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

NT-proBNP Levels Following IVIG Treatment for Multisystem Inflammatory Syndrome in Children

BACKGROUND

N-terminal of pro-brain natriuretic peptide (NT-proBNP) and C-reactive protein (CRP) levels are often elevated in Multisystem Inflammatory Syndrome in Children (MIS-C) secondary to inflammation, myocardial dysfunction, or increased wall tension. Intravenous Immunoglobulin (IVIG), accepted treatment for MIS-C, may transiently increase myocardial tension and contribute to an increase in NT-proBNP.

OBJECTIVE

We sought to study the association between pre- and post-IVIG levels of NT-proBNP and CRP and their clinical significance.

METHODS

This single center retrospective cohort study included consecutive children, ages ≤ 21 years, with diagnosis of MIS-C who received IVIG from April 2020 through October 2021. Data collection included clinical characteristics, laboratory tests, management, and outcomes. Study cohort consisted of patients who received IVIG and had NT-proBNP levels available pre- and post-IVIG.

RESULTS

Among 35 patients with MIS-C, 30 met inclusion criteria. Twenty-four, 80%, showed elevation in NT-proBNP post-IVIG. The median NT-proBNP level pre-IVIG was 1,921 pg/mL (IQR 548, 3,956), significantly lower than the post-IVIG median of 3,756 pg/mL (IQR 1,342, 7,634)) (p=0.0010). The median pre-IVIG CRP level was significantly higher than the post-IVIG level (12 mg/dL vs 8 mg/dL, p= 0.0006). All but one recovered prior to discharge, and none had signs of worsening cardiac function post-IVIG. In those who recovered, NT-proBNP had normalized by discharge or 1-week follow-up.

CONCLUSIONS

Our study shows that NT-proBNP levels often transiently increase immediately after IVIG therapy without signs of worsening myocardial function. These values should be interpreted in the context of CRP levels and clinical recovery.

Risk Factors of Intravenous Immunoglobulin Resistance in Children With Kawasaki Disease: A Meta-Analysis of Case-Control Studies

Previous studies have shown that children with Kawasaki disease (KD) who fail to respond to intravenous immunoglobulin (IVIG) therapy are at higher risk of developing coronary artery lesions (CALs). We aimed to conduct a meta-analysis to uncover the risk factors associated with IVIG resistance in children with KD. PubMed, Embase, and Cochrane Library databases were searched up to 31st October 2019, and 23 case-control studies were finally eligible, enrolling 2,053 patients of IVIG resistance and 16,635 patients of IVIG sensitivity. Potential factors were comprehensively analyzed by using stata15 software with a standard meta-analysis procedure and consequently found that in addition to patients with polymorphous rash or swelling of extremities symptoms had a tendency to be non-responders, IVIG resistance was more likely to occur in patients with severe anemia, hypoalbuminemia, decreased baseline platelet count, and elevated levels of erythrocyte sedimentation rate (ESR), total bilirubin, alanine aminotransferase (ALT) and neutrophils percentage. Particularly, male sex, hyponatraemia, increased aspartate aminotransferase (AST), and C-reactive protein (CRP) were confirmed as the risk factors favor IVIG resistance in Mongoloids from Asia countries, but not in Caucasians from non-Asia regions. In summary, we report several risk factors relevant to IVIG resistance in children with KD, which may provide guidance for the prediction of IVIG resistance. But a proposing of an optimal prediction system with high specificity and sensitivity needs further studies because of confounding factors.

The role of age-specific N-terminal pro-brain natriuretic peptide cutoff values in predicting intravenous immunoglobulin resistance in Kawasaki disease: a prospective cohort study

BACKGROUND

The prediction of resistance to intravenous immunoglobulins (IVIG) is currently still one of the main research areas in Kawasaki disease (KD). Several studies have reported on the use of N-terminal pro-brain natriuretic peptide (NT-ProBNP) to this end. However, considering the age-dependency of NT-ProBNP levels, age- specific NT-ProBNP cutoff levels to predict IVIG resistance in KD might be more precise and should be evaluated.

METHODS

A prospective cohort study with standardized data collection involving 393 KD patients aged 1 month to 125 months was conducted between June 2015 and April 2018. The demographic characteristics, clinical manifestations and laboratory data were compared between the patients responding to initial intravenous immunoglobulin (IVIG-response group) and those who did not (IVIG-resistance group). We further distinguished four subgroups according to patients' age (< 1 year, 1-2 years, 2-6 years, > 6 years). The cutoff values of NT-ProBNP for the prediction of IVIG resistance overall and in the subgroups were obtained using receiver operating characteristic (ROC) analysis.

