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Chang CM, Kuo KC, Chen WH, Su CH, Lee CP, Chen KJ, Yang YH, Yen JB, Sheen JM. Maternal risk factors associated with offspring biliary atresia: population-based study. Pediatr Res 2023; 93:1064-1071. [PMID: 35760951 DOI: 10.1038/s41390-022-02166-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 05/30/2022] [Accepted: 06/06/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Biliary atresia (BA) is a progressive, idiopathic, fibro-obliterative disease of the intra and extrahepatic biliary tree. If untreated, it results in severe liver injury and death. The etiology and pathogenesis of BA remain unclear. Few studies have investigated the association between maternal illness/drug use and the occurrence of BA in offspring. METHODS We used the data from the Birth Certificate Application of Taiwan and linked to National Health Insurance Research Database and Taiwan Maternal and Child Health Database for the years 2004 to 2017 (N = 1,647,231) on 2022/03, and identified BA cases according to diagnosis and procedure code. A total of 285 BA cases were identified. RESULTS Mothers with type 2 diabetes mellitus and non-dependent drug abuse had higher rates having BA children than non-BA children, with an odds ratio of 2.17 (95% confidence interval [CI] = 1.04-4.53) and OR: 3.02 (95% CI = 1.34-6.78), respectively. CONCLUSION These results support the notion that BA occurrence is related to maternal reasons. Further studies should be designed to identify additional maternal and pregnancy risk factors and to understand the underlying pathophysiology. IMPACT 1. The occurrence of offspring biliary atresia may be related to maternal illness/drug use. 2. Maternal drug abuse and type 2 diabetes mellitus pose a high risk for offspring biliary atresia. 3. If maternal etiology is found, biliary atresia might be a preventable disease.
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Affiliation(s)
- Ching-Min Chang
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Kuang-Che Kuo
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wan-Hsuan Chen
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Chung-Hao Su
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Chuan-Pin Lee
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ko-Jung Chen
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yao-Hsu Yang
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Ju-Bei Yen
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Chiayi, Taiwan.
| | - Jiunn-Ming Sheen
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Chiayi, Taiwan.
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Tsuboi K, Watayo H, Tsukui T, Suda K, Abe E, Fujimoto T, Ochi T, Lane GJ, Koga H, Yamataka A. Native liver survivors of portoenterostomy for biliary atresia with excellent outcome: redefining "successful" portoenterostomy. Pediatr Surg Int 2022; 39:24. [PMID: 36454515 DOI: 10.1007/s00383-022-05313-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE Native liver survivors (NLS) after portoenterostomy (PE) for biliary atresia (BA) with normal biomarkers defined as total bilirubin (T-Bil), aspartate aminotransferase (AST)/alanine aminotransferase (ALT) for liver function (LF), cholinesterase (ChE), platelet count (PC), and absence of portal hypertension (PHT) were reviewed to redefine "successful" PE. METHODS 92 post-PE BA patients were classified as NLS-1: normal biomarkers, PHT (-); NLS-2: at least one abnormal biomarker, PHT (-); NLS-3: normal biomarkers, PHT ( +); NLS-4: abnormal biomarkers, PHT ( +) and reviewed for a maximum 32 years. RESULTS As of June 2022, 55/92 (59.8%) had received liver transplants and 37/92 (40.2%) were NLS. NLS patients were classified as excellent outcome (EO): NLS-1 (n = 10; 27.0%) or non-EO: NLS-2: (n = 8; 21.6%), NLS-3: (n = 6; 16.2%), and NLS-4: (n = 13; 35.1%). Compared with non-EO, EO had PE earlier (50.5 versus 65 days; not significant; p = 0.08), significantly earlier onset of symptoms (13 days versus 32 days; p = 0.01) and significantly shorter jaundice-clearance (JC; 34.5 days versus 56.0 days; p < 0.001). Durations of follow-up were similar: 13 years in EO, 18.5 years in NLS-2, 20 years in NLS-3, and 15 years in NLS-4. CONCLUSION Incidence of "successful" PE or EO is low and correlated with early onset of symptoms and quicker JC.
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Affiliation(s)
- Koichi Tsuboi
- Department of Pediatric Surgery, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Hiroko Watayo
- Department of Pediatric Surgery, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Takafumi Tsukui
- Department of Pediatric Surgery, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kazuto Suda
- Department of Pediatric Surgery, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Eri Abe
- Department of Pediatric Surgery, Juntendo Urayasu Hospital, Chiba, Japan
| | - Takamori Fujimoto
- Department of Pediatric Surgery, Juntendo Nerima Hospital, Tokyo, Japan
| | - Takanori Ochi
- Department of Pediatric Surgery, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Geoffrey J Lane
- Department of Pediatric Surgery, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hiroyuki Koga
- Department of Pediatric Surgery, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric Surgery, Faculty of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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3
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Hukkinen M, Ruuska S, Pihlajoki M, Kyrönlahti A, Pakarinen MP. Long-term outcomes of biliary atresia patients surviving with their native livers. Best Pract Res Clin Gastroenterol 2021; 56-57:101764. [PMID: 35331404 DOI: 10.1016/j.bpg.2021.101764] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/20/2021] [Accepted: 08/30/2021] [Indexed: 01/31/2023]
Abstract
Portoenterostomy (PE) has remained as the generally accepted first line surgical treatment for biliary atresia (BA) for over 50 years. Currently, close to half of BA patients survive beyond 10 years with their native livers, and most of them reach adulthood without liver transplantation (LT). Despite normalization of serum bilirubin by PE, ductular reaction and portal fibrosis persist in the native liver. The chronic cholangiopathy progresses to cirrhosis, complications of portal hypertension, recurrent cholangitis or hepatobiliary tumors necessitating LT later in life. Other common related health problems include impaired bone health, neuromotor development and quality of life. Only few high-quality trials are available for evidence-based guidance of post-PE adjuvant medical therapy or management of the disease complications. Better understanding of the pathophysiological mechanisms connecting native liver injury to clinical outcomes is critical for development of accurate follow-up tools and novel therapies designed to improve native liver function and survival.
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Affiliation(s)
- Maria Hukkinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, University of Helsinki, Stenbackinkatu 11 PO Box 281, 00029, HUS, Finland.
| | - Satu Ruuska
- Department of Pediatric Gastroenterology, Pediatric Liver and Gut Research Group, Children's Hospital, University of Helsinki, Stenbäckinkatu 9/PO BOX 347, 00029, HUS, Finland.
| | - Marjut Pihlajoki
- Pediatric Research Center, Children's Hospital, University of Helsinki, Tukholmankatu 8, 00290, Helsinki, Finland.
| | - Antti Kyrönlahti
- Pediatric Research Center, Children's Hospital, University of Helsinki, Stenbackinkatu 11 PO Box 281, 00029, HUS, Finland.
| | - Mikko P Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, University of Helsinki, Stenbackinkatu 11 PO Box 281, 00029, HUS, Finland.
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4
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Prepregnancy Assessment of Liver Function to Predict Perinatal and Postpregnancy Outcomes in Biliary Atresia Patients with Native Liver. J Clin Med 2021; 10:jcm10173956. [PMID: 34501403 PMCID: PMC8432127 DOI: 10.3390/jcm10173956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/24/2021] [Accepted: 08/31/2021] [Indexed: 11/16/2022] Open
Abstract
Considering that some biliary atresia (BA) survivors with native liver have reached reproductive age and face long-lasting complications, specific attention needs to be paid to pregnant cases. This study aimed to investigate the relationship between liver function, perinatal outcomes, and prognosis. A database review was conducted to identify pregnant BA cases with native liver and perinatal data, and clinical information on BA-related complications was analyzed. Perinatal serum cholinesterase (ChE) levels, model for end-stage liver-disease (MELD) score, and platelet trends were analyzed, and the association between these indicators and perinatal outcomes was investigated. Patients were categorized into three groups according to the perinatal clinical outcomes: favorable (term babies with or without several episodes of cholangitis; n = 3), borderline (term baby and following liver dysfunction; n = 1), and unfavorable (premature delivery with subsequent liver failure; n = 1). Lower serum ChE levels, lower platelet counts, and higher MELD scores were observed in the unfavorable category. Borderline and unfavorable patients displayed a continuous increase in MELD score, with one eventually needing a liver transplantation. Pregnancy in patients with BA requires special attention. Serum ChE levels, platelet counts, and MELD scores are all important markers for predicting perinatal prognosis.
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Caruso M, Di Dato F, Mollica C, Vallone G, Romeo V, Liuzzi R, Mainenti PP, Petretta M, Iorio R, Brunetti A, Maurea S. Imaging prediction with ultrasound and MRI of long-term medical outcome in native liver survivor patients with biliary atresia after kasai portoenterostomy: a pilot study. Abdom Radiol (NY) 2021; 46:2595-2603. [PMID: 33532908 DOI: 10.1007/s00261-021-02958-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/07/2021] [Accepted: 01/15/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE To comparatively assess the role of abdominal ultrasound (US) and magnetic resonance imaging (MRI) in predicting long-term medical outcome in native liver survivor patients with biliary atresia (BA) after Kasai portoenterostomy (KP). METHODS Twenty-four retrospectively enrolled patients were divided in two groups according to clinical and laboratory data at initial evaluation after KP (median follow-up = 9.7 years; range = 5-25 years) as with ideal (Group 1; n = 15) or non-ideal (Group 2; n = 9) medical outcome. All patients were re-evaluated for a period of additional 4 years using clinical and laboratory indices. US and MRI studies were qualitatively analyzed assessing imaging signs suggestive of chronic liver disease (CLD). RESULTS At re-evaluation, 6 patients (40%) of Group 1 changed their medical outcome in non-ideal (Group 1A); the other 9 patients (60%) remained stable (Group 1B); the mean time to change the medical outcome in non-ideal status at re-evaluation was 43.5 ± 2.3 months. The area under the ROC curve was 0.84 and 0.87 for US and MRI scores to predict long-term medical outcome with the best cut-off value score > 4 for both modalities (p = 0.89). In Group 2, 6 (67%) patients showed a clinical progression (Group 2A) with a mean time of 39.8 ± 3.8 months; in the other 3 (33%) patients, no clinical progression was observed (Group 2B). CONCLUSION In BA patients with ideal medical outcome after KP, US and MRI may both predict long-term outcome. US, non-invasive and widely available technique, should be preferred.
