open-label, blinded-endpoints trial at 74 hospitals in Japan between Sept 29, 2008, and Dec 2, 2010. Patients with severe Kawasaki disease were randomly assigned by a minimisation method to receive either intravenous immunoglobulin (2 g/kg for 24 h and aspirin 30 mg/kg per day) or intravenous immunoglobulin plus prednisolone (the same intravenous immunoglobulin regimen as the intravenous immunoglobulin group plus prednisolone 2 mg/kg per day given over 15 days after concentrations of C-reactive protein normalised). Patients and treating physicians were unmasked to group allocation. The primary endpoint was incidence of coronary artery abnormalities during the study period. Analysis was by intention to treat. This trial is registered with the University Hospital Medical Information Network clinical trials registry, number UMIN000000940. FINDINGS We randomly assigned 125 patients to the intravenous immunoglobulin plus prednisolone group and 123 to the intravenous immunoglobulin group. Incidence of coronary artery abnormalities was significantly lower in the intravenous immunoglobulin plus prednisolone group than in the intravenous immunoglobulin group during the study period (four patients [3%] vs 28 patients [23%]; risk difference 0·20, 95% CI 0·12-0·28, p<0·0001). Serious adverse events were similar between both groups: two patients had high total cholesterol and one neutropenia in the intravenous immunoglobulin plus prednisolone group, and one had high total cholesterol and another non-occlusive thrombus in the intravenous immunoglobulin group. INTERPRETATION Addition of prednisolone to the standard regimen of intravenous immunoglobulin improves coronary artery outcomes in patients with severe Kawasaki disease in Japan. Further study of intensified primary treatment for this disease in a mixed ethnic population is warranted. FUNDING Japanese Ministry of Health, Labour and Welfare.
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Affiliation(s)
- Tohru Kobayashi
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan.
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Nomura Y, Arata M, Masuda K, Koriyama C, Suruki N, Ueno K, Yoshikawa H, Eguchi T, Kawano Y. Kawasaki disease patients with six principal symptoms have a high risk of being a non-responder. Pediatr Int 2012; 54:14-8. [PMID: 22115193 DOI: 10.1111/j.1442-200x.2011.03512.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND A diagnosis of Kawasaki disease (KD) is established using six principal symptoms. Because the principal symptoms are deeply connected with KD, it is thus important to investigate the usefulness of the principal symptoms for evaluating the disease severity of KD. METHODS Patients with definite KD or suspicion of KD were retrospectively examined. Blood test data and the incidence of patients who failed to respond to the initial i.v. immunoglobulin treatment (non-responders) were compared between patients with six principal symptoms, including fever of ≤ 4 days, before treatment of KD (six-symptom patients), and those with five or fewer symptoms (five-symptom patients). RESULTS The study group of 207 patients who were treated with immunoglobulin consisted of 121 six-symptom patients and 86 five-symptom patients. The six-symptom patients were older and had higher neutrophil proportion and total bilirubin, and lower serum sodium at diagnosis than the five-symptom patients. Although the treatments did not differ between the groups, the six-symptom patients had a higher incidence of non-responders than the five-symptom patients (17% vs 5%; P= 0.008). Logistic regression analysis showed that six-symptom status was related to the risk of being a non-responder (odds ratio [OR], 5.3; 95% confidence interval [95%CI]: 1.6-17.4). This association was still significant after adjustment for the effect of age, neutrophil proportion, and total bilirubin and sodium (OR, 4.4; 95%CI: 1.4-17.3). CONCLUSIONS The number of principal symptoms before treatment is a useful guide to KD disease severity. Six-symptom patients have a higher risk of being a non-responder than five-symptom patients.
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Affiliation(s)
- Yuichi Nomura
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan.