RESULTS

In all KD patients, the level of NT-ProBNP was significantly higher in the IVIG-resistance compared to the IVIG-response group (P = 0.006). This findings was similar in the subgroups except for patients older than six years. The best cutoff values of NT-ProBNP to predict IVIG resistance were 3755 pg/ml for all KD patients, 3710 pg/ml, 2800 pg/ml, 2480 pg/ml for those aged 2-6 years, 1-2 years and < 1 year, respectively. The corresponding sensitivities were 44.0, 52.2, 50.0 and 75.0%, while the specifities were 84.1, 86.3, 77.9 and 71.8%, respectively.

CONCLUSIONS

NT-proBNP is a complementary laboratory marker for the prediction of IVIG resistance in KD patients, particularly for those younger than one year. Applying age-specific cutoff values is more precise than one value for all ages.

Predictors and management of intravenous immunoglobulin-resistant Kawasaki disease

Kawasaki disease (KD) is a systemic vasculitis that mainly affects younger children. Intravenous immunoglobulin (IVIG) resistant cases are at increasing risk for coronary artery complications. The strategy on prediction of potential nonresponders and treatment of IVIG-resistant patients is now controversial. In this review the definition and predictors of IVIG-resistant KD and current evidence to guide management are discussed.

Biomarkers for Kawasaki Disease: Clinical Utility and the Challenges Ahead

Kawasaki disease (KD) has replaced acute rheumatic fever as the most common cause of acquired heart disease in children in the developed world and is increasingly being recognized from several developing countries. It is a systemic vasculitis with a predilection for coronary arteries. The diagnosis is based on a constellation of clinical findings that appear in a temporal sequence. Quite understandably, this can become a problem in situations wherein the clinical features are not typical. In such situations, it can be very difficult, if not impossible, to arrive at a diagnosis. Several biomarkers have been recognized in children with acute KD but none of these has reasonably high sensitivity and specificity in predicting the course of the illness. A line up of inflammatory, proteomic, gene expression and micro-RNA based biomarkers has been studied in association with KD. The commonly used inflammatory markers e.g. erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and total leucocyte counts (TLC) lack specificity for KD. Proteomic studies are based on the identification of specific proteins in serum, plasma and urine by gel electrophoresis. A host of genetic studies have identified genes associated with KD and some of these genes can predict the course and coronary outcomes in the affected individuals. Most of these tests are in the early stages of their development and some of these can predict the course, propensity to develop coronary artery sequelae, intravenous immunoglobulin (IVIg) resistance and the severity of the illness in a patient. Development of clinical criteria based on these tests will improve our diagnostic acumen and aid in early identification and prevention of cardiovascular complications.

A Decade of NT-proBNP in Acute Kawasaki Disease, from Physiological Response to Clinical Relevance

Kawasaki disease (KD) is an inflammatory febrile illness of early childhood and the primary cause of acquired heart disease during childhood. Coronary artery aneurysms (CAA) are a serious complication of KD, leading to ischemic heart disease, myocardial infarction, and sudden cardiac death. Timely diagnosis in the first ten days of fever is crucial to reduce the risk of coronary artery complications. Nitrogen-terminal B-type natriuretic peptide (NT-proBNP), originally used for the management of adults with heart disease, was shown to be useful in the diagnosis and management of patients with KD. NT-proBNP is released by cardiomyocytes in response to mechanical factors such as the dilation of cardiac chambers, and to pro-inflammatory cytokines. The utility of NT-proBNP as a biological marker in KD is based on the universal myocardial inflammatory component early in the course of the disease. Patients with KD have higher NT-proBNP at the time of diagnosis than febrile controls, with a pooled sensitivity of 89% (95% confidence interval 78–95), and a specificity of 72% (95% confidence interval 58–82). The positive likelihood ratio is 3.2:1 (95% confidence interval 2.1–4.8). Moreover, patients with resistance to intravenous immunoglobulin treatment and CAA were found to have higher levels of NT-proBNP, suggesting a prognostic role. Nevertheless, the non-specificity of NT-proBNP to KD limits its use as a stand-alone test. In this light, a tentative associative retrospective diagnostic algorithm was highly reliable for including all cases at risk of CAA, which warrants further prospective studies for a better diagnostic index of suspicion and risk stratification of patients.

Cardiac function on 3-D speckle tracking imaging and cytokines in Kawasaki disease

BACKGROUND

Serum N-terminal pro-brain natriuretic peptide (NT-proBNP) tends to rise in acute phase Kawasaki disease (KD), but the cause of NT-proBNP elevation has not been clarified. In a previous study, cardiac function evaluated on 2-D echocardiography (2D-E) such as ejection fraction was normal, but this does not reflect subtle changes in cardiac dysfunction, and hence the association between cardiac function and NT-proBNP elevation is still controversial. The aim of this study was therefore to elucidate the influence of cardiac function on NT-proBNP elevation, by evaluating cardiac function via strain on 3-D speckle tracking imaging (3D-STI), in acute and subacute KD patients. Given that cytokines are also thought to induce NT-proBNP in acute phase KD, serum cytokines and cytokine receptors were measured at the same time.

