Acute renal failure in typical Kawasaki disease

Few cases of Kawasaki disease with acute renal failure have been described and only three articles report histological findings. We present an 8-year-old boy with typical Kawasaki disease and acute renal failure who did not require dialysis and had a complete recovery. Pathological findings in percutaneous biopsy included tubulointerstitial nephropathy with mild mesangial expansion, without vessel involvement or deposits in basal membrane. These findings were similar to those previously reported. We also detected apoptotic bodies in tubules. Received: 11 June 2001 / Revised: 2 January 2002 / Accepted: 4 January 2002     

Exanthema and acute anuric renal failure

A 15-year-old girl with a history of Kawasaki disease was admitted to our nephrological department due to acute renal failure. Despite antibiotic therapy because of fever and the symptoms of a pharyngitis in the last few days, the girl showed persisting fever and developed arthralgias, an exanthema and a rising serum creatinine as well as anuria. A wide variety of differential diagnoses has to be thought of because of the history of the Kawasaki disease (symptoms like fever, pharyngitis, exanthema and arthralgia), i.e. hemolytic-uremic syndrome, vasculitis, ascending infection, postinfection glomerulonephritis. In consideration of etiologically unclear "rapidly progressive renal failure" with anuria and thrombocytopenia an immediate renal biopsy was done and revealed a severe drug induced acute interstitial nephritis. Due to this diagnosis we treated the patient with corticosteroids. Within 4 weeks serum creatinine declined to 1.8 mg/dl but did not normalize.     

Popliteal aneurysm presenting as acute thrombosis and ischemia in a middle-aged man with a history of Kawasaki disease

Kawasaki disease is known to cause a vasculitis of small and medium-sized vessels, with subsequent aneurysm formation. Most of the severe manifestations of the disease occur as a result of coronary aneurysm formation. However, many other arteries have been documented to be involved. A case is presented of a middle-aged man with a history of Kawasaki disease who had an acute ischemic limb from a thrombosed popliteal aneurysm that formed as a result of the disease. This is the first known case report of Kawasaki disease resulting in delayed lower extremity ischemia. Typical findings of patients with Kawasaki disease are presented, along with a case report and review of the literature. A history of Kawasaki disease is an extremely rare but possible cause of peripheral aneurysms, even in middle-aged patients. (J Vasc Surg 1997;26:884-7.)     

Coronary bypass surgery in kawasaki disease in a four-year-old patient: case report

Kawasaki disease is an acute vasculitis syndrome of unknown etiology that mainly affects small and medium-sized arteries, particularly the coronary arteries. This disease is rarely seen in infants and young people in Turkey. In this short report, we present a four-year-old patient who has Kawasaki disease associated with coronary artery aneurysm and underwent coronary bypass grafting.     

Medium-size-vessel vasculitis

Medium-size-artery vasculitides do occur in childhood and manifest, in the main, as polyarteritis nodosa (PAN), cutaneous PAN and Kawasaki disease. Of these, PAN is the most serious, with high morbidity and not inconsequential mortality rates. New classification criteria for PAN have been validated that will have value in epidemiological studies and clinical trials. Renal involvement is common and recent therapeutic advances may result in improved treatment options. Cutaneous PAN is a milder disease characterised by periodic exacerbations and often associated with streptococcal infection. There is controversy as to whether this is a separate entity or part of the systemic PAN spectrum. Kawasaki disease is an acute self-limiting systemic vasculitis, the second commonest vasculitis in childhood and the commonest cause of childhood-acquired heart disease. Renal manifestations occur and include tubulointerstitial nephritis and renal failure. An infectious trigger and a genetic predisposition seem likely. Intravenous immunoglobulin (IV-Ig) and aspirin are effective therapeutically, but in resistant cases, either steroid or infliximab have a role. Greater understanding of the pathogenetic mechanisms involved in these three types of vasculitis and better long-term follow-up data will lead to improved therapy and prediction of prognosis.     

Subdural effusion in the acute stage of Kawasaki disease (Mucocutaneous lymph node syndrome)

A 6-month-old girl with complications of subdural effusions at the acute stage of Kawasaki disease is reported. Based on the pathology of Kawasaki disease and considering the possibility of systemic vasculitis, the subdural effusions were assumed to be attributable to vasculitis involving the dura mater.     