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36
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Abstract
The epidemiologic pictures of Kawasaki disease (KD) in Jilin Province of China is still not clear. We sent a questionnaire form and diagnostic guidelines for KD to the province's 32 hospitals above the county and city level with pediatric in-patients. All patients with KD diagnosed during January 1999 through December 2008 were recruited in this survey. The incidence of KD was 1.39 to 11.07 (5.26 ± 3.97) per 100,000 children under the age of 5 years between 1999 and 2008. The ratio of male to female was 1.96 to 1. Ages at onset ranged from 58 days to 14 years. Patients under 5 years of age accounted of 88.73%. The disease occurred throughout the year, but it occurred more frequently in May to July and November. The most common cardiac abnormality was coronary artery dilatation (49.5%). Age at onset and hypoalbuminemia (<30 g/l) were selected for multivariate logistic regression equation. In conclusion, incidences of KD increased in Jilin Province. Age and gender distribution shared similarities with previous reports, and the seasonal distribution was different. Age and lower serum albumin were the most important risk factors of coronary arterial lesions (CAL) in KD. In addition, patients treated with steroids also had a possible heightened risk of contracting CAL.
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37
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Kaneko K, Yoshimura K, Ohashi A, Kimata T, Shimo T, Tsuji S. Prediction of the risk of coronary arterial lesions in Kawasaki disease by brain natriuretic peptide. Pediatr Cardiol 2011; 32:1106-9. [PMID: 21487793 DOI: 10.1007/s00246-011-9986-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 03/24/2011] [Indexed: 10/18/2022]
Abstract
Kawasaki disease (KD) is an acute systemic vasculitis associated with the development of coronary arterial lesions (CALs) occurring in 3-5% of children treated by intravenous immune globulin (IVIG). However, a considerable number of patients who are not responding to IVIG are at much higher risk. Although studies have explored potential biomarkers to predict patients with KD who are at risk of CAL, no useful single marker exists. We hypothesized that the serum concentrations of the N-terminal moiety of brain natriuretic peptide (NT-proBNP) can be useful to predict CAL. Forty-three children with KD (29 males and 14 females) were enrolled in this study. Despite IVIG, 6 of the 43 patients developed CAL. There were, however, no significant differences in variables between children with CAL and those without CAL: These include age, gender, day of the illness, leukocyte count, and the serum levels of sodium, C-reactive protein, and albumin. The serum NT-proBNP level was significantly higher in children with CAL than those without CAL (2,611 ± 1,699 vs. 1,073 ± 1,427 pg/ml; P = 0.03): the cutoff value of 1,000 pg/ml to predict CAL produced a specificity of 0.68, sensitivity of 0.83, and an odds ratio as high as 10.4. In conclusion, NT-proBNP is increased in KD patients who are developing CAL, and patients with an elevated serum NT-proBNP >1,000 pg/ml have a risk of CAL ~10 times higher than that of patients with a modest increase.
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Affiliation(s)
- Kazunari Kaneko
- Department of Pediatrics, Kansai Medical University, Osaka, Japan.
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38
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Kanai T, Ishiwata T, Kobayashi T, Sato H, Takizawa M, Kawamura Y, Tsujimoto H, Nakatani K, Ishibashi N, Nishiyama M, Hatai Y, Asano Y, Kobayashi T, Takeshita S, Nonoyama S. Ulinastatin, a urinary trypsin inhibitor, for the initial treatment of patients with Kawasaki disease: a retrospective study. Circulation 2011; 124:2822-8. [PMID: 22104548 DOI: 10.1161/circulationaha.111.028423] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Markedly activated neutrophils or higher plasma levels of neutrophil elastase are involved in the poor response to intravenous immunoglobulin (IVIG) and the formation of coronary artery lesions (CAL) in patients with acute Kawasaki disease. We hypothesized that ulinastatin (UTI), by both direct and indirect suppression of neutrophils, would reduce the occurrence of CAL. METHODS AND RESULTS We retrospectively analyzed the clinical records of patients with Kawasaki disease between 1998 and 2009. Three hundred sixty-nine patients were treated with a combination of UTI, aspirin, and IVIG as an initial treatment (UTI group), and 1178 were treated with a conventional initial treatment, and IVIG with aspirin (control group). The baseline characteristics did not demonstrate notable differences between the two groups. The occurrence of CAL was significantly lower in the UTI group than in the control group (3% versus 7%; crude odds ratio [OR], 0.46; 95% confidence interval [CI], 0.25-0.86; P=0.01). The OR adjusted for sex, Gunma score (the predictive score for IVIG unresponsiveness), and dosage of initial IVIG (1 or 2 g/kg) was 0.32 (95% CI, 0.17-0.60; P<0.001). In addition, most CAL occurred in patients requiring additional rescue treatment and the proportion of those patients was significantly lower in the UTI group than in the control group (13% versus 22%; crude OR, 0.52; 95% CI, 0.38-0.73; P<0.001). The adjusted OR was 0.30 (95% CI, 0.20-0.44; P<0.001). CONCLUSIONS UTI was associated with fewer patients requiring additional rescue treatment and reduction of CAL in this retrospective study.
