Increased circulating granulocyte colony-stimulating factor in acute Kawasaki disease

Predicting factors for refractory kawasaki disease

Background and Objectives

About 10-15% of Kawasaki disease (KD) is refractory to intravenous immunoglobulin (IVIG) therapy. This study was designed to investigate the predicting factors for refractory KD.

Subjects and Methods

We reviewed retrospectively the clinical records of 77 patients with typical KD admitted at Wonju Christian Hospital from January, 2005, to December, 2008. The variance of laboratory and demographic parameters between the IVIG-responsive group and IVIG-resistant group were analyzed. Thirteen patients with urinary tract infections were randomly collected as a febrile control group.

Results

Among 77 patients diagnosed with complete KD, 13 patients (16.9%) were IVIG-resistant. The febrile period and hospital days were significantly longer in the IVIG-resistant group than IVIG-responsive group (p<0.001, p=0.002). Serum levels of albumin and sodium were significantly lower in the IVIG-resistant group (p=0.025). The Kobayashi score could differentiate these two groups (p=0.015). Fewer lymphocytes was observed during the subacute phase in the IVIG-resistant group (p=0.032). Coronary arterial dilatations (CADs) were observed in 10.9% (7/64) of IVIG-responders and 38.5% (5/13) of IVIG-resistant patients (p=0.038).

Conclusion

The percentage of neutrophils and lymphocytes in patients with KD, in addition to known risk factors for refractory KD, may help predict IVIG-resistance in patients with KD.

Risk stratification in the decision to include prednisolone with intravenous immunoglobulin in primary therapy of Kawasaki disease

BACKGROUND

We reported previously that intravenous immunoglobulin (IVIG) plus prednisolone for initial therapy for Kawasaki disease (KD) prevented coronary artery abnormalities (CAA) more effectively than IVIG alone. However, questions remain as to whether PSL has potential benefit in all KD patients. The present study was designed to explore the possibility of stratified initial therapy including PSL in patients with and without a high predicted risk of being an IVIG nonresponder.

METHODS

We retrospectively analyzed data from KD patients who received IVIG (n = 896) or IVIG + PSL (n = 110) by scoring the likely risk of being an IVIG nonresponder. We compared clinical and coronary outcomes between treatment-defined groups separately for high- and low-risk patients.

RESULTS

Among low-risk patients (score 0-4), clinical and coronary outcomes were similar. Among high-risk patients (score 5 or more), incidences of treatment failure and coronary artery abnormalities until 1-month follow-up were more frequent in the IVIG than in the IVIG + PSL group. Sex- and score point-adjusted odds ratios for IVIG + PSL were 0.17 (95% confidence interval, 0.08-0.39) for treatment failure and 0.27 (95% confidence interval, 0.07-0.85) for coronary artery abnormalities A among high-risk patients.

CONCLUSIONS

IVIG + PSL treatment was associated with improving clinical and coronary outcomes in patients at high risk of being IVIG nonresponders.

Elevated granulocyte colony-stimulating factor levels predict treatment failure in patients with Kawasaki disease

BACKGROUND

Kawasaki disease (KD) is an acute vasculitis in young children, frequently associated with coronary artery aneurysms. The intravenous infusion of high-dose IgG (IVIG) effectively reduces the systemic inflammation and the incidence of coronary artery lesions, although the precise underlying mechanisms are unknown.

OBJECTIVE

We performed expression profiling of whole blood cells to investigate the mechanisms underlying the effect of IVIG and to identify biomarkers associated with unresponsiveness to IVIG.

METHODS

We compared the transcript abundance among pre-IVIG and post-IVIG patients and febrile control patients. Then we analyzed the mRNA levels and the protein levels among the different cohort of patients with KD who were either responsive or nonresponsive to the initial IVIG.

RESULTS

A total of 298 transcripts were overrepresented or underrepresented in the pre-IVIG patients compared with post-IVIG patients and febrile controls, of which 15 transcripts were differentially expressed in nonresponsive patients with KD compared with responsive patients before IVIG. The protein levels of polycythemia rubra vera 1, which was one of the most variably expressed transcripts in pre-IVIG patients, and the serum granulocyte colony-stimulating factor levels were significantly higher in nonresponsive patients than in responsive patients before the initial IVIG administration.

CONCLUSION

These findings suggest that the variable gene expression profiles were correlated to the responses of patients with KD to IVIG administration. Polycythemia rubra vera 1 and granulocyte colony-stimulating factor levels may be good biomarkers for predicting response to IVIG in patients with KD.