Renal histology of mucocutaneous lymph node syndrome (Kawasaki disease)

Renal involvement is well described in patients with mucocutaneous lymph node syndrome (MCLNS), or Kawasaki disease and is manifested by mild azotemia, hematuria, pyuria or cylinduria, and more often, proteinuria. Renal morphology during the acute stages of the illness has never been reported. In this paper we describe the renal histopathologic changes in a child with MCLNS. The glomerular histopathologic findings suggest immune complex damage to the kidney as a possible mechanism of nephrotoxicity in MCLNS. Presence of kidney lesions, which speak in favor of the injurious role of immune complexes in MLCNS may be relevant to the understanding of the pathogenesis of the vascular lesions that are characteristic of this disease.     

Surgical presentation of Kawasaki disease (mucocutaneous lymph node syndrome)

Five patients with Kawasaki disease (mucocutaneous lymph node syndrome) are reported whose varied presentations included acute abdominal pain, peripheral arterial aneurysms, digital gangrene and sterile pyuria and whose presenting pathology ranged from hydrops of the gallbladder to enteric pseudo-obstruction. As the complications of the disease can usually be managed without resort to surgery, which is associated with a mortality rate of up to 25 per cent, the recognition of Kawasaki disease will prevent hazardous and unnecessary laparotomy.     

Kawasaki disease manifesting with acute cholangitis. A case report.

A 3-year-old boy, who developed the signs and symptoms characteristic of Kawasaki disease, is described. The child also had an 8 cm tender hepatomegaly. Hydrops of the gallbladder could not be shown. Liver biopsy showed marked infiltration of inflammatory cells, including neutrophil and eosinophil leucocytes in the portal tracts involving the periphery of the portal arteries and veins, and acute inflammation of the bile ducts with neutrophil and eosinophil infiltration of the walls. Overt cholangitis has been described only once before in Kawasaki disease, when a viral agent was suggested as being important in the pathogenesis. Although the clinical and laboratory findings in cases of Kawasaki disease clearly suggest an acute infection--as they did in this case--no aetiological agent has yet been incriminated. The possibility of a drug-induced auto-allergic or hypersensitivity state is considered. Evidence for such a state includes a history of drug administration, pathological findings similar to peri-arteritis nodosa--a condition often associated with a hypersensitivity state--the presence of eosinophils in the lesions and a response to treatment with aspirin, a drug known to ameliorate hypersensitivity states.     

Anti-neutrophil cytoplasmic antibodies and anti-endothelial cell antibodies

Anti-netrophil cytosolic antibodies (ANCA) and anti-endothelial cell antibodies (AECA) have been identified in a wide variety of disorders, but their pathophysiological role remains unclear. ANCA appear to be particularly associated with various forms of vasculitis including Wegener's granulomatosis, Kawasaki disease and microscopic polyartiritis. Cytoplasmic staining (cANCA) on indirect immunofluorescence is associated with extrarenal disease and a perinuclear pattern (pANCA) with renal limited disease. The cANCA antigen appears to be proteinase 3 and that for pANCA myeloperoxidase. AECA have been detected in systemic lupus erythematosus, scleroderma and dermatomyositis but are also found in systemic vasculiitis. Kawasaki disease, haemolytic uraemic syndrome, thrombotic thrombocytopenic purpura and renal allograft recipients at the time of rejection. Their presence appears to be correlated with disease activity and they may be directed against epitopes on as yet unidentified infective agents that precipitate some of the diseases in which they are found that cross-react with antigenic sites exposed on endothelial cells. Measurement of these antibodies has a diagnostic role, facilitates monitoring of disease activity and may prove valuable in understanding the pathogenesis of the diseases in which they are found.     

Anesthesia for aorto-coronary bypass graft surgery in children with Kawasaki disease

We investigated anesthetic management of aorto-coronary bypass graft surgery (CABG) in the children who have coronary disease due to acute febrile mucocutaneous lymph node syndrome (Kawasaki disease). A retrospective observation was made on anesthetic management of 17 patients with Kawasaki disease. They were 13 boys and 4 girls and their ages ranged from 5 to 13 years. They underwent CABG during the past 10 years (1976-1986) in Tokyo Women's Medical College Daini Hospital. Induction of anesthesia was carried out with halothane-nitrous oxide-oxygen (GOF) in 16 patients and morphine-nitrous oxide-oxygen (GOM) in one patient. Anesthesia was maintained with GOF in 11 patients, and in 6 patients with GOF and narcotics. High-dose fentanyl was not used for anesthetic induction in children with Kawasaki disease. Pulse rate increased significantly after endotracheal intubation. Blood pressure increased after endotracheal intubation in 5 patients and after sternotomy in one patient. Hypotension developed in 2 patients. Coronary spasm did not occur during the all procedures. Control of blood pressure during CABG in children was easier than in adult patients. But the control of pulse rate offers a problem in anesthetic management of the children with Kawasaki disease.     

Review: surgical treatment of giant coronary aneurysms in pediatric patients with Kawasaki disease

In Kawasaki disease (KD), giant coronary aneurysms in the proximal segments of the coronary arteries have long been among the serious complications associated with acute myocardial infarction. To treat myocardial ischemia in children, Kitamura et al. first performed coronary artery bypass grafting in a pediatric patient using an autologous saphenous vein. In the early 1980s, they began to use the internal thoracic artery (ITA) as a bypass graft to the left anterior descending artery, which later was proven to improve long-term life expectancy with its favorable long-term patency, as well as growth potential. Thus, the excellent characteristics of the ITA have come to be widely known among pediatric cardiac surgeons, and a growing number of coronary bypass surgery procedures using the ITA are now being performed worldwide. Although a longer follow-up with more patients is necessary, downsizing reconstructive procedure may be a treatment of choice for giant aneurysms of non-LAD territories to improve coronary circulation. The efficacy of surgical treatment for giant coronary aneurysms in pediatric patients with Kawasaki disease is now well established. Pediatric coronary artery bypass grafting using the ITA, either single or bilateral, can be safe not only for patients with Kawasaki coronary disease but also for infants with congenital coronary lesions.     

Coronary artery abnormalities in children with systemic-onset juvenile idiopathic arthritis

Still's disease (Systemic-onset Juvenile Idiopathic Arthritis: SoJIA) is characterised by high-spiking daily fevers, arthritis and evanescent rashes. Diagnosis of Still's disease is often challenging. Infectious diseases and other inflammatory conditions, especially in young children, Kawasaki disease may look similar. Clinicians often rely on echocardiographic evidence of coronary artery abnormalities to differentiate between Kawasaki disease and Still's disease. Coronary artery dilation would typically favour the diagnosis of Kawasaki disease. We present four children with Still's disease and coronary artery abnormalities who were initially misdiagnosed as Kawasaki disease. The first patient had pericarditis and an irregular wall of the left coronary artery, without dilation on echocardiography. The second patient had a left coronary artery dilatation and a pericarditis. The third patient had thickened left coronary artery walls, and the fourth patient had a hyperechogenicity of the left and right coronary arteries. They received IVIG without success. The diagnosis of Still's disease was made secondary with evidence of persistent arthritis. All but one patient finally needed biologic treatments. Coronary abnormalities may be observed during various febrile conditions and do not exclude the diagnosis of Still's disease.     

MiR-155、miR-208和miR-499在川崎病患儿中的表达检测与分析

目的本文探讨心血管疾病相关的miR-155、miR-208和miR-499在川崎病患者中的表达水平及临床意义。方法纳入川崎病患儿52例,正常儿童20例作为对照;收集外周血,提取血浆中的RNA;采用实时荧光定量PCR检测这三种miRNA的表达并以RNU6B作为内参基因进行分析。结果与对照组比川崎病患儿中的miR-155表达水平明显升高(P=0.018),且miR-155表达水平与冠脉损害程度成一定程度的正相关。miR-208和miR-499在川崎病中的表达有一定程度升高,但均无显著性差异。结论 miR-155的高表达与儿童川崎病有关,提示其可以作为诊断川崎病的潜在标志物。     

Symptomatic coronary obstruction due to Kawasaki disease in an adult

Kawasaki disease is the most common cause of pediatric ischemic heart disease in the world, but it is unusual in adults. We present a case of Kawasaki disease in a young adult. This 20-year-old man presented with angina. Coronary angiography revealed aneurysmal obstructive lesions consistent with remote Kawasaki disease. The patient underwent coronary artery bypass grafting with arterial conduits. Postoperative echocardiography was normal and stress myocardial perfusion imaging showed no ischemia. He remained asymptomatic 12 months after surgery. There is controversy regarding optimal therapy, choice of conduit, treatment of proximal aneurysms, and surveillance in adults with Kawasaki disease.     