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Affiliation(s)
- Takashi Kanai
- The Department of Pediatrics, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan.
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Cyclosporin A treatment for Kawasaki disease refractory to initial and additional intravenous immunoglobulin. Pediatr Infect Dis J 2011; 30:871-6. [PMID: 21587094 DOI: 10.1097/inf.0b013e318220c3cf] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND There are still no definite treatments for refractory Kawasaki disease (KD). In this pilot study, we evaluated the use of cyclosporin A (CyA) treatment in patients with refractory KD. METHODS We prospectively collected clinical data of CyA treatment (4-8 mg/kg/d, oral administration) for refractory KD patients using the same protocol among several hospitals. Refractory KD is defined as the persistence or recurrence of fever (37.5°C or more of an axillary temperature) at the end of the second intravenous immunoglobulin (2 g/kg) following the initial one. RESULTS Subjects were enrolled out of 329 KD patients who were admitted to our 8 hospitals between January 2008 and June 2010. Among a total of 28 patients of refractory KD treated with CyA, 18 (64.3%) responded promptly to be afebrile within 3 days and had decreased C-reactive protein levels, the other 4 became afebrile within 4 to 5 days. However, 6 patients (21.4%) failed to become afebrile within 5 days after the start of CyA and/or high fever returned after becoming afebrile within 5 days. Although hyperkalemia developed in 9 patients at 3 to 7 days after the start of CyA treatment, there were no serious adverse effects such as arrhythmias. Four patients (1.2%), 2 before and the other 2 after the start of CyA treatment, developed coronary arterial lesions. CONCLUSION CyA treatment is considered safe and well tolerated, and a promising option for patients with refractory KD. Further investigations will be needed to clarify optimal dose, safety, and timing of CyA treatment.
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Alexoudi I, Kanakis M, Kapsimali V, Vaiopoulos G. Kawasaki disease: current aspects on aetiopathogenesis and therapeutic management. Autoimmun Rev 2011; 10:544-7. [PMID: 21549860 DOI: 10.1016/j.autrev.2011.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 04/09/2011] [Indexed: 02/02/2023]
Abstract
Kawasaki disease (KD) is a vasculitis that affects mainly children of 6 months to 4 years old. It is important to be early recognised so as to limit the inflammatory cascade that may lead to aneurysmatic dilatations of coronary arteries. The causative agent of KD has not been still indentified and the aetiopathogenetic theories are based on epidemiologic, laboratory and histological data. The management of the disease is divided according to the clinical stage and patients' follow up should be continued for years after the disease onset. The exact period is determined by the risk level of the KD.
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Affiliation(s)
- Iliana Alexoudi
- University of Athens, Internal Medicine, 17 St. Thomas St., 11527, Athens.