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Affiliation(s)
- Martina Caruso
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy.
| | - Fabiola Di Dato
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Carmine Mollica
- Institute of Bio-Structures and Bio-Imaging of the National Research Council (CNR), Via Tommaso De Amicis, 80145, Napless, Italy
| | - Gianfranco Vallone
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Valeria Romeo
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Raffaele Liuzzi
- Institute of Bio-Structures and Bio-Imaging of the National Research Council (CNR), Via Tommaso De Amicis, 80145, Napless, Italy
| | - Pier Paolo Mainenti
- Institute of Bio-Structures and Bio-Imaging of the National Research Council (CNR), Via Tommaso De Amicis, 80145, Napless, Italy
| | - Mario Petretta
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Raffaele Iorio
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Arturo Brunetti
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Simone Maurea
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
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Operational Definitions for Chronic Liver Disease Manifestations and Recurring Clinical Events in Biliary Atresia. J Pediatr Gastroenterol Nutr 2021; 72:584-591. [PMID: 33306582 DOI: 10.1097/mpg.0000000000002992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The disease course of biliary atresia (BA) may be complicated by development of chronic liver disease (CLD) manifestations (eg, ascites) and recurring clinical events (eg, cholangitis). Most pediatric CLD-manifestations/events lack standardized operational definitions, leading to inconsistent identification in clinical research. This study aimed to develop operational research definitions of CLD-manifestations/events in BA for application in retrospective analysis. METHODS Operational definitions of CLD-manifestations/events were developed by literature review and revised by a panel of experienced pediatric hepatologists. Definitions were applied to a single-center review of infants with BA post-Kasai. Manifestations/events were captured until last clinical visit with native liver (SNL), liver transplantation (LT), or death. Native liver survival and event-free survival were estimated by Kaplan-Meier method. Cluster analysis was performed to identify similar patterns of manifestation/event development. RESULTS Of 65 infants with BA post-Kasai (2006-18; median Kasai 56.8 days; 65% girls), 29 underwent LT (median 12.9 months) and 4 died without LT (median 6.9 months). Seventy-six percent of CLD-manifestations/events presented within the first year. Presence of definite clinically evident portal hypertension, thrombocytopenia, and dCE ascites were associated with poor transplant-free survival (P < 0.01). Similar pattern developments of CLD-manifestations/events identified 3 outcome groups: poor outcomes (87.8% LT/death), SNL with manifestations/events, and SNL with few/no events. CONCLUSIONS Operational definitions can provide a timely description of the disease course progression in infants with BA. Research definitions may provide better consistency in future pediatric CLD studies. Furthermore, definitions may serve as endpoints in therapeutic trials or used as variables for disease pattern identification in potential multicenter studies.
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7
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Caruso M, Cuocolo R, Di Dato F, Mollica C, Vallone G, Romeo V, Petretta M, Liuzzi R, Mainenti PP, Iorio R, Brunetti A, Maurea S. Ultrasound, shear-wave elastography, and magnetic resonance imaging in native liver survivor patients with biliary atresia after Kasai portoenterostomy: correlation with medical outcome after treatment. Acta Radiol 2020; 61:1300-1308. [PMID: 32008344 DOI: 10.1177/0284185120902379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Biliary atresia (BA) is a rare obliterative cholangiopathy and Kasai portoenterostomy (KP) represents its first-line treatment; clinical and laboratory parameters together with abdominal ultrasound (US) are usually performed during the follow-up. Shear-wave elastography (SWE) is able to evaluate liver parenchyma stiffness; magnetic resonance imaging (MRI) has also been proposed to study these patients. PURPOSE To correlate US, SWE, and MRI imaging findings with medical outcome in patients with BA who are native liver survivors after KP. MATERIAL AND METHODS We retrospectively enrolled 24 patients. They were divided in two groups based on "ideal" (n = 15) or "non-ideal" (n = 9) medical outcome. US, SWE, and MRI exams were analyzed qualitatively and quantitatively for imaging signs suggestive of chronic liver disease (CLD). RESULTS Significant differences were found in terms of liver surface (P = 0.007) and morphology (P = 0.013), portal vein diameter (P = 0.012) and spleen size (P = 0.002) by US, liver signal intensity (P = 0.013), portal vein diameter (P = 0.010), presence of portosystemic collaterals (P = 0.042), and spleen size (P = 0.001) by MRI. The evaluation of portal vein diameter (moderate, κ = 0.44), of portosystemic collaterals (good, κ = 0.78), and spleen size (very good, κ = 0.92) showed the best agreement between US and MRI. A significant (P = 0.01) difference in liver parenchyma stiffness by SWE was also found between the two groups (cut-off = 9.6 kPa, sensitivity = 55.6%, specificity = 100%, area under the ROC curve = 0.82). CONCLUSION US, SWE, and MRI findings correlate with the medical outcome in native liver survivor patients with BA treated with KP.
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Affiliation(s)
- Martina Caruso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Renato Cuocolo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Fabiola Di Dato
- Department of Translational Medical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Carmine Mollica
- Institute of Bio-Structures and Bio-Imaging of the National Research Council (CNR), Naples, Italy
| | - Gianfranco Vallone
- Department of Advanced Biomedical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Valeria Romeo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Mario Petretta
- Department of Translational Medical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Raffaele Liuzzi
- Institute of Bio-Structures and Bio-Imaging of the National Research Council (CNR), Naples, Italy
| | - Pier Paolo Mainenti
- Institute of Bio-Structures and Bio-Imaging of the National Research Council (CNR), Naples, Italy
| | - Raffaele Iorio
- Department of Translational Medical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Arturo Brunetti
- Department of Advanced Biomedical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Simone Maurea
- Department of Advanced Biomedical Sciences, University of Naples “Federico II,” Naples, Italy
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Kelly C, Nayagam JS, Vogli S, Samyn M, Joshi D. Paediatric cholestatic liver disorders for the adult gastroenterologist: a practical guide. Frontline Gastroenterol 2020; 12:404-413. [PMID: 35401959 PMCID: PMC8989003 DOI: 10.1136/flgastro-2020-101554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/16/2020] [Accepted: 06/20/2020] [Indexed: 02/04/2023] Open
Abstract
With improvements in the outcomes for cholestatic liver diseases that present in childhood, increasing numbers of patients will require ongoing care as adults. The recent advances in management options coupled with the fact that each adult physician will have a limited number of patients with these conditions means there is a need for those in adult services to develop expertise in these conditions that were historically the domain of paediatrics. This review provides an overview of the most common paediatric cholestatic liver diseases and outlines the clinical manifestations and potential complications, and identifies key management issues unique to each condition for effective ongoing care of these patients.
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Affiliation(s)
- Claire Kelly
- Institute of Liver Studies, King's College Hospital, London, UK
| | | | - Stamatina Vogli
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Marianne Samyn
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
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9
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Yassin NA, El-Tagy G, Abdelhakeem ON, Asem N, El-Karaksy H. Predictors of Short-Term Outcome of Kasai Portoenterostomy for Biliary Atresia in Infants: a Single-Center Study. Pediatr Gastroenterol Hepatol Nutr 2020; 23:266-275. [PMID: 32483548 PMCID: PMC7231743 DOI: 10.5223/pghn.2020.23.3.266] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 12/12/2019] [Accepted: 01/29/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The outcome predictors of Kasai portoenterostomy (KPE) for biliary atresia (BA) are controversial. This study aimed to identify possible short-term outcome predictors of KPE for BA in infants. METHODS This retrospective study included infants with BA who underwent KPE between January 2015 and December 2017 and were followed up for at least 6 months after surgery at the Pediatric Hepatology Unit, Cairo University Pediatric Hospital, Egypt. The short-term outcome was jaundice clearance within 6 months following surgery. All data were compared between the jaundice free group and those with persistent jaundice to identify the predictors of jaundice clearance. RESULTS The study included 75 infants. The mean age at the time of surgery was 82.43±22.77 days (range, 37-150 days), and 28 (37.3%) infants cleared their jaundice within 6 months postoperative. Age at surgery did not significantly affect the outcome (p=0.518). Infants with persistent jaundice had significantly higher pre-operative levels of aspartate aminotransferase (AST) than those who were jaundice free (p=0.041). Receiver operating characteristic curve analysis showed that preoperative AST ≤180 IU/L was predictive of a successful KPE, with sensitivity 74.5% and specificity 60.7%. Infants with bile plugs in liver biopsy had a 6-fold higher risk of persistent jaundice than those without bile plugs (95% confidence interval: 1.59-20.75, p=0.008). CONCLUSION Jaundice clearance after KPE for BA can be predicted using preoperative AST and presence of bile plugs in liver biopsy.
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Affiliation(s)
| | - Gamal El-Tagy
- Department of Pediatric Surgery, Cairo University, Cairo, Egypt
| | | | - Noha Asem
- Department of Community Medicine, Cairo University, Cairo, Egypt
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10
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de Carvalho NMN, Torres SM, Cavalcante JCB, Ximenes ACM, Junior JAL, da Silveira Moreira SO. Hepatoportoenterostomy surgery technique. J Pediatr Surg 2019; 54:1715-1718. [PMID: 30442462 DOI: 10.1016/j.jpedsurg.2018.10.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 10/04/2018] [Indexed: 01/20/2023]
Abstract
Biliary atresia (BA) is a pathology that causes jaundice in children because of an obstruction of the obliterated biliary tract. Despite being considered a rare disease, the incidence can reach 1/2400 live births in the Pacific region. The etiology is unknown. If untreated, it will lead to cirrhosis and death. Early operation (within 60 days after birth) is the most important prognostic factor. The objective of this article is to present the technical description step by step of a hepatoportoenterostomy operation in a female 61 days of age with BA.
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Affiliation(s)
| | - Sarah Monte Torres
- General Surgery Residency Program at Hospital Geral de Fortaleza, Fortaleza, CE, Brazil
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11
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Hukkinen M, Lohi J, Heikkilä P, Kivisaari R, Jahnukainen T, Jalanko H, Pakarinen MP. Noninvasive Evaluation of Liver Fibrosis and Portal Hypertension After Successful Portoenterostomy for Biliary Atresia. Hepatol Commun 2019; 3:382-391. [PMID: 30859150 PMCID: PMC6396371 DOI: 10.1002/hep4.1306] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 11/26/2018] [Indexed: 12/19/2022] Open
Abstract
We investigated noninvasive follow‐up markers for histologic liver fibrosis and portal hypertension (PH) in patients with biliary atresia after successful portoenterostomy (PE). Among children with bilirubin <20 µmol/L after PE (n = 39), Metavir fibrosis stage was evaluated at PE and in follow‐up protocol liver biopsies (n = 83). PH was defined as endoscopically confirmed esophageal varices or thrombocytopenia associated with splenomegaly. The accuracy of liver biochemistry and stiffness in detecting liver fibrosis and PH was analyzed by the area under the receiving operating characteristic curve (AUROC) and multiple regression models. During a median native liver survival of 8.3 years (interquartile range 2.5‐10.8 years), cirrhosis (Metavir F4) had developed in 51% of patients and PH in 54% of patients. Cirrhosis was equally common in all age tertiles of 1.2‐2.1 years (n = 10/27), 3.9‐5.8 years (n = 12/28), and 9.0‐14 years (n = 12/28). In the two oldest age tertiles, histologic liver fibrosis had progressed further in patients with PH than without PH (P < 0.001). PH was accurately predicted by the aspartate aminotransferase‐to‐platelet ratio index (APRI) (cutoff, 0.70; AUROC, 0.92), bile acids (cutoff, 49 µmol/L; AUROC, 0.91), and liver stiffness (cutoff, 16.9 kPa; AUROC, 0.89; P < 0.001 each) across all age tertiles. Liver stiffness was the most accurate predictor of cirrhosis overall (AUROC, 0.82; P < 0.001), whereas bilirubin was >11 µmol/L in the youngest tertile (AUROC, 0.91; P < 0.001), bile acids was >80 µmol/L in the middle tertile (AUROC, 0.81; P = 0.009), and liver stiffness was >24 kPa in the oldest age tertile (AUROC, 0.96; P = 0.002). Conclusion: After successful PE, development of PH associates with progression of liver fibrosis and can be accurately detected by APRI and stiffness. Liver stiffness most accurately identified cirrhosis in older children, whereas biochemical markers of cholestasis closely reflected histologic cirrhosis in younger children.