METHODS

Laboratory data and echocardiography in 52 KD patients in the acute and subacute phases were reviewed.

RESULTS

Median NT-proBNP was significantly elevated in the acute phase compared with the subacute phase (356.5 pg/mL; IQR, 145-904 pg/mL vs 103.5 pg/mL; IQR, 59-150 pg/mL, P < 0.01). All cytokines were also significantly elevated in the acute phase compared with the subacute phase. Tumor necrosis factor (TNF)-α, soluble TNF receptor (sTNFR)1, and sTNFR2 concentration were all significantly higher in the acute phase. Indices of cardiac function were not significant different between phases. NT-proBNP in the acute and subacute phases correlated with sTNFR1 (r = 0.63/0.43, P < 0.01), sTNFR2 (r = 0.50/0.31, P < 0.05), and interleukin-6 (r = 0.58/0.43, P < 0.01). NT-proBNP did not correlate with global longitudinal strain (GLS) on 3D-STI.

CONCLUSION

Although no correlation was seen between NT-proBNP and GLS on 3D-STI, correlations between NT-proBNP and cytokines were clear. NT-proBNP might be a marker of inflammation in KD, but is not a marker of cardiac function.

Predictors of intravenous immunoglobulin-resistant Kawasaki disease in children: a meta-analysis of 4442 cases

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.

Factors Predicting Resistance to Intravenous Immunoglobulin Treatment and Coronary Artery Lesion in Patients with Kawasaki Disease: Analysis of the Korean Nationwide Multicenter Survey from 2012 to 2014

Background and Objectives

Approximately 10–15% of children with Kawasaki disease (KD) do not respond to initial intravenous immunoglobulin (IVIG) and have higher risk for coronary artery lesion (CAL). The aim of this study was to identify predictive factors from laboratory findings in patients who do not respond to IVIG treatment and develop CAL from KD.

Methods

We retrospectively collected nationwide multicenter data from the Korean Society of Kawasaki Disease and included 5,151 patients with KD between 2012 and 2014 from 38 hospitals.

Results

Among 5,151 patients with KD, 524 patients belonged to the IVIG-resistant group. The patients in the IVIG-resistant group had a significantly higher serum N-terminal pro-brain natriuretic peptide (NT-proBNP) level (1,573.91±3,166.46 vs. 940.62±2,326.10 pg/mL; p<0.001) and a higher percentage of polymorphonuclear neutrophils (PMNs) (70.89±15.75% vs. 62.38±32.94%; p<0.001). Multivariate logistic regression analyses revealed that significantly increased PMN, NT-proBNP, C-reactive protein (CRP), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were the predictors of IVIG resistance (p<0.05). Multivariate logistic regression analyses also showed that only CRP was associated with the risk of CAL (p<0.01), while PMN, NT-proBNP, AST, and ALT were not.

Conclusions

Elevated PMN, serum NT-proBNP, CRP, AST, and ALT levels are significantly associated with IVIG resistance in patients with KD. Moreover, serum CRP is significantly increased in patients with KD with CAL.

Predictive factors of resistance to intravenous immunoglobulin and coronary artery lesions in Kawasaki disease

Purpose

We conducted a study to determine which factors may be useful as predictive markers in identifying Kawasaki disease (KD) patients with a high risk of resistance to intravenous immunoglobulin (IVIG) and developing coronary artery lesions (CAL).

Methods

We enrolled 287 patients in acute phase of KD at a single center. The demographic, clinical and laboratory data were collected retrospectively.

Results

There were 34 patients in the IVIG resistant group. The IVIG resistant group had significantly higher serum N-terminal-pro-brain natriuretic protein (NT-proBNP) levels (P<0.01) and polymorphonuclear neutrophil (PMN) percentage (P<0.01) in comparison to the IVIG responders. The results yielded sensitivity (78.8%, 60.6%), specificity (58.2%, 90%) and cutoff value (628.6 pg/mL, 80.3%) of NT-proBNP and PMN respectively, in predicting IVIG resistance. Despite IVIG administration, 13 of the 287 patients developed CAL. The patients in the CAL group had higher NT-proBNP levels (P<0.01) and higher PMN percentage (P<0.01). In these patients, the results yielded sensitivity (73.3%, 56.7%), specificity (67.9%, 88.9%) and cutoff value (853.4 pg/mL, 80.3%) of NT-proBNP and PMN respectively, for predicting CAL. The area under the curve (AUC) for predicting resistance to IVIG was NT-proBNP 0.712, PMN 0.802. The AUC for predicting CAL was NT-proBNP 0.739, and PMN 0.773.

Conclusion

Serum NT-proBNP levels and PMN percentage were significantly elevated in patients with KD with IVIG resistance and CAL. Thus, they may be useful predicting markers for IVIG resistance and development of CAL in KD patients.

N-terminal pro-brain natriuretic peptide in acute Kawasaki disease correlates with coronary artery involvement

BACKGROUND

We have lately documented the importance of N-terminal pro-brain natriuretic peptide in aiding the diagnosis of Kawasaki disease.

OBJECTIVES

We sought to investigate the potential value of N-terminal pro-brain natriuretic peptide pertaining to the prediction of coronary artery dilatation (Z-score>2.5) and/or of resistance to intravenous immunoglobulin therapy. We hypothesised that increased serum N-terminal pro-brain natriuretic peptide level correlates with increased coronary artery dilatation and/or resistance to intravenous immunoglobulin.

METHODS

We carried out a prospective study involving newly diagnosed patients treated with 2 g/kg intravenous immunoglobulin within 5-10 days of onset of fever. Echocardiography was performed in all patients at onset, then weekly for 3 weeks, then at month 2, and month 3. Coronary arteries were measured at each visit, and coronary artery Z-score was calculated. All the patients had N-terminal pro-brain natriuretic peptide serum level measured at onset, and the Z-score calculated.

RESULTS

There were 109 patients enrolled at 6.58±2.82 days of fever, age 3.79±2.92 years. High N-terminal pro-brain natriuretic peptide level was associated with coronary artery dilatation at onset in 22.2 versus 5.6% for normal N-terminal pro-brain natriuretic peptide levels (odds ratio 4.8 [95% confidence interval 1.05-22.4]; p=0.031). This was predictive of cumulative coronary artery dilatation for the first 3 months (p=0.04-0.02), but not during convalescence at 2-3 months (odds ratio 1.28 [95% confidence interval 0.23-7.3]; p=non-significant). Elevated N-terminal pro-brain natriuretic peptide levels did not predict intravenous immunoglobulin resistance, 15.3 versus 13.5% (p=1).

CONCLUSION

Elevated N-terminal pro-brain natriuretic peptide level correlates with acute coronary artery dilatation in treated Kawasaki disease, but not with intravenous immunoglobulin resistance.

Intravenous immunoglobulin, pharmacogenomics, and Kawasaki disease

Kawasaki disease (KD) is a systemic vasculitis of unknown etiology and it is therefore worth examining the multifactorial interaction of genes and environmental factors. Targeted genetic association and genome-wide association studies have helped to provide a better understanding of KD from infection to the immune-related response. Findings in the past decade have contributed to a major breakthrough in the genetics of KD, with the identification of several genomic regions linked to the pathogenesis of KD, including ITPKC, CD40, BLK, and FCGR2A. This review focuses on the factors associated with the genetic polymorphisms of KD and the pharmacogenomics of the response to treatment in patients with intravenous immunoglobulin resistance.

The Harada score in the US population of children with Kawasaki disease

OBJECTIVE

To describe and quantify the presentations of Kawasaki disease (KD) in a children's hospital over 10 years to assess the Harada score in a US population.

METHODS

A retrospective chart review from 2001 to 2011 of children discharged from Cleveland Clinic with the diagnosis of KD. Demographic and clinical data were collected and Harada scores were derived to evaluate efficacy in predicting risk for coronary artery aneurysms (CAAs).

RESULTS

A total of 105 children met diagnostic criteria for KD, and 97 of 105 had long-term follow-up. Full criteria for KD were found in 67 of 105 (64%); 38 had incomplete presentations. CAA developed in 10 children, 5 during follow-up despite treatment with intravenous immunoglobulin (IVIG.) Children with incomplete presentations had a higher risk of developing CAA (20% vs 5%, P = .03) and a delayed diagnosis (median days from fever to diagnosis 8.0 vs 5.0 days, P < .001). Of children who developed CAA, 9 of 10 had a positive Harada score (sensitivity of 90%). All children who developed CAA after IVIG were in the high-risk group, but 1 child with an incomplete presentation who had a CAA at presentation was missed by the score. Overall, the negative predictive value was 98%.

CONCLUSIONS

As in Japanese studies, a positive Harada score in a US population could be used to identify a high-risk population for CAA development. All children who developed CAA after treatment with IVIG would have been assigned to a high-risk category. Though not specific enough to select initial therapy, the score might be useful in identifying high-risk children for evaluation of new therapies and more frequent follow-up.