Retrospective analysis of clinical predictors of outcomes in children with acute severe colitis

Abstract

Introduction: Acute severe ulcerative colitis (ASUC) is a catastrophic pre-sentation of ulcerative colitis with a significant short-and long-term risk of colectomy. Infliximab has gained a role as second-line therapy. Accelerated dosing of three doses (15 mg/kg) within 24 days has been shown to further reduce colectomy rates. We report our single-center experience of children with ASUC healed with infliximab, with a focus on severity predictors: C-reactive protein (CRP), albumin, and Days 0 and 3 Paediatric Ulcerative Colitis Activity Index (PUCAI). Methods: We conducted a retrospective chart review of all children presenting to our tertiary center with ASUC (PUCAI score > 65) from 2014 to 2018. The minimum follow-up was 3 months (median, 1 year). Results: A total of 27 children (with 30 episodes) presented with a PUCAI score > 65 (median age, 13 years [3-16]; 15 (54%) male). Twenty patients had ASUC at first presentation, and seven presented after diagnosis (mean, 13.5 months; range, 1.8-41 months). For three patients, there was a second episode of ASUC. Eight responded to intravenous steroids, and 19/27 required escalation to infliximab. Three patients received 10 mg/kg in the first 24 days, 10 received 15 mg/kg, and eight received 20(+) mg/kg. At 6 months, 15/24 (62.5%) were in clinical remission (PUCAI score < 10; only 12 in steroid-and biological-free remission), and two patients (8.3%) had a colectomy. At 12 months, five patients (62.5%) had progressed to colectomy (median, 8 months [2-12.2]). Four patients were in mucosal remission, and four had clinical and biochemical remission. Four have on going low-grade disease (PUCAI score, 5-15). The best adverse predictors for colectomy were Day 0 PUCAI score (80% vs 65%), Day 3 intravenous steroids PUCAI (50% vs 35%), CRP (60% vs 19%), atypical P-ANCA (including PR3) (100% vs 54%), and albumin (28% vs 31%). Conclusion: In the modern era of infliximab as second-line therapy, only eight patients reached steroid-free remission, including accelerated dosing outcomes, at 12 months, with PUCAI score, albumin and CRP the best predictors.L6244311402018-10-23 <br />