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Affiliation(s)
- Maria Hukkinen
- Pediatric Liver and Gut Research Group and Section of Pediatric Surgery Children's Hospital, Helsinki University Hospital Helsinki Finland
| | - Jouko Lohi
- Department of Pathology HUSLAB, Helsinki University Hospital Helsinki Finland
| | - Päivi Heikkilä
- Department of Pathology HUSLAB, Helsinki University Hospital Helsinki Finland
| | - Reetta Kivisaari
- HUS Medical Imaging Center, Children's Hospital, Helsinki University Hospital University of Helsinki Helsinki Finland
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation Children's Hospital, Helsinki University Hospital Helsinki Finland
| | - Hannu Jalanko
- Department of Pediatric Nephrology and Transplantation Children's Hospital, Helsinki University Hospital Helsinki Finland
| | - Mikko P Pakarinen
- Pediatric Liver and Gut Research Group and Section of Pediatric Surgery Children's Hospital, Helsinki University Hospital Helsinki Finland
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12
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Ruuska SM, Lääperi MT, Hukkinen M, Jalanko H, Kolho KL, Pakarinen MP. Growth of children with biliary atresia living with native livers: impact of corticoid therapy after portoenterostomy. Eur J Pediatr 2019; 178:341-349. [PMID: 30519970 PMCID: PMC6437119 DOI: 10.1007/s00431-018-3302-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/05/2018] [Accepted: 11/27/2018] [Indexed: 12/24/2022]
Abstract
We addressed growth of biliary atresia (BA) patients living with native livers between ages 0-6 and effects of post-surgical corticosteroid treatment on growth. Growth charts of 28 BA patients born in Finland between 1987 and 2017 were retrospectively evaluated. Dosage and length of corticosteroid treatment and hydrocortisone substitution were reviewed. At birth, BA patients were shorter (median height - 0.6 (interquartile range (IQR) - 1.3 to - 0.1) SDS, n = 28, P < 0.001) than general population. Height remained stable during early childhood (median height - 0.6 (IQR - 1.4 to 0.1) SDS for girls and - 0.4 (IQR - 1.6 to 0.2) SDS for boys at 6 years of age). Patients were of normal height adjusted weight at 6 years with a median age and sex-adjusted body mass index (ISO-BMI) of 20.9 (IQR 19.3 to 25.0) for girls and 22.1 (IQR 20.7 to 25.6) for boys. Higher (≥ 50 mg/kg) cumulative post-portoenterostomy prednisolone dosage resulted in 0.18 SDS lower height per treatment week (β - 0.18, SE 0.04, P < 0.001) compared to lower dosage (< 50 mg/kg).Conclusion: BA patients grow normally during early childhood. As high postoperative corticosteroid dosage has a short-term negative effect on height, very high dosages should be avoided. What Is Known: • Growth of biliary atresia patients has mostly been shown to be within normal limits • Corticosteroids may decrease growth rate What Is New: • Biliary atresia patients surviving with their native livers are shorter than general population and their mid-parental target height at birth • A high (> 50 mg/kg) cumulative prednisolone dosage has a negative transitory impact on height gain after portoenterostomy.
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Affiliation(s)
- Satu Maria Ruuska
- Department of Gastroenterology, Children's Hospital, Helsinki University Hospital, PL 347, 00029 HUS, Helsinki, Finland. .,Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, Helsinki, Finland.
| | - Mitja Tapani Lääperi
- 0000 0000 9950 5666grid.15485.3dPediatric Research Center, Children’s Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Maria Hukkinen
- 0000 0000 9950 5666grid.15485.3dPediatric Liver and Gut Research Group, Children’s Hospital, Helsinki University Hospital, Helsinki, Finland ,0000 0000 9950 5666grid.15485.3dSection of Pediatric Surgery, Children’s Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Hannu Jalanko
- 0000 0000 9950 5666grid.15485.3dDepartment of Pediatric Nephrology and Transplantation, Children’s Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Kaija-Leena Kolho
- 0000 0001 2314 6254grid.502801.eUniversity of Tampere, Tampere, Finland ,0000 0004 0628 2985grid.412330.7Tampere University Hospital, Tampere, Finland
| | - Mikko P. Pakarinen
- 0000 0000 9950 5666grid.15485.3dPediatric Liver and Gut Research Group, Children’s Hospital, Helsinki University Hospital, Helsinki, Finland ,0000 0000 9950 5666grid.15485.3dPediatric Research Center, Children’s Hospital, Helsinki University Hospital, Helsinki, Finland ,0000 0000 9950 5666grid.15485.3dSection of Pediatric Surgery, Children’s Hospital, Helsinki University Hospital, Helsinki, Finland
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13
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Ng VL, Sorensen LG, Alonso EM, Fredericks EM, Ye W, Moore J, Karpen SJ, Shneider BL, Molleston JP, Bezerra JA, Murray KF, Loomes KM, Rosenthal P, Squires RH, Wang K, Arnon R, Schwarz KB, Turmelle YP, Haber BH, Sherker AH, Magee JC, Sokol RJ. Neurodevelopmental Outcome of Young Children with Biliary Atresia and Native Liver: Results from the ChiLDReN Study. J Pediatr 2018; 196:139-147.e3. [PMID: 29519540 PMCID: PMC5924604 DOI: 10.1016/j.jpeds.2017.12.048] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/09/2017] [Accepted: 12/18/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To assess neurodevelopmental outcomes among participants with biliary atresia with their native liver at ages 12 months (group 1) and 24 months (group 2), and to evaluate variables predictive of neurodevelopmental impairment. STUDY DESIGN Participants enrolled in a prospective, longitudinal, multicenter study underwent neurodevelopmental testing with either the Bayley Scales of Infant Development, 2nd edition, or Bayley Scales of Infant and Toddler Development, 3rd edition. Scores (normative mean = 100 ± 15) were categorized as ≥100, 85-99, and <85 for χ2 analysis. Risk for neurodevelopmental impairment (defined as ≥1 score of <85 on the Bayley Scales of Infant Development, 2nd edition, or Bayley Scales of Infant and Toddler Development, 3rd edition, scales) was analyzed using logistic regression. RESULTS There were 148 children who completed 217 Bayley Scales of Infant and Toddler Development, 3rd edition, examinations (group 1, n = 132; group 2, n = 85). Neurodevelopmental score distributions significantly shifted downward compared with test norms at 1 and 2 years of age. Multivariate analysis identified ascites (OR, 3.17; P = .01) and low length z-scores at time of testing (OR, 0.70; P < .04) as risk factors for physical/motor impairment; low weight z-score (OR, 0.57; P = .001) and ascites (OR, 2.89; P = .01) for mental/cognitive/language impairment at 1 year of age. An unsuccessful hepatoportoenterostomy was predictive of both physical/motor (OR, 4.88; P < .02) and mental/cognitive/language impairment (OR, 4.76; P = .02) at 2 years of age. CONCLUSION Participants with biliary atresia surviving with native livers after hepatoportoenterostomy are at increased risk for neurodevelopmental delays at 12 and 24 months of age. Those with unsuccessful hepatoportoenterostomy are >4 times more likely to have neurodevelopmental impairment compared with those with successful hepatoportoenterostomy. Growth delays and/or complications indicating advanced liver disease should alert clinicians to the risk for neurodevelopmental delays, and expedite appropriate interventions. TRIAL REGISTRATION Clinicaltrials.gov: NCT00061828 and NCT00294684.
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Affiliation(s)
- Vicky L Ng
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Lisa G Sorensen
- Department of Child & Adolescent Psychiatry, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Estella M Alonso
- Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Emily M Fredericks
- C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI
| | - Wen Ye
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Jeff Moore
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Saul J Karpen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA
| | - Benjamin L Shneider
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Jean P Molleston
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Rylie Hospital for Children, Indianapolis, IN
| | - Jorge A Bezerra
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Karen F Murray
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington and Seattle Children's, Seattle, WA
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, CA
| | | | - Kasper Wang
- Division of Pediatric Surgery, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Ronen Arnon
- Division of Gastroenterology, Hepatology and Nutrition, Mount Sinai Hospital, New York, NY
| | | | | | - Barbara H Haber
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Averell H Sherker
- Liver Diseases Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Ronald J Sokol
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
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14
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Abstract
The oldest survivors from the Kasai portoenterostomy originate in Sendai, Japan and are approaching their 60th birthday. These represent the tip of an expanding cohort of adults born with this previously fatal condition. Increasingly transition to adult-biased hepatologists and physicians will be the expectation of many with this condition. However unlike their usual patients with alcohol, drugs, virally mediated liver disease these are different with different expectations of health and quality of life. Cure is not on the cards for most of these and they survive still with impaired bile flow and increased liver fibrosis and cirrhosis with the threat of cholangitis and portal hypertension still apparent. We review the reported statistics on long-term survival essentially from Japan and Western Europe (such as the UK and France) and the range of complications that may still beset this group.
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Affiliation(s)
- Arun Kelay
- Department of Paediatric Surgery, Kings College Hospital, London SE5 9RS
| | - Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, London SE5 9RS.
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15
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Safwan M, Ramachandran P, Reddy MS, Shanmugam N, Rela M. Living donor liver transplantation for biliary atresia - An Indian experience. Pediatr Transplant 2016; 20:1045-1050. [PMID: 27385081 DOI: 10.1111/petr.12749] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2016] [Indexed: 11/26/2022]
Abstract
LT has played a significant role in improving the outcome of children with BA. We review our five-yr experience of LDLT for children with BA. Records of all children who underwent LDLT in our institution over a five-yr period (August 2010-June 2015) were reviewed and those with a primary diagnosis of BA were selected for our study. Data were extracted from a prospectively maintained database. Additional data were collected by review of case notes and imaging studies. Analysis was carried out using standard statistical means. One hundred and thirty-two children underwent LDLT at our center over the study period, of which 58 children (31 females) had a primary diagnosis of BA. Thirty-three (56.9%) children had undergone a prior KPE and 25 (43.1%) had a primary LT. Thirty-four children had at least one post-op complication, of which 13 had minor complications (Clavien grades I and II) and 21 had major complications (Clavien grade >II). Thirty-day survival was 96.6% and one-yr survival was 91.4%. Univariate analysis of variables comparing children who did and did not have a KPE prior to LT showed that age at LT, weight at LT, PELD, and GRWR were significantly different. LDLT provides excellent outcomes in children with BA. Primary LDLT and LT after KPE provide equivalent results, although the former is technically more challenging as the child is younger.
