Liver biopsy in children: position paper of the ESPGHAN Hepatology Committee

Predicting and managing liver fibrosis in biliary atresia

Regardless of the underlying etiology and success of PE, progressive liver fibrosis and eventually cirrhosis represent the dominant pathology and the end-stage of BA. Ascending bile duct injury-induced cholestasis, inflammation and ductular reaction provide profibrogenic cytokine environment leading to myofibroblast activation and rapid progression of fibrosis especially after unsuccessful portoenterostomy. Although liver fibrosis and development of cirrhosis play a crucial role in determining BA outcomes, the exact prognostic significance and dynamics of mild to moderate liver fibrosis remain unclear. Manual scoring systems categorizing the degree of liver fibrosis are prone to intra- and interobserver variability, whereas novel combinations of digital pathology with artificial intelligence quantification can provide accurate information on fibrosis structure and dynamics at the level of individual collagen fibers. Although several studies have analyzed noninvasive assessment of fibrosis at time of PE, including imaging-based elastography and different serum biomarkers, current knowledge on their accuracy during the postoperative follow-up of BA is scarce. While therapeutic management of liver fibrosis in BA remains in its infancy, the resolution potential for liver fibrosis has been demonstrated after successful PE. Achievement of effective antifibrotic treatment may require combination of different therapies with complementary modes of action like anti-inflammatory medication, antioxidants and bile acid lowering agents.

Time-driven cost analysis of pediatric liver biopsy completed in pediatric sedation clinic and operating room

BACKGROUND

Pediatric ultrasound (US)-guided percutaneous liver biopsy is a commonly performed procedure in children, and may be performed in a variety of clinical settings. However, there is little research on the relative costs associated with different sedation methods and locations.

OBJECTIVE

This study uses time-driven activity-based costing (TDABC) to identify relevant costs associated with different biopsy sedation techniques and locations to help inform providers and patients as well as guide value-conscious care. This study analyzes the direct costs associated with pediatric liver biopsy performed in an OR versus a dedicated pediatric sedation clinic.

MATERIALS AND METHODS

A single-center retrospective review including data from consecutive procedures all completed by one board-certified interventional radiology physician between June 2021 and April 2024 was performed. Exclusion criteria included procedures with lack of timestamps (N = 3), and multiple procedures being completed causing a deviation from the standard pathway process (N = 19). Direct costs were calculated using cost capacity rates (CCR) and TDABC methodology. Propensity score matching between procedures performed in a sedation clinic versus an operating room (OR) was performed adjusting for age, gender, American Society of Anesthesiologists (ASA) status, and inpatient status, and subsequent matches were analyzed via paired t-test in SPSS.

RESULTS

A total of 111 procedures performed in the OR (N = 71) or sedation clinic (N = 40) were found and considered for analysis (N = 55 male, N = 56 female; mean age = 9.13, SD = 6.69 years). A technical success rate of 100% and a complication frequency of 5% (N = 3, mean = 13.67, SD = 2.05, all grade 1) were observed. Complication frequency was not statistically significant between the sedation clinic (N = 1) and OR (N = 2) groups (P = 0.28). After propensity matching, N = 58 matched procedures (OR, N = 29; sedation clinic, N = 29) were included. Pre-procedure times in the sedation clinic were shorter in duration (62.11 ± 42.25) than in the OR (111.96 ± 62.11, P < 0.001). Total procedure times were also shorter in duration in the sedation clinic (14.07 ± 4.99) than in the OR (21.76 ± 18.22, P = 0.03). In addition, procedures completed in the OR utilized additional anesthesia staff for an average of 72 min, contributing to overall cost. The average total included costs for matched liver biopsy procedures were $1,089.51 ± 384.34 in the sedation clinic and $2,801.36 ± 1,201.52 in the OR (P < 0.001).

CONCLUSIONS

Liver biopsies completed in the sedation clinic were associated with significantly lower direct costs and were not associated with higher complication rates. These findings provide evidence for promoting pediatric sedation clinics as a safe and cost-effective location to perform liver biopsies in appropriate patients.

Correlation Between Clinical Indicators and Liver Pathology in Children with Chronic Hepatitis B

Background: Chronic hepatitis B (CHB) in children presents a significant global health challenge, with liver inflammation and fibrosis being critical concerