Kawasaki Disease and Clinical Outcome Disparities Among Black Children
Luz A Padilla 1, Jacqueline L Collins 2, Adeniyi J Idigo 3, Yung Lau 2, Michael A Portman 4, Sadeep Shrestha 3
J Pediatr. 2020 Sep 24;S0022-3476(20)31244-0. doi: 10.1016/j.jpeds.2020.09.052. Online ahead of print. PMID: 32980379. PMCID: PMC7513890. DOI: 10.1016/j.jpeds.2020.09.052
Take-Home Points :
- Black children with Kawasaki disease have a higher prevalence of Intravenous Immunoglobulin therapy refractoriness when compared to white children.
- Black children present with increased inflammatory markers but lower albumin, sodium when compared to white children even though no difference exists in time from fever to admission in between both the groups.
- Black children receive more ancillary drugs and stay longer in the hospital when compared to white children with Kawasaki disease and have higher persistence of coronary abnormalities on follow up echocardiograms.
The disparate outcomes seem to be more related to biologic/genetic variation than health care access and delivery in this cohort of patients admitted to a tertiary level children’s hospital in the South Eastern United States.
Commentary from Dr. Venu Amula (Salt Lake City, USA), section editor of Pediatric & Fetal Cardiology Journal Watch: Race and ethnic variation in the incidence and outcomes of Kawasaki disease have been well reported worldwide. Though racial differences exist in health care access and delivery, it is unknown whether the Black race poses a significant risk for poor outcomes in Kawasaki Disease. Data show that Black children may be disproportionately affected by the Kawasaki disease and manifest altered response to treatment.
The authors conducted a retrospective observational cohort study of Black and White children who met the American Heart Association Criteria for Kawasaki Disease and admitted to a tertiary level children’s hospital between January 2000 to 2015. The hospital serves proportionate Black and White populations and gave the investigators a unique opportunity to evaluate any differences in Kawasaki disease characteristics and clinical outcomes between the two communities. The groups were classified by race as assigned by the parent report. Children who failed to meet AHA criteria, presented 36 hrs. after Intravenous Immunoglobulin treatment rendered at an outside hospital, and those with inadequate documentation at admission were excluded. Patients were identified using ICD codes from the hospital database. The baseline characteristics, hospital presentation, treatment, and echocardiography findings during Kawasaki disease hospitalization were compared between the two racial groups.
The study resulted in a final cohort of 369 patients, comprising 192 Whites and 177 Blacks with no significant differences in age at admission or sex between the two racial groups. Mean hemoglobin and hematocrit levels were significantly lower in Black children at admission. Inflammatory markers at admission were higher, particularly C-reactive protein (CRP) and erythrocyte sedimentation rate.
There was no difference in time to treatment (initiation of IVIG infusion) or healthcare delivery in both racial groups. Ninety-four percent of the Black children and 89.7% of the White children received IVIG within ten days of fever onset, per the AHA guidelines. Among those treated, Black children had a lower IVIG response rate compared with whites (86.6% vs. 95.6%; P = .007). IVIG refractoriness was defined as persistent or recurrent fever within 36 hrs. of completing the treatment. More Black children than White children received alternative therapies (9.6% vs. 2.6%; P = .003. And also had a longer average length of hospital stay. Black children are also noted to have a higher proportion of persistent coronary abnormalities upon follow-up echocardiograms.
This critical study evaluates whether disparate outcomes exist in black children with Kawasaki disease than white children in a tertiary level children’s hospital. Even though racial differences exist in response to the disease and IVIG therapy refractoriness, there is no difference in time to intervention suggesting uniform health care provision. The outcomes and sequelae of Kawasaki disease may be related to underlying biological and genetic variation. This study is limited by being a single-center study with a high likelihood of selection bias. Nevertheless, genetic differences in response to treatment cannot be underestimated.