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Affiliation(s)
- Mohamed Safwan
- Institute of Liver Disease and Transplantation, Global Health City, Perumbakkam, Chennai, Tamil Nadu, India
| | - Priya Ramachandran
- Institute of Liver Disease and Transplantation, Global Health City, Perumbakkam, Chennai, Tamil Nadu, India.,National Foundation for Liver Research, Perumbakkam, Chennai, Tamil Nadu, India
| | - Mettu Srinivas Reddy
- Institute of Liver Disease and Transplantation, Global Health City, Perumbakkam, Chennai, Tamil Nadu, India
| | - Naresh Shanmugam
- Institute of Liver Disease and Transplantation, Global Health City, Perumbakkam, Chennai, Tamil Nadu, India.,National Foundation for Liver Research, Perumbakkam, Chennai, Tamil Nadu, India
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Global Health City, Perumbakkam, Chennai, Tamil Nadu, India.,National Foundation for Liver Research, Perumbakkam, Chennai, Tamil Nadu, India
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16
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Chen S, Liao B, Zhong Z, Zheng Y, Liu B, Shan Q, Xie X, Zhou L. Supersonic shearwave elastography in the assessment of liver fibrosis for postoperative patients with biliary atresia. Sci Rep 2016; 6:31057. [PMID: 27511435 PMCID: PMC4980634 DOI: 10.1038/srep31057] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 07/13/2016] [Indexed: 02/08/2023] Open
Abstract
To explore an effective noninvasive tool for monitoring liver fibrosis of children with biliary atresia (BA) is important but evidences are limited. This study is to investigate the predictive accuracy of supersonic shearwave elastography (SSWE) in liver fibrosis for postoperative patients with BA and to compare it with aspartate aminotransferase to platelet ratio index (APRI) and fibrosis-4 (FIB-4). 24 patients with BA received SSWE and laboratory tests before scheduled for liver biopsy. Spearman rank coefficient and receiver operating characteristic (ROC) were used to analyze data. Metavir scores were F0 in 3, F1 in 2, F2 in 4, F3 in 7 and F4 in 8 patients. FIB-4 failed to correlate with fibrosis stage. The areas under the ROC curves of SSWE, APRI and their combination were 0.79, 0.65 and 0.78 for significant fibrosis, 0.81, 0.64 and 0.76 for advanced fibrosis, 0.82, 0.56 and 0.84 for cirrhosis. SSWE values at biopsy was correlated with platelet count (r = -0.426, P = 0.038), serum albumin (r = -0.670, P < 0.001), total bilirubin (r = 0.419, P = 0.041) and direct bilirubin levels (r = 0.518, P = 0.010) measured at 6 months after liver biopsy. Our results indicate that SSWE is a more promising tool to assess liver fibrosis than APRI and FIB-4 in children with BA.
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Affiliation(s)
- Shuling Chen
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound , The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, P.R. China
| | - Bing Liao
- Department of pathology , The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, P.R. China
| | - Zhihai Zhong
- Department of pediatric surgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou 510080, P. R. China
| | - Yanling Zheng
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound , The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, P.R. China
| | - Baoxian Liu
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound , The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, P.R. China
| | - Quanyuan Shan
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound , The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, P.R. China
| | - Xiaoyan Xie
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound , The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, P.R. China
| | - Luyao Zhou
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound , The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, P.R. China
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17
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Chang HK, Chang EY, Ryu S, Han SJ. Cyclooxygenase-2 Inhibitor Reduces Hepatic Stiffness in Pediatric Chronic Liver Disease Patients Following Kasai Portoenterostomy. Yonsei Med J 2016; 57:893-9. [PMID: 27189282 PMCID: PMC4951465 DOI: 10.3349/ymj.2016.57.4.893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/24/2015] [Accepted: 09/25/2015] [Indexed: 12/17/2022] Open
Abstract
PURPOSE The purpose of this study was to define the role of cyclooxygenase-2 inhibitors (COX-2i) in reducing hepatic fibrosis in pediatric patients with chronic liver disease. MATERIALS AND METHODS From September 2009 to September 2010, patients over 2 years old who visited our outpatient clinic for follow-up to manage their chronic liver disease after Kasai portoenterostomy for biliary atresia, were included in this study. Volunteers were assigned to the study or control groups, according to their preference. A COX-2i was given to only the study group after obtaining consent. The degree of hepatic fibrosis (liver stiffness score, LSS) was prospectively measured using FibroScan, and liver function was examined using serum analysis before and after treatment. After 1 year, changes in LSSs and liver function were compared between the two groups. RESULTS Twenty-five patients (18 females and 7 males) were enrolled in the study group. The control group included 44 patients (26 females and 18 males). After 1 year, the least square mean values for the LSSs were significantly decreased by 3.91±0.98 kPa (p=0.004) only in the study group. Serum total bilirubin did not decrease significantly in either group. CONCLUSION COX-2i treatment improved the LSS in patients with chronic liver disease after Kasai portoenterostomy for biliary atresia.
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Affiliation(s)
- Hye Kyung Chang
- Department of Pediatric Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun Young Chang
- Department of Pediatric Surgery, Severance Children's Hospital, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seonae Ryu
- Department of Pediatric Surgery, Severance Children's Hospital, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seok Joo Han
- Department of Pediatric Surgery, Severance Children's Hospital, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.
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18
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Ramachandran P, Safwan M, Srinivas S, Shanmugam N, Vij M, Rela M. The extended Kasai portoenterostomy for biliary atresia: A preliminary report. J Indian Assoc Pediatr Surg 2016; 21:66-71. [PMID: 27046977 PMCID: PMC4790131 DOI: 10.4103/0971-9261.176941] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Aims: In 1955, Professor Morio Kasai first performed a hepatic portoenterostomy. Since then, the procedure has changed the lives of children with biliary atresia (BA). We report our initial experience in performing “extended” Kasai portoenterostomy (KPE), a modification of the original procedure. Materials and Methods: Since 2013, we have used the technique of “extended KPE” and prospectively recorded data on all children undergoing this operation. Data on demographics, clinical features, liver function tests, and perioperative cholangiogram findings were collected. Outcome of KPE was measured by Jaundice Disappearance Rate (JDR) and Native Liver Survival Rate (NLSR). We present our preliminary results from a 30-month period (February 2013 to May 2015). Results: Thirty-one children underwent KPE during this period (19 males) and only 1 child had biliary atresia splenic malformation (BASM). The mean age at KPE was 73 ± 24 days. Five (16.1%) children were more than 90 days old at the time of KPE. Fourteen children cleared jaundice (JDR 45.2%). Eleven (35.5%) children developed episodes of cholangitis, of whom 8 had early cholangitis (within 3 months of the operation). The proportion of children who survived with their own liver 6 months after KPE (NLSR) was 84.2%. Of those children older than 90 days, 2 cleared jaundice and have survived with their native livers for more than 16 months. Conclusion: In our preliminary report of 31 children, we conclude that the extended KPE leads to increased jaundice clearance and improved NLSR in children with BA.
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Affiliation(s)
- Priya Ramachandran
- Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India; Department of Pediatric Surgery, Kanchi Kamakoti CHILDS Trust Hospital, CHILDS Trust Medical Research Foundation, Chennai, Tamil Nadu, India; National Foundation for Liver Research, Chennai, Tamil Nadu, India
| | - Mohamed Safwan
- Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Sankaranarayanan Srinivas
- Department of Pediatric Surgery, Kanchi Kamakoti CHILDS Trust Hospital, CHILDS Trust Medical Research Foundation, Chennai, Tamil Nadu, India
| | - Naresh Shanmugam
- Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India; National Foundation for Liver Research, Chennai, Tamil Nadu, India
| | - Mukul Vij
- Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India; National Foundation for Liver Research, Chennai, Tamil Nadu, India
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19
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Early type I collagen deposition is associated with prognosis in biliary atresia. J Pediatr Surg 2016; 51:379-85. [PMID: 26452701 DOI: 10.1016/j.jpedsurg.2015.08.061] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/13/2015] [Accepted: 08/15/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Biliary atresia (BA) is a cholestatic liver disease of children that progresses to hepatic fibrosis. BA is the main indication of pediatric liver transplantation (LTx). Histopathological markers in liver biopsies could be useful for predicting progression to end-stage disease. OBJECTIVE To establish histopathological or immunohistochemical markers in liver biopsies of BA patients and correlate those markers with prognosis. METHOD Histological analysis of biliary alterations and morphometric assessment of liver fibrosis were performed, in addition to indirect immunofluorescence assays (IF) for type I, III, IV and V collagens in initial and final liver biopsies of 36 patients with BA who underwent Kasai hepatoportoenterostomy (KPE) and LTx in the last 20years at a single center. RESULTS Histopathological markers had no correlation with evolutive time until LTx. The perisinusoidal deposition of type III and V collagens was more prominent in the initial biopsies (p<0.01), whereas deposition of type I and IV collagens indicated progression (p<0.01). Patients with large amounts of perisinusoidal type I collagen in the initial biopsies had worse progression time curves until LTx (p=0.04). CONCLUSION Morphometric assessment of perisinusoidal deposition of type I collagen by IF in the initial biopsy can correlate with progression time to LTx in post-surgical BA.
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20
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Meng L, Quezada M, Levine P, Han Y, McDaniel K, Zhou T, Lin E, Glaser S, Meng F, Francis H, Alpini G. Functional role of cellular senescence in biliary injury. THE AMERICAN JOURNAL OF PATHOLOGY 2015; 185:602-9. [PMID: 25619959 DOI: 10.1016/j.ajpath.2014.10.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 10/06/2014] [Accepted: 10/28/2014] [Indexed: 01/02/2023]
Abstract
Cellular senescence is a state of irreversible cell cycle arrest that has been involved in many gastrointestinal diseases, including human cholestatic liver disorders. Senescence may play a role in biliary atresia, primary sclerosing cholangitis, cellular rejection, and primary biliary cirrhosis, four liver diseases affecting cholangiocytes and the biliary system. In this review, we examine proposed mechanisms of senescence-related biliary diseases, including hypotheses associated with the senescence-associated phenotype, induction of senescence in nearby cells, and the depletion of stem cell subpopulations. Current evidence for the molecular mechanisms of senescence in the previously mentioned diseases is discussed in detail, with attention to recent advances on the role of pathways associated with senescence-associated phenotype, stress-induced senescence, telomere dysfunction, and autophagy.