Urinary doubly refractile lipid bodies in nonglomerular renal diseases

Urinary doubly refractile lipid bodies (DRLB) are a characteristic finding in patients with glomerular renal diseases causing heavy proteinuria. DRLB are felt to be an uncommon finding in glomerular diseases without heavy proteinuria, and a rare finding in nonglomerular renal diseases. In order to determine whether DRLB are found in nonglomerular renal diseases, we reviewed the medical records of all patients who had urinalyses performed in our laboratory from February 1975 to June 1983. Three hundred sixty one patients demonstrated less than or equal to +2 proteinuria, and at least two DRLB. Of these, 290 were identified as having a single renal diagnosis. One hundred forty eight patients (51%) had a variety of acute and chronic glomerular diseases, and 125 patients (43.2%) had nonglomerular renal diseases, including acute tubular necrosis (ATN), prerenal azotemia, chronic interstitial nephritis, polycystic kidney disease, acute interstitial nephritis, renal neoplasia, and acute myeloma kidney. Ten patients had transient proteinuria associated with acute illness, and seven patients had no renal disease at all. Only two patients with nonglomerular renal disease had more than five DRLB per 20 high power microscopic fields. The frequency of DRLB in patients with nonglomerular renal diseases was: chronic interstitial nephritis, 26%; polycystic kidney disease, 38%; prerenal azotemia, 20%; ATN, 15%; and acute interstitial nephritis, 33%. These data suggest that at lower levels of proteinuria, DRLB are found frequently in nonglomerular renal diseases, and that DRLB do not differentiate glomerular from nonglomerular renal diseases unless more than five DRLB are found on urinary sediment examination.     

Peritoneal dialysis for acute renal failure in children

Fifty infants and children with acute renal failure were treated with acute peritoneal dialysis between 1987 and 1990. The patients were dialyzed using either a catheter introduced percutaneously over a guide-wire (n=40) or a Tenckhoff catheter (n=10). The cause of the acute renal failure was primary renal disease in 17 children, cardiac disease in 19, and trauma/sepsis in 14. Peritoneal dialysis succeeded in controlling metabolic abnormalities, improving fluid balance, and relieving the complications of uremia. The procedure had few major complications. Overall mortality was 50%, reflecting the serious nature of the underlying diseases. We conclude that acute peritoneal dialysis is a safe and effective treatment in most pediatric patients with acute renal failure. Our series of patients treated with acute peritoneal dialysis serves as a basis of comparison for the evaluation of new modalities of therapy in childhood acute renal failure.     

Nephrotic syndrome in Kawasaki disease: a report of three cases

Background

Renal manifestations are rare in Kawasaki disease (KD). Acute renal failure with tubular necrosis, tubulointerstitial nephritis and renovascular hypertension have been reported in KD, but only one case of a patient with KD associated with nephrotic syndrome (NS) has been reported to date, with the patient improving on steroid therapy but dying from coronary aneurysm.

Methods

We report the cases of three children, aged 4, 4.5 and 8?years, respectively, who presented with typical KD symptoms (high fever, diffuse maculopapular rash, conjunctivitis, peripheral oedema, cervical adenopathies and high C reactive protein levels) and developed NS.

Results

Patient 1 had a haemodynamic shock due to cardiac dysfunction and transient renal failure. Ten days later, he developed a NS which spontaneously disappeared 1 week later. Patient 2 had a NS on admission with normal plasma creatinine and no haematuria. Proteinuria disappeared within 10?days. Patient 3 developed NS 5?days after onset with a moderate increase in plasma creatinine. Proteinuria disappeared within 2?weeks. All three patients were treated with intravenous immunoglobulins, antibiotic therapy and aspirin, but none of them received steroid therapy. To date, all three patients have maintained long-term remission.

Conclusions

In conclusion, proteinuria with NS may develop during the acute phase of KD with persistent remission occurring without steroid therapy.     

Predictors of Postoperative Acute Renal Failure after Noncardiac Surgery in Patients with Previously Normal Renal Function

Background: The authors investigated the incidence and risk factors for postoperative acute renal failure after major noncardiac surgery among patients with previously normal renal function.

Methods: Adult patients undergoing major noncardiac surgery with a preoperative calculated creatinine clearance of 80 ml/min or greater were included in a prospective, observational study at a single tertiary care university hospital. Patients were followed for the development of acute renal failure (defined as a calculated creatinine clearance of 50 ml/min or less) within the first 7 postoperative days. Patient preoperative characteristics and intraoperative anesthetic management were evaluated for associations with acute renal failure. Thirty-day, 60-day, and 1-yr all-cause mortality was also evaluated.

Results: A total of 65,043 cases between 2003 and 2006 were reviewed. Of these, 15,102 patients met the inclusion criteria; 121 patients developed acute renal failure (0.8%), and 14 required renal replacement therapy (0.1%). Seven independent preoperative predictors were identified (P < 0.05): age, emergent surgery, liver disease, body mass index, high-risk surgery, peripheral vascular occlusive disease, and chronic obstructive pulmonary disease necessitating chronic bronchodilator therapy. Several intraoperative management variables were independent predictors of acute renal failure: total vasopressor dose administered, use of a vasopressor infusion, and diuretic administration. Acute renal failure was associated with increased 30-day, 60-day, and 1-yr all-cause mortality.