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External validation of a risk score to predict intravenous immunoglobulin resistance in patients with kawasaki disease. Pediatr Infect Dis J 2011; 30:145-7. [PMID: 20802375 DOI: 10.1097/inf.0b013e3181f386db] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND we previously developed a new risk score to predict intravenous immunoglobulin (IVIG) resistance in Kawasaki disease. However, the IVIG dosage used in that study (1 g/kg/d for 2 consecutive days) differs from the single infusion of 2 g/kg recommended in the United States and elsewhere. Our aim was to assess the validity and applicability of our risk score in patients treated with a single infusion. METHODS we used a database of 1626 patients with Kawasaki disease given initial IVIG treatment at a dose of 1 g/kg/d for 2 consecutive days (n = 990; IVIG- 1 g/kg × 2) or 2 g/kg/d for 1 day (n = 636; IVIG- 2 g/kg × 1) across 17 hospitals in Japan. Patients received the total IVIG dose within 36 hours in IVIG- 1 g/kg × 2 and 24 hours in IVIG- 2 g/kg × 1. We stratified the patients according to a risk scoring system developed to predict IVIG unresponsiveness, based on scores of ≥ 5 points. We compared the accuracy of prediction between the 2 groups using receiver operating characteristic analysis. RESULTS baseline characteristics and clinical outcomes were similar between both groups. The areas under the receiver operating characteristic curve in IVIG- 2 g/kg × 1 were similar to those of IVIG- 1 g/kg × 2. Using a cut-off risk score of ≥ 5 points, we could identify IVIG resistance in terms of coronary artery abnormalities within 1 month and coronary artery abnormalities at 1 month with equivalent sensitivity and specificity in both groups. CONCLUSION our risk score can be used to predict IVIG unresponsiveness to a regimen based on a single infusion of 2 g/kg IVIG.
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Primary treatment of incomplete Kawasaki disease with infliximab and methylprednisolone in a patient with a contraindication to intravenous immune globulin. Pediatr Infect Dis J 2010; 29:978-9. [PMID: 20431427 DOI: 10.1097/inf.0b013e3181e05564] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Incomplete Kawasaki disease was diagnosed in a 3-year-old boy. Because intravenous immune globulin infusion was not tolerated, he was treated with infliximab and methylprednisolone. Coronary aneurysms were not visualized on initial or follow-up echocardiograms. To our knowledge, this is the first report to document the use of infliximab and methylprednisolone as first line therapy for Kawasaki disease.
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Prieto Tato LM, Cuesta Rubio MT, Guillén Martín S, Ruiz Jiménez M, Cortés Coto MT, Rubio Gribble B, Ramos Amador JT. Enfermedad de Kawasaki: diagnóstico y tratamiento. An Pediatr (Barc) 2010; 73:25-30. [DOI: 10.1016/j.anpedi.2010.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 01/25/2010] [Accepted: 02/04/2010] [Indexed: 10/19/2022] Open
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Abstract
Kawasaki disease (KD) is the most common systemic vasculitis in childhood after Henoch-Schonlein purpura, and the most common cause of acquired heart disease among children living in Western countries. Its diagnosis relies on clinical findings; laboratory tests are useful to rule out other causes of unexplained fever but are not specific for the diagnosis of KD. Numerous efforts to produce a diagnostic algorithm have been made, but without success. Expert opinion is therefore required in doubtful cases, especially those that lack classical criteria (the so-called atypical or incomplete cases). Renal, gastrointestinal, neurologic, pulmonary and ocular involvements have all been described. Infants may be at higher risk of complications since recognising manifestations of the disease might be more difficult in this group. Approaches to treatment and follow-up of KD are changing in parallel with changes in concepts of what constitutes classical and incomplete KD. Guiding this evolution is the probability that the diagnosis is actually KD, the duration of the child's illness and the desired effects of therapy. Until a gold standard for diagnosing KD is available, these therapeutic decisions will continue to be made on an individual basis.
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Affiliation(s)
- R Cimaz
- AOU Meyer and University of Florence, 50139 Florence, Italy.
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