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Affiliation(s)
- Luke Meng
- Department of Research, Central Texas Veterans Health Care System, Temple, Texas; Department of Medicine, Digestive Disease Research Center, Scott & White Healthcare, Texas A&M Health Science Center, College of Medicine, Baylor Scott & White Health, Temple, Texas; Doctor of Medicine Program, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Morgan Quezada
- Department of Medicine, Digestive Disease Research Center, Scott & White Healthcare, Texas A&M Health Science Center, College of Medicine, Baylor Scott & White Health, Temple, Texas
| | - Phillip Levine
- Department of Medicine, Digestive Disease Research Center, Scott & White Healthcare, Texas A&M Health Science Center, College of Medicine, Baylor Scott & White Health, Temple, Texas; Academic Operations, Scott & White Memorial Hospital, Baylor Scott & White Health, Temple, Texas
| | - Yuyan Han
- Department of Research, Central Texas Veterans Health Care System, Temple, Texas; Department of Medicine, Digestive Disease Research Center, Scott & White Healthcare, Texas A&M Health Science Center, College of Medicine, Baylor Scott & White Health, Temple, Texas
| | - Kelly McDaniel
- Department of Research, Central Texas Veterans Health Care System, Temple, Texas; Department of Medicine, Digestive Disease Research Center, Scott & White Healthcare, Texas A&M Health Science Center, College of Medicine, Baylor Scott & White Health, Temple, Texas; Academic Operations, Scott & White Memorial Hospital, Baylor Scott & White Health, Temple, Texas
| | - Tianhao Zhou
- Department of Research, Central Texas Veterans Health Care System, Temple, Texas; Department of Medicine, Digestive Disease Research Center, Scott & White Healthcare, Texas A&M Health Science Center, College of Medicine, Baylor Scott & White Health, Temple, Texas
| | - Emily Lin
- Department of Research, Central Texas Veterans Health Care System, Temple, Texas; Department of Medicine, Digestive Disease Research Center, Scott & White Healthcare, Texas A&M Health Science Center, College of Medicine, Baylor Scott & White Health, Temple, Texas
| | - Shannon Glaser
- Department of Research, Central Texas Veterans Health Care System, Temple, Texas; Department of Medicine, Digestive Disease Research Center, Scott & White Healthcare, Texas A&M Health Science Center, College of Medicine, Baylor Scott & White Health, Temple, Texas
| | - Fanyin Meng
- Department of Research, Central Texas Veterans Health Care System, Temple, Texas; Department of Medicine, Digestive Disease Research Center, Scott & White Healthcare, Texas A&M Health Science Center, College of Medicine, Baylor Scott & White Health, Temple, Texas; Academic Operations, Scott & White Memorial Hospital, Baylor Scott & White Health, Temple, Texas
| | - Heather Francis
- Department of Research, Central Texas Veterans Health Care System, Temple, Texas; Department of Medicine, Digestive Disease Research Center, Scott & White Healthcare, Texas A&M Health Science Center, College of Medicine, Baylor Scott & White Health, Temple, Texas; Academic Operations, Scott & White Memorial Hospital, Baylor Scott & White Health, Temple, Texas
| | - Gianfranco Alpini
- Department of Research, Central Texas Veterans Health Care System, Temple, Texas; Department of Medicine, Digestive Disease Research Center, Scott & White Healthcare, Texas A&M Health Science Center, College of Medicine, Baylor Scott & White Health, Temple, Texas.
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21
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Thakur RK, Davenport M. Improving treatment outcomes in patients with biliary atresia. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.973402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ng VL, Haber BH, Magee JC, Miethke A, Murray KF, Michail S, Karpen SJ, Kerkar N, Molleston JP, Romero R, Rosenthal P, Schwarz KB, Shneider BL, Turmelle YP, Alonso EM, Sherker AH, Sokol RJ. Medical status of 219 children with biliary atresia surviving long-term with their native livers: results from a North American multicenter consortium. J Pediatr 2014; 165:539-546.e2. [PMID: 25015575 PMCID: PMC4144331 DOI: 10.1016/j.jpeds.2014.05.038] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/21/2014] [Accepted: 05/21/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To examine the medical status of children with biliary atresia (BA) with their native livers after hepato- portoenterostomy (HPE) surgery. STUDY DESIGN The Childhood Liver Disease Research and Education Network database was utilized to examine subjects with BA living with their native livers 5 or more years after HPE and to describe the prevalence of subjects with BA with an "ideal" outcome, defined as no clinical evidence of chronic liver disease, normal liver biochemical indices (aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transpeptidase, platelet count, total bilirubin, international normalized ratio, and albumin), and normal health-related quality of life 5 or more years after HPE. RESULTS Children with BA (n = 219; 43% male) with median age 9.7 years were studied. Median age at HPE was 56 (range 7-125) days. Median age- and sex-adjusted height and weight z-scores at 5-year follow-up were 0.487 (IQR -0.27 to 1.02) and 0.00 (IQR -0.74 to 0.70), respectively. During the 12 preceding months, cholangitis and bone fractures occurred in 17% and 5.5%, respectively. Health-related quality of life was reported normal by 53% of patients. However, only 1.8% met the study definition of "ideal" outcome. Individual tests of liver synthetic function (total bilirubin, albumin, and international normalized ratio) were normal in 75%, 85%, and 73% of the study cohort. CONCLUSION Cholangitis and fractures in long-term survivors underscore the importance of ongoing medical surveillance. Over 98% of this North American cohort of subjects with BA living with native livers 5 or more years after HPE have clinical or biochemical evidence of chronic liver disease.
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Affiliation(s)
- Vicky Lee Ng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Barbara H Haber
- Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Alexander Miethke
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Karen F Murray
- Hepatobiliary Program, Seattle Children's Hospital and University of Washington, Seattle, WA
| | - Sonia Michail
- Department of Gastroenterology and Nutrition, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA
| | - Saul J Karpen
- Texas Children's Hospital, Houston, TX; Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Nanda Kerkar
- Department of Gastroenterology and Nutrition, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA; Division of Pediatric Hepatology, Mount Sinai School of Medicine, New York, NY
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children, Indiana University, Indianapolis, IN
| | - Rene Romero
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Philip Rosenthal
- Pediatrics Gastroenterology, Hepatology, and Nutrition, University of California San Francisco Benioff Children's Hospital, University of California, San Francisco, CA
| | - Kathleen B Schwarz
- Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Benjamin L Shneider
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yumirle P Turmelle
- Division of Gastroenterology and Nutrition, Washington University, St. Louis, MO
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital and Northwestern University, Chicago, IL
| | | | - Ronald J Sokol
- Department of Gastroenterology, Hepatology, and Nutrition, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
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Tomita H, Masugi Y, Hoshino K, Fuchimoto Y, Fujino A, Shimojima N, Ebinuma H, Saito H, Sakamoto M, Kuroda T. Long-term native liver fibrosis in biliary atresia: development of a novel scoring system using histology and standard liver tests. J Hepatol 2014; 60:1242-8. [PMID: 24548530 DOI: 10.1016/j.jhep.2014.01.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/18/2013] [Accepted: 01/27/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Although liver fibrosis is an important predictor of outcomes for biliary atresia (BA), postsurgical native liver histology has not been well reported. Here, we retrospectively evaluated postsurgical native liver histology, and developed and assessed a novel scoring system - the BA liver fibrosis (BALF) score for non-invasively predicting liver fibrosis grades. METHODS We identified 259 native liver specimens from 91 BA patients. Of these, 180 specimens, obtained from 62 patients aged ≥1 year at examination, were used to develop the BALF scoring system. The BALF score equation was determined according to the prediction of histological fibrosis grades by multivariate ordered logistic regression analysis. The diagnostic powers of the BALF score and several non-invasive markers were assessed by area under the receiver operating characteristic curve (AUROC) analyses. RESULTS Natural logarithms of the serum total bilirubin, γ-glutamyltransferase, and albumin levels, and age were selected as significantly independent variables for the BALF score equation. The BALF score had a good diagnostic power (AUROCs=0.86-0.94, p<0.001) and good diagnostic accuracy (79.4-93.3%) for each fibrosis grade. The BALF score revealed a strong correlation with fibrosis grade (r=0.77, p<0.001), and was the preferable non-invasive marker for diagnosing fibrosis grades ⩾F2. In a serial liver histology subgroup analysis, 7/15 patients exhibited liver fibrosis improvement with BALF scores being equivalent to histological fibrosis grades of F0-1. CONCLUSIONS In postsurgical BA patients aged ⩾1year, the BALF score is a potential non-invasive marker of native liver fibrosis.
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Affiliation(s)
- Hirofumi Tomita
- Department of Pediatric Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yohei Masugi
- Department of Pathology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Ken Hoshino
- Department of Pediatric Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yasushi Fuchimoto
- Division of Surgery, Department of Surgical Subspecialities, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo 157-8535, Japan
| | - Akihiro Fujino
- Department of Pediatric Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Naoki Shimojima
- Department of Pediatric Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Hirotoshi Ebinuma
- Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Hidetsugu Saito
- Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Michiie Sakamoto
- Department of Pathology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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Hahn SM, Kim S, Park KI, Han SJ, Koh H. Clinical benefit of liver stiffness measurement at 3 months after Kasai hepatoportoenterostomy to predict the liver related events in biliary atresia. PLoS One 2013; 8:e80652. [PMID: 24260445 PMCID: PMC3832463 DOI: 10.1371/journal.pone.0080652] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 10/06/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The progression of hepatic fibrosis may result in decompensated hepatic failure with cirrhosis, liver related events (LRE) such as ascites, variceal bleeding, and death after successful and timely Kasai hepatoportoenterostomy (HPE) in biliary atresia. The aim of this study is to suggest clinical benefit of the liver stiffness measurement (LSM) using transient elastography at 3 months after the Kasai operation to predict LRE. METHODS Between January 2007 and December 2011, 69 eligible biliary atresia patients who underwent Kasai HPE and performed transient elastography before and 3 months after HPE were included. The occurrences of LRE were analyzed for all patients. All patients were divided into 2 groups (with and without LRE) for comparison. Multivariate analysis was used to detect the independent risk factors of LRE. The area under the receiver operation characteristics curve (AUROC) was used to establish the LSM optimal cutoff value of 3 months after Kasai operation in predicting LRE. RESULTS LSM value, aminotransferase, albumin, bilirubin, and PT-INR significantly differed among the two groups. Multivariate analysis demonstrated LSM value as the most powerful independent factor of the development of LRE. The cut-off value of 19.9 kPa was calculated to be optimal for predicting LRE development with total sensitivity and specificity of 1.804. AUROC resulted in 0.943, with sensitivity of 85.3% and specificity of 95.2%. CONCLUSIONS The LSM value of 3 months after Kasai HPE can be a useful predictor of LRE development.