Increased CD11b expression on polymorphonuclear leucocytes and cytokine profiles in patients with Kawasaki disease

Clinical evidence implicates polymorphonuclear leucocytes in the pathogenesis of vasculitis in Kawasaki disease. We examined modulation of expression of adhesion molecules (CD11b and CD62L) on polymorphonuclear leucocytes and how this expression is related to serum cytokine concentrations. In 18 patients with Kawasaki disease and 15 control subjects, adhesion molecule expression was determined by two-colour immunofluorescence staining of blood leucocytes and flow cytometry. Eight cytokines and chemokines were also measured. In patients with Kawasaki disease, mean fluorescence intensity for CD11b before giving intravenous immunoglobulin was significantly higher than in normal subjects (P<0 x 005). After intravenous immunoglobulin, mean fluorescence intensity for CD11b decreased significantly. With coronary artery lesions present, mean CD11b fluorescence intensity was significantly higher than without coronary artery lesions (P=0 x 005 before intravenous immunoglobulin; P=0 x 024 after intravenous immunoglobulin). No differences were seen in CD62L expression on polymorphonuclear leucocytes between patients with Kawasaki disease and normal subjects. CD11b expression on polymorphonuclear leucocytes correlated positively with serum interleukin (IL)-6, IL-10, granulocyte colony-stimulating factor, percentage of neutrophils among white cells and C-reactive protein. Polymorphonuclear leucocytes from patients with Kawasaki disease showed increased CD11b expression, which was associated with increased serum cytokines and appeared to be related to coronary artery lesions.

Neutrophilic involvement in the damage to coronary arteries in acute stage of Kawasaki disease

BACKGROUND

There has been no morphological evidence that polymorphonuclear leukocytes (PMNL) infiltrate the coronary arterial lesions of acute Kawasaki disease (KD) patients, although clinical data indicate the activation of PMNL.

METHODS

The experimental materials consisted of eight autopsy patients who died during the acute phase of KD. Duration of the illness ranged from 6 to 32 days. The tissues were fixed and embedded in paraffin. Hematoxylin and eosin, elastica van Gieson and azan-Mallory stainings were performed for routine histological examination. In addition, antibodies to CD3, CD20, CD68 and neutrophil elastase were used for immunohistochemistry to identify infiltrating cells in arterial lesions.

RESULTS

The inflammatory cells that appeared in the coronary arterial lesions were mainly composed of macrophages in all patients. In addition, numerous neutrophils were also identified in the coronary arterial lesions of the patients who died 10 days after the onset of KD. Neutrophilic infiltration reached a peak earlier than the peaks of CD68+ macrophages, CD3+ T lymphocytes and CD20+ B lymphocytes.

CONCLUSIONS

These results suggest that neutrophils are involved in the damage occurring to coronary arteries in the early stage of KD. Vasodilation might occur as a result of injury to vascular walls caused by neutrophils, as well as macrophages.

Sera from patients with Kawasaki disease induce intercellular adhesion molecule-1 but not Fas in human endothelial cells

BACKGROUND

Kawasaki disease (KD) is an acute vasculitis of unknown etiology occurring in childhood, characterized by abnormalities of the immune system including elevations of proinflammatory cytokines in the serum. We investigated the effect of serum from patients with KD on the expression of intercellular adhesion molecule-1 (ICAM-1) and Fas by human umbilical vein endothelial cells (HUVEC).

METHODS

Confluent monolayers of HUVEC were incubated with sera from patients in the acute or convalescent phase of KD. Expression of ICAM-1 and Fas by HUVEC was assessed by flow cytometry. Concentrations of tumor necrosis factor (TNF)-alpha and interleukin (IL)-1beta in sera from patients with KD were measured by an immunoradiometric assay and an enzyme-linked immunosorbent assay, respectively.

RESULTS

Sera from patients in the acute phase of KD produced significantly greater ICAM-1 expression by HUVEC than sera from patients in the convalescent phase. In contrast, KD sera did not induce Fas expression. While the mean serum concentration of TNF-alpha in patients in the acute phase of KD was significantly higher than in those in the convalescent phase, IL-1beta concentrations did not differ between the acute and convalescent phases. Exposure of HUVEC to recombinant human TNF-alpha increased the expression of both ICAM-1 and Fas, but a much lower concentration was required for an effect upon ICAM-1. Exogenous TNF-alpha did not induce apoptosis in HUVEC.

CONCLUSIONS

These results suggest that increased expression of ICAM-1 by endothelial cells might be involved in the pathogenesis of acute KD, and that TNF-alpha might induce ICAM-1 expression.

Serum levels of neutrophil activation cytokines in Kawasaki disease

BACKGROUND

The aim of the present study was to investigate whether neutrophils are early effector cells for vascular endothelial damage in the acute phase of Kawasaki disease (KD) by examining serial changes in neutrophil counts and serum levels of neutrophil activation cytokines, such as granulocyte colony stimulating factor (G-CSF) and interleukin (IL)-8.

METHODS

From October 1994 to June 1998, a total of 52 patients with KD were included in the study. Thirty-three patients had some infectious diseases, while 20 healthy children served as control subjects. Serial changes in neutrophils were counted by the optimal Wright-Giemsa staining method and serum levels of IL-8 and G-CSF in patients with KD were measured by an enzyme-linked immunosorbent assay system.

RESULTS

Serum G-CSF levels both before and after intravenous immunoglobulin therapy (IVIG; P<0.05) and neutrophil counts after IVIG (P<0.005) were higher in KD patients with coronary arterial lesions (CAL) than those without CAL. However, serum IL-8 levels before and after IVIG showed no significant differences in these two groups.

CONCLUSIONS

These data suggest that neutrophils may be important as early effector cells for vascular endothelial damage and that G-CSF may play a more important role than IL-8 in KD.