ReviewFrontiers in immunology2026
Hepatobiliary involvement in Kawasaki disease: from cholestatic hepatitis to the hepatic vascular-biliary unit hypothesis-a state-of-the-art review.
Review in Frontiers in immunology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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3 authors.
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Abstract
Background: This review provides a comprehensive synthesis of hepatobiliary involvement in Kawasaki disease (KD), with emphasis on cholestatic hepatitis as a clinical sentinel of hyperinflammation. We critically evaluate current evidence, propose an integrated pathogenic framework-the hepatic vascular-biliary unit injury hypothesis-and identify priority research areas. Data sources: Narrative review of high-quality literature (2015-2025) with inclusion of seminal historical studies, using Oxford Centre for Evidence-Based Medicine (OCEBM) evidence-level grading. Results: Cholestatic hepatitis occurs in 5.2%-17.8% of acute KD cases, rising to 22%-35% among intravenous immunoglobulin (IVIG)-resistant patients. Large retrospective cohort studies (OCEBM Level 3b) have identified a clinical "risk triangle" comprising IVIG resistance, coronary artery lesions (CALs), and cholestasis as interdependent factors. We propose the hepatic vascular-biliary unit injury hypothesis as an integrated pathogenic framework, supported by correlative pathological and molecular evidence (OCEBM Level 3-4), though causality remains unproven and requires validation in conditional endothelial-specific animal models. Current therapeutic evidence for moderate-to-severe cholestasis derives exclusively from retrospective cohorts and case series (OCEBM Level 3-4). Emerging evidence from Phase I/IIa trials supports the use of interleukin-1 blockade (anakinra) in refractory cases, predominantly derived from studies of coronary artery aneurysms rather than cholestasis-specific populations. Conclusions: KD-associated cholestatic hepatitis is a critical marker of disease severity with prognostic significance. The hepatic vascular-biliary unit hypothesis provides a mechanistic framework linking systemic vasculitis to cholestasis, pending experimental validation. Definitive evidence for optimal therapeutic strategies is lacking; well-designed randomized controlled trials specifically targeting the cholestasis subpopulation are urgently needed. Given the highest incidence in East Asian populations, clinicians in this region should maintain a particularly high index of suspicion for KD-associated cholestasis, particularly in infants presenting with unexplained jaundice.
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