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Affiliation(s)
- Seung Min Hahn
- Department of Pediatrics, Yonsei University College of Medicine, Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Seoul, Korea
| | - Seung Kim
- Department of Pediatrics, Yonsei University College of Medicine, Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Seoul, Korea
| | - Kook In Park
- Department of Pediatrics, Yonsei University College of Medicine, Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Seoul, Korea
| | - Seok Joo Han
- Department of Pediatric surgery, Yonsei University College of Medicine, Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Seoul, Korea
| | - Hong Koh
- Department of Pediatrics, Yonsei University College of Medicine, Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Seoul, Korea
- * E-mail:
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Petersen C, Davenport M. Aetiology of biliary atresia: what is actually known? Orphanet J Rare Dis 2013; 8:128. [PMID: 23987231 PMCID: PMC3766137 DOI: 10.1186/1750-1172-8-128] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 08/23/2013] [Indexed: 01/27/2023] Open
Abstract
Biliary atresia (BA) is a rare disease of unknown etiology and unpredictable outcome, even when there has been timely diagnosis and exemplary surgery. It has been the commonest indication for liver transplantation during childhood for the past 20 years. Hence much clinical and basic research has been directed at elucidating the origin and pathology of BA. This review summarizes the current clinical variations of BA in humans, its occasional appearance in animals and its various manifestations in the laboratory as an experimental model.
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Affiliation(s)
- Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Carl-Neuberg-Str, 1, 30625 Hannover, Germany.
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26
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Chardot C, Buet C, Serinet MO, Golmard JL, Lachaux A, Roquelaure B, Gottrand F, Broué P, Dabadie A, Gauthier F, Jacquemin E. Improving outcomes of biliary atresia: French national series 1986-2009. J Hepatol 2013; 58:1209-17. [PMID: 23402746 DOI: 10.1016/j.jhep.2013.01.040] [Citation(s) in RCA: 157] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 01/22/2013] [Accepted: 01/27/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS This study analyses the prognosis of biliary atresia (BA) in France since liver transplantation (LT) became widely available. METHODS The charts of all BA patients living in France and born between 1986 and 2009 were reviewed. Patients were divided into 3 cohorts according to their years of birth: 1986-1996, 1997-2002, and 2003-2009. RESULTS 1107 BA children were identified, 990 born in metropolitan France (incidence 1/18,400 live births). Kasai operation was performed in 1044 (94%), leading to complete clearance of jaundice (total serum bilirubin ≤ 20 μmol/L) in 38% of patients. Survival with native liver (SNL) after Kasai operation was 40%, 36%, and 30% at 5, 10, and 20 years, stable in the 3 cohorts. Median age at Kasai operation was 59 days, unchanged over time. Twenty-year SNL was 39%, 32%, 28%, and 19% after Kasai operation performed in the first, second, third months of life or thereafter (p=0.0002). 588 children underwent 692 LTs. Mortality without transplantation decreased over time: 16%, 7%, and 4% in the 3 cohorts (p<0.0001). Survival after transplantation was 83%, 82%, and 77% at 5, 10, and 20 years in the whole series. Five-year post-transplant survival was 75%, 90%, and 89% in the 3 cohorts (p<0.0001). In the whole series, overall BA patient survival was 81%, 80%, and 77% at 5, 10, and 20 years. Five-year BA patient overall survival increased over time: 72%, 88%, and 89% in the 3 cohorts (p<0.0001). CONCLUSIONS BA patients currently have an 89% live expectancy, and a 30% chance to reach adulthood without transplantation. Early Kasai operation, without age threshold, reduces the need for liver transplantation until adulthood.
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Affiliation(s)
- Christophe Chardot
- Observatoire français de l'atrésie des voies biliaires, Hôpital Necker - Enfants malades, Université Paris Descartes, Paris, France.
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Schecter SC, Courtier J, Cho SJ, Saadai P, Hirose S, Mackenzie TC, Miniati D. Hepatic portocholecystostomy for biliary atresia: a 25-year follow-up and review. J Pediatr Surg 2013; 48:262-6. [PMID: 23331828 DOI: 10.1016/j.jpedsurg.2012.10.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 10/25/2012] [Accepted: 10/26/2012] [Indexed: 12/14/2022]
Abstract
We report the successful salvage of a patient's native liver 25 years after hepatic portocholecystostomy for biliary atresia. Our case demonstrates the effectiveness of biliary specific, high-resolution CT imaging in the diagnosis of, and operative planning for complex cases of biliary obstruction. We also report the longest-term pathologic follow-up of biliary atresia after hepatic portocholecystostomy. Life-long follow-up of patients with biliary atresia is important to prevent life-threatening complications of biliary stasis/obstruction.
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Affiliation(s)
- Samuel C Schecter
- East Bay Surgery Program, University of California San Francisco, San Francisco, CA 94143-0570, USA.
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28
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Abstract
Introduction Biliary atresia (BA) is the most common cause of cholestatic jaundice in infancy. Early diagnosis and surgical management, ideally before 60 days of age, result in improved outcomes. We aimed to determine the age at diagnosis of BA in the Military Health System (MHS) and to compare the age at diagnosis by access to care models. We hypothesized that children with BA receiving primary care in military facilities have an earlier age at diagnosis due to decreased economic and access barriers. Methods Data for all Tricare enrollees born in fiscal years 2004–2008 with a diagnosis of BA were extracted from MHS databases. Non-parametric tests, Kaplan-Meier curves and log rank tests compared differences in age at diagnosis by type of primary care facility, gender, prematurity and presence of additional anomalies. Results 64 subjects were identified within the five year period. Median age at diagnosis was 40 days [range 1–189], with 67% diagnosed by 60 days and 80% by 90 days. 45 (70%) received civilian primary care within the MHS. There was no difference in the median age at diagnosis between subjects in the MHS with civilian primary care vs. military primary care (37 days [1–188] vs. 46 days [1–189]; p = 0.58). Conclusion In the MHS, two-thirds of infants with biliary atresia are diagnosed prior to 60 days of life. Gender, prematurity or presence of additional anomalies do not affect the timing of diagnosis. Civilian and military primary care models within the MHS make timely diagnoses of biliary atresia at equivalent rates.
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Liu Y, Huang ZH, Xu SQ, Huang YJ, Zhou H, Dong YS, Feng JX. Value of histopathologic examination in differential diagnosis of infantile cholestasis. Shijie Huaren Xiaohua Zazhi 2012; 20:2200-2204. [DOI: 10.11569/wcjd.v20.i23.2200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare differences in liver histopathology between extrahepatic biliary atresia (EHBA) and infantile cholestatic infantile hepatitis (IH) and to explore the value of liver histopathologic examination in differential diagnosis of these diseases.
METHODS: The clinical data for 65 patients with EHBA and 24 patients with IH who were pathologically diagnosed from April 2002 to December 2009 were retrospectively analyzed.
RESULTS: There were some common histopathologic features between EHBA and IH. The major histopathological features of EHBA were bile duct proliferation, portal fibrosis and inflammatory cell infiltration (all P < 0.05), while the outstanding features of IH were hepatic giant cell transformation and extramedullary hematopoiesis (both P < 0.05).
CONCLUSION: Although there are some differences between EHBA and IH in histopathologic features, some features are overlapped. Therefore, clinical features for the patients should also be considered. In some cases, exploratory laparotomy is required for differential diagnosis.
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Abstract
Biliary atresia (BA) remains an enigmatic disease with a degree of etiologic heterogeneity. A number of variants can be defined clinically, and these include the syndromic group (typically BA splenic malformation), cystic BA, and cytomegalovirus (CMV) IgM +ve associated BA. The remainder, and still the largest group, may be termed isolated BA(.) There is a wide variation in incidence across the globe from 1 in 5000 in Taiwan to 1 in 20,000 live births in Northern Europe, although the reasons for such a disparity remain obscure. Management remains primarily surgical with an attempt to restore bile flow by resection of extrahepatic biliary remnants and a reconstruction portoenterostomy (the Kasai procedure), reserving liver transplantation for those where this fails or complications of chronic liver disease supervene. Clearance of jaundice to normal values has been achieved in 40%-55% of cases in large series from around the world, with an expectation of 5-year native liver survival of similar proportions.
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Affiliation(s)
- Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London, United Kingdom.
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Kumagi T, Drenth JPH, Guttman O, Ng V, Lilly L, Therapondos G, Hiasa Y, Michitaka K, Onji M, Watanabe Y, Sen S, Griffiths W, Roberts E, Heathcote J, Hirschfield GM. Biliary atresia and survival into adulthood without transplantation: a collaborative multicentre clinic review. Liver Int 2012; 32:510-8. [PMID: 22098694 DOI: 10.1111/j.1478-3231.2011.02668.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Accepted: 09/17/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary atresia is a progressive biliary injury which occurs only in infants. AIMS To review the experience of patients surviving into adulthood without the need for liver transplantation in childhood. METHODS A multicentre review of patients with biliary atresia treated surgically who survived into adulthood without the need for transplantation. RESULTS Twenty-two patients were identified across four centres. Median age at the last follow-up was 25 years (range: 18-46), and 21 patients had clinical features of portal hypertension. At last follow-up values of liver enzymes varied from normal to 15 × the upper limit of normal (ULN) for ALT (median 2.11 × ULN) and 9 × the ULN for ALP (median 2.02 × ULN). Six patients had a serum bilirubin > 50 μmol/l. Pruritus and jaundice were noted in 8 of 20 patients (40%) and 11 of 22 patients (50%) respectively. Thirteen patients (59.1%) were shown to have imaging features of sclerosing cholangitis, with strictures of intrahepatic bile duct(s) (IHBD), dilatation of IHBD (n = 8), or stone(s) within the IHBD (n = 5). A history of presumed bacterial cholangitis was present in 11 patients (50%). Successful pregnancies were recorded in three of fourteen female patients. Four patients underwent transplant between the ages of 20-27 years. Twenty-one patients (95.5%) were alive, including 18 (81.8%) with their native liver at the time of last follow-up. CONCLUSIONS Some patients treated for biliary atresia will survive into adulthood with their native liver, but commonly with secondary biliary disease including cholangitis and portal hypertension.
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de Vries W, Homan-Van der Veen J, Hulscher JBF, Hoekstra-Weebers JEHM, Houwen RHJ, Verkade HJ. Twenty-year transplant-free survival rate among patients with biliary atresia. Clin Gastroenterol Hepatol 2011; 9:1086-91. [PMID: 21820397 DOI: 10.1016/j.cgh.2011.07.024] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 07/17/2011] [Accepted: 07/25/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Surgical treatment with Kasai portoenterostomy has improved the prognosis for patients with biliary atresia, although most patients ultimately require liver transplantation. Well-described patients with long-term, transplant-free survival are scarce; we assessed liver status and health perception among Dutch patients who survived 20 years after therapy and investigated whether the rate of transplant-free survival increases with time. METHODS By using the Dutch national database for biliary atresia, we identified 104 patients, born between 1977 and 1988. We collected data on clinical characteristics, liver biochemistry, and ultrasonography from all transplant-free patients who were alive at age 20 years (n = 28; 27% of the patients). General health perception data (RAND-36) were collected at the last examination. RESULTS The 20-year transplant-free survival rate increased from 20% (10 of 49) in the 1977 to 1982 cohort to 32% (18 of 55) in the 1983 to 1988 cohort (P = .03). Twenty-one percent of the long-term survivors (6 of 28) had normal liver biochemistry test results and no clinical or ultrasonographic signs of cirrhosis. The general health perception of female, but not male, patients, was lower, compared with controls (RAND-36 score, 54 ± 14 vs 74 ± 18; P = .005). CONCLUSIONS More than 25% of patients with biliary atresia survive at least 20 years without liver transplantation in The Netherlands. Women with biliary atresia have a reduced perception of their health, compared with control patients. Twenty percent of long-term survivors are symptom-free, without clinical or ultrasonographic signs of cirrhosis or portal hypertension.
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Affiliation(s)
- Willemien de Vries
- Department of Pediatric Gastroenterology and Hepatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Jung E, Park WH, Choi SO. Late complications and current status of long-term survivals over 10 years after Kasai portoenterostomy. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011; 81:271-5. [PMID: 22111083 PMCID: PMC3219853 DOI: 10.4174/jkss.2011.81.4.271] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 07/11/2011] [Accepted: 07/22/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE Whereas the Kasai portoenterostomy (KPE) is an accepted first line of surgery for bile drainage in infants with biliary atresia, its long-term effectiveness is not clear because its etiology and pathogenesis remains unknown. This study was aimed to investigate the late complications occurring in long-term survivors and the current status of living patients who survived over 10 years after KPE. METHODS A retrospective analysis of the medical records of 32 patients who underwent KPE from 1990 to 2000 was done. We analyzed 10-year survival rates with the Kaplan-Meier method and the current status of the long-term survivors. RESULTS The overall 10-year survival rate by Kaplan-Meier method after KPE was 76.2%. Eight (25%) patients had died, including 4 who were transplanted. Nineteen (59.4%) patients survived over 10 years. Among them, 6 (31.6%) patients had portal hypertension, and 5 (26.3%) had episodes of cholangitis. Two had intrahepatic cyst and 2 had intestinal obstruction. Six (31.6%) patients have been well without any complications. CONCLUSION The long-term survival rate of biliary atresia is slightly improving. However, two thirds of patients suffer from various complications. One-third of survivors go on without any complication. As biliary atresia is known as a progressive inflammatory disease, careful life-long follow- up is needed in long-term survivals after KPE.
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Affiliation(s)
- Eunyoung Jung
- Department of Pediatric Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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34
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Hadžić N, Quaglia A, Portmann B, Paramalingam S, Heaton ND, Rela M, Mieli-Vergani G, Davenport M. Hepatocellular carcinoma in biliary atresia: King's College Hospital experience. J Pediatr 2011; 159:617-22.e1. [PMID: 21489554 DOI: 10.1016/j.jpeds.2011.03.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 02/01/2011] [Accepted: 03/02/2011] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To establish risks for development of hepatocellular carcinoma (HCC) in children with biliary atresia (BA), the most common chronic liver disease of childhood. STUDY DESIGN In our tertiary referral center database we have identified children with BA who had development of or have been incidentally found to have HCC. Their demographic, clinical, radiologic, and histologic features were analyzed. RESULTS Between 1990 and 2008, 387 infants were diagnosed with BA at our center. Of these, three (0.8 %) who underwent operation at a median age of 68 (range 66 to 71) days had development of a histologically proven HCC detected at a median age of 2.1 (range 1.8 to 4.9) years. Another two, referred later, were diagnosed with HCC on their liver explants at ages 1.1 and 17.75 years, respectively. Overall, two had elevated serum levels of alpha-fetoprotein. All five children underwent successful liver transplantation at a median age of 2.1 years (range 1.1 to 17.75) and remain well after a median of 2.5 (range 2 to 5.7) years. CONCLUSION HCC develops in a small percentage of children with BA. Serum alpha-fetoprotein levels and ultrasound screening are helpful but not absolute markers of the malignant change. In the absence of the extrahepatic involvement, liver transplantation represents an effective treatment.
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Affiliation(s)
- Nedim Hadžić
- Paediatric Liver Centre, King's College Hospital, Denmark Hill, London, United Kingdom.
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Abstract
Biliary atresia (BA) is a cholangiodestructive disease affecting biliary tract, which ultimately leads to cirrhosis, liver failure and death if not treated. The incidence is higher in Asian countries than in Europe. Up to 10% of cases have other congenital anomalies, such as polysplenia, asplenia, situs inversus, absence of inferior vena cava and pre-duodenal portal vein, for which we have coined the term Biliary Atresia Splenic Malformation (BASM) syndrome. For these infants the aetiology lies within the first trimester of gestation. For others affected with BA, aetiology is more obscure and perinatal destruction of fully-formed ducts perhaps by the action of hepatotropic viruses has been suggested. Whatever the cause, the lumen of the extrahepatic duct is obliterated at a variable level and this forms the basis for the commonest classification (Types I, II, III). All patients with BA present with varying degree of conjugated jaundice, pale non-pigmented stools and dark urine. Key diagnostic tests include ultrasonography, biochemical liver function tests, viral serology, and (in our centre) a percutaneous liver biopsy. In some centres, duodenal intubation and measurement of intralumenal bile is the norm. Currently BA is being managed in two stages. The first stage involves the Kasai operation, which essentially excises all extrahepatic biliary remnants leaving a transected portal plate, followed by biliary reconstruction using a Roux loop onto that plate as a portoenterostomy. If bile flow is not restored by Kasai procedure or life-threatening complications of cirrhosis ensue then consideration should be given to liver transplantation as a second stage. The outcome following the Kasai operation can be assessed in two ways: clearance of jaundice to normal values and the proportion who survive with their native liver. Clearance of jaundice (<2 mg/dL or <34 µmol/L) after Kasai has been reported to be around 60%, whereas five years survival with native liver ranges from 40% to 65%.
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Affiliation(s)
- C K Sinha
- Department of Pediatric Surgery, King's College Hospital, Denmak Hill, London SE5 9RS UK
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Erlichman J, Hohlweg K, Haber BA. Biliary atresia: how medical complications and therapies impact outcome. Expert Rev Gastroenterol Hepatol 2009; 3:425-34. [PMID: 19673629 DOI: 10.1586/egh.09.30] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Biliary atresia (BA) is a progressive fibro-obliterative disease of the extrahepatic biliary tree that presents with biliary obstruction in the neonatal period. Untreated, BA is a uniformly fatal disease and, yet, even with our existing therapies, at least 50% of children with BA will undergo liver transplantation by the age of 2 years. Current treatment strategies are, at best, palliative; they focus on prompt diagnosis, supportive nutritional care and interventions for sequelae. The purpose of this article is to discuss the current treatment paradigm for BA and to assess the impact these strategies have on outcomes. As more children with BA survive into adulthood with their native liver, it is important to understand which factors predict good and poor outcomes.
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Affiliation(s)
- Jessi Erlichman
- Division of GI, Hepatology and Nutrition, The Childrens' Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 19104, USA
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Bone health in a nonjaundiced population of children with biliary atresia. Gastroenterol Res Pract 2009; 2009:387029. [PMID: 19606216 PMCID: PMC2705890 DOI: 10.1155/2009/387029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Revised: 03/31/2009] [Accepted: 04/30/2009] [Indexed: 12/17/2022] Open
Abstract
Objectives. To assess bone health in a cohort of nonjaundiced children with biliary atresia (BA) and the effect of growth and development on bone outcomes.
Methods. Children ages one to eighteen years receiving care from Children's Hospital of Philadelphia were recruited. Each child was seen once and assessed for growth, pubertal development, concurrent medications, bilirubin, ALT, albumin, vitamin D status, bone mineral density (BMD), and bone mineral content (BMC) of the lumbar spine and whole body. Results. BMD declined significantly with age, and upon further analysis with a well-phenotyped control cohort, it was found that BMC was significantly decreased for both lumbar spine and whole body, even after adjustment for confounding variables. An age interaction was identified, with older subjects having a significantly greater impairment in BMC. Conclusions. These preliminary results demonstrate that children with BA, including those without jaundice, are likely to have compromised bone health even when accounting for height and puberty, which are common confounding factors in chronic disease. Further investigation is needed to identify the determinants of poor bone mineral status and to develop strategies to prevent osteoporosis later in life.
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Mieli-Vergani G, Vergani D. Biliary atresia. Semin Immunopathol 2009; 31:371-81. [PMID: 19533128 DOI: 10.1007/s00281-009-0171-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Accepted: 06/01/2009] [Indexed: 12/17/2022]
Abstract
Biliary atresia (BA) is a condition unique to infancy. It results from inflammatory destruction of the intrahepatic and extrahepatic bile ducts. It is the most frequent surgically correctable liver disorder in infancy and the most frequent indication for liver transplantation in paediatric age. Clinical presentation is in the first few weeks of life with conjugated hyperbilirubinaemia (dark urine and pale stools); other manifestations of liver disease, such as failure to thrive, splenomegaly and ascites, appear only later, when surgery is unlikely to be successful. Hence, all infants with conjugated hyperbilirubinaemia must be urgently referred to specialised centres for appropriate treatment. Success of surgery depends on the age at which it is performed. With corrective surgery, followed, when necessary, by liver transplantation, the overall survival rate is approximately 90%. The cause of BA is unknown, but there is evidence for the involvement of infectious, genetic and immunologic mechanisms, which will be discussed in this review.
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Affiliation(s)
- Giorgina Mieli-Vergani
- Paediatric Liver Centre, Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
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Abstract
BACKGROUND Little information is available on contemporary, prospectively collected data on the long-term outcome of national cohorts of children with biliary atresia. OBJECTIVE This study aimed to describe the current outcome of a national cohort of children with biliary atresia. PATIENTS AND METHODS All 93 cases of biliary atresia in the United Kingdom and Ireland diagnosed between March 1993 and February 1995 were followed up prospectively. RESULTS A total of 91 children underwent Kasai portoenterostomy in 15 individual centres. Only 2 centres treated more than 5 children annually. Median age at last follow-up was 12 years (range 0.25-14). Fifteen children (16%) have died: 10 after unsuccessful portoenterostomy, 1 of sepsis after successful portoenterostomy, and 4 after liver transplantation. Forty-two (45%) underwent liver transplantation at a median age of 1 year (range 0.5-9), with 90% survival. All 41 children with failed portoenterostomy (and 2 without portoenterostomy) died or underwent liver transplantation at a median age of 0.8 years (range 0.25-6.5). When the portoenterostomy was successful, 40 of 50 patients (80%) are alive without liver transplantation. The 13-year actuarial survival without liver transplantation is 43.8% overall and is better in children treated at centres that treat more than 5 cases yearly (54% vs 27.3%, P = 0.005). CONCLUSIONS If the portoenterostomy is successful, then few children with biliary atresia will need transplantation before adolescence. Children with biliary atresia should be treated in experienced centres to maximize the chance of successful surgery.
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Camilla R, Magnetti F, Barbera C, Bignamini E, Riggi C, Coppo R. Children with chronic organ failure possibly ending in organ transplantation: a survey in an Italian region of 5,000,000 inhabitants. Acta Paediatr 2008; 97:1285-91. [PMID: 18477063 DOI: 10.1111/j.1651-2227.2008.00854.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM The Italian Piedmont region sponsored in 2005 a population-based registry to assess the epidemiology of childhood chronic organ failure involving kidneys, liver, heart or lungs. METHODS Patients in chronic organ failure who were younger than 18 years were selected, and entered the registry when accomplishing the standard failure criteria for each organ. The cases were reported by the general paediatricians of the region and integrated with the data gathered by the Children University Hospital, a tertiary care centre. RESULTS In Piedmont (647,727 inhabitants < 18 years), a total of 146 children (217 cases per million of paediatric population) were found to be affected by chronic organ failure (mean age 10 years; range 0-17). The organ failure involved kidneys in 68 subjects (48%), liver in 24 (17%), heart in 21 (15%) and lungs in 28 (20%), and was severe in 32 subjects (6 on transplantation waiting list). The most represented disease leading to chronic renal failure was renal hypodysplasia (79%). Chronic liver failure was mostly caused by biliary atresia (30%), autoimmune hepatitis (25%) and Wilson's disease (21%). Dilated cardiomyopathy (62%) and surgically treated congenital cardiopathy were the two leading causes of chronic heart failure. The most represented disease leading to chronic lung failure was cystic fibrosis (89%). CONCLUSION This is the first report of the literature focusing on the epidemiology of chronic organ failure in children encompassing a region of 4,000,000 inhabitants. This clinical condition is rare, but medically and socially very demanding not only in childhood but the life along, as most of these patients will need solid organ transplantation decades later.
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Affiliation(s)
- R Camilla
- Nephrology, Dialysis, Transplantation, Regina Margherita University Children Hospital, Turin, Italy.
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Kuroda T, Saeki M, Morikawa N, Watanabe K. Management of adult biliary atresia patients: should hard work and pregnancy be discouraged? J Pediatr Surg 2007; 42:2106-9. [PMID: 18082718 DOI: 10.1016/j.jpedsurg.2007.08.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Accepted: 08/08/2007] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of the paper was to study the potential risk and management of adult biliary atresia (BA) patients. MATERIALS AND METHODS Clinical courses and biochemical data were retrospectively analyzed in 52 BA patients who were operated in our department and are now older than 15 years, with special emphasis on 47 patients who survived beyond the age of 20 years. RESULTS Of these 47 patients, 45 (95.7%) are employed, receiving higher education, and/or married. Thirty-three patients showed favorable liver function at the age of 20 years with their native liver. Thereafter, 6 (18.2%) developed liver dysfunction after working hard or pregnancy. In these 6 patients, cholinesterase levels were significantly lower at the age of 20 years than those in the 27 stable patients (239.5 +/- 42.6 vs 285.8 +/- 47.5, P = .0216), whereas no significant difference was found in alanine aminotransferase, aspartate aminotransferase, or total protein levels at the age of 20 years or in any biochemical parameters at the age of 15 years. Of the 14 transplanted patients, 5 who underwent transplantation after the age of 20 years had relatively uneventful courses until the age of 20 years; however, their biochemical data already showed significant deterioration at puberty. CONCLUSION Social activities and pregnancy should be managed individually according to the risk assessment for potential hepatic failure even in stable adult BA patients. A falling cholinesterase level after the age of 20 years may predict the risk for the late hepatic dysfunction.
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Affiliation(s)
- Tatsuo Kuroda
- Department of Surgery, National Center for Child Health and Development, Tokyo, Japan.
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Abstract
Extra-hepatic biliary atresia occurs in approximately 1:15,000 live births leading to about 50 new cases/year in the UK. Presentation is with prolonged jaundice, usually in a term baby who develops signs of obstructive jaundice. Management has been improved by public and professional education to encourage early referral and diagnosis to facilitate initial surgery before 8 weeks of age. Surgical management is complementary and includes an attempt to restore biliary flow (the Kasai portoenterostomy) and liver transplantation if necessary. Medical management consists of antibiotics, ursodeoxycholic acid to encourage bile flow, fat soluble vitamin supplementation and nutritional support. Centralising surgery to specialised centres has improved survival of this potentially fatal disease to over 90% in the UK. Over half of infants undergoing portoenterostomy will clear the jaundice and have a greater than 80% chance of a good quality of life, reaching adolescence without transplantation. For those children developing intractable complications of cirrhosis and portal hypertension, liver transplantation provides a 90% chance of achieving normal life.
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Affiliation(s)
- Deirdre A Kelly
- The Liver Unit, Birmingham Children's Hospital NHS Trust, Birmingham, UK.
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Carter-Kent C, Radhakrishnan K, Feldstein AE. Increasing calories, decreasing morbidity and mortality: is improved nutrition the answer to better outcomes in patients with biliary atresia? Hepatology 2007; 46:1329-31. [PMID: 17969044 DOI: 10.1002/hep.22043] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Affiliation(s)
- Benjamin L Shneider
- Department of Pediatrics, Thomas E. Starzl Transplantation Institute, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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DeRusso PA, Ye W, Shepherd R, Haber BA, Shneider BL, Whitington PF, Schwarz KB, Bezerra JA, Rosenthal P, Karpen S, Squires RH, Magee JC, Robuck PR, Sokol RJ. Growth failure and outcomes in infants with biliary atresia: a report from the Biliary Atresia Research Consortium. Hepatology 2007; 46:1632-8. [PMID: 17929308 PMCID: PMC3881187 DOI: 10.1002/hep.21923] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
UNLABELLED Malnutrition is a significant clinical problem in infants with biliary atresia. The natural history of poor growth and its potential association with early transplantation or death in children with biliary atresia was determined. Serial weight- and length-for-age z-scores were computed as part of a retrospective study of 100 infants who underwent hepatoportoenterostomy (HPE) for biliary atresia at 9 U.S. pediatric centers between 1997 and 2000. Poor outcome was defined as transplantation or death by 24 months of age (n = 46) and good outcome was defined as survival with native liver at 24 months of age with total serum bilirubin less than 6 mg/dL (n = 54). Growth velocity was significantly slower in the poor outcome group compared to the good outcome group (P < 0.001 for both weight and length). Mean weight z-scores were significantly lower by 6 months after HPE in the poor outcome group (-2.1 +/- 1.4) compared to the good outcome group (-1.2 +/- 1.4) (P < 0.001). In a subgroup with total bilirubin between 2 and 6 mg/dL at 3 months after HPE (n = 28), the weight z-scores at 3 months after HPE were significantly lower in the poor outcome group (-2.0 +/-1.2) compared to the good outcome group (-1.0 +/- 1.2) (P = 0.04) despite similar bilirubin concentrations. CONCLUSION Growth failure after HPE was associated with transplantation or death by 24 months of age. The combination of intermediate bilirubin concentrations and poor mean weight z-scores 3 months after HPE was also associated with poor clinical outcome.
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Affiliation(s)
- Patricia A. DeRusso
- Johns Hopkins School of Medicine and The Johns Hopkins Children's Center, Baltimore, Maryland
| | - Wen Ye
- The University of Michigan, Ann Arbor
| | - Ross Shepherd
- Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, Missouri
| | - Barbara A. Haber
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Kathleen B. Schwarz
- Johns Hopkins School of Medicine and The Johns Hopkins Children's Center, Baltimore, Maryland
| | | | - Philip Rosenthal
- University of California, San Francisco, San Francisco, California
| | - Saul Karpen
- Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | | | | | - Patricia R. Robuck
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Ronald J. Sokol
- University of Colorado School of Medicine and The Children's Hospital, Denver, Colorado
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Sokol RJ, Shepherd RW, Superina R, Bezerra JA, Robuck P, Hoofnagle JH. Screening and outcomes in biliary atresia: summary of a National Institutes of Health workshop. Hepatology 2007; 46:566-81. [PMID: 17661405 PMCID: PMC3888317 DOI: 10.1002/hep.21790] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biliary atresia is the most common cause of end-stage liver disease in the infant and is the leading pediatric indication for liver transplantation in the United States. Earlier diagnosis (<30-45 days of life) is associated with improved outcomes following the Kasai portoenterostomy and longer survival with the native liver. However, establishing this diagnosis is problematic because of its rarity, the much more common indirect hyperbilirubinemia that occurs in the newborn period, and the schedule for routine infant health care visits in the United States. The pathogenesis of biliary atresia appears to involve immune-mediated fibro-obliteration of the extrahepatic and intrahepatic biliary tree in most patients and defective morphogenesis of the biliary system in the remainder. The determinants of the outcome of portoenterostomy include the age at surgery, the center's experience, the presence of associated congenital anomalies, and the postoperative occurrence of cholangitis. A number of screening strategies in infants have been studied. The most promising are early measurements of serum conjugated bilirubin and a stool color card given to new parents that alerts them and their primary care provider to alcholic stools. This report summarizes a National Institutes of Health workshop held on September 12 and 13, 2006, in Bethesda, MD, that addressed the issues of outcomes, screening, and pathogenesis of biliary atresia.
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Affiliation(s)
- Ronald J Sokol
- Department of Pediatrics, University of Colorado School of Medicine, The Children's Hospital, Denver, CO, USA.
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Abstract
Untreated, biliary atresia remains a fatal condition of the newborn. Most present within four to six weeks of conjugated jaundice and acholic stools and, although still a challenging diagnosis to make, therein lies the opportunity of changing the course of this otherwise inexorable disease. The aim of surgery is to restore bile flow, alleviate jaundice and abbreviate the cholangiodestructive process within the liver. The Kasai portoenterostomy, introduced almost 50 years ago in Japan, aims to expose microscopic biliary ductules within the fibroinflammatory mass at the porta hepatis and restore bile drainage into a mobilised Roux loop. About 50% of infants with BA will be able to clear their jaundice following Kasai alone, given appropriately experienced surgeons and if performed prior to the onset of overt cirrhosis. They have a reasonable expectation of long-term survival to adulthood with a good quality-of-life. The remainder may be candidates for liver transplantation (where available) although donor organ shortage and immunosuppresion-related complications remain significant problems.
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Affiliation(s)
- Mark Davenport
- Department of Pediatric Surgery, King's College Hospital, London SE5 9RS, United Kingdom.
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Iorio R, Giannattasio A, Lamberti E, Della Corte C, Nicastro E, Spagnuolo MI. Hyper-gamma-glutamyltransferase is commonly present in non-breast-fed infants with biliary atresia successfully treated with portoenterostomy. Clin Chem 2006; 52:1430. [PMID: 16798967 DOI: 10.1373/clinchem.2006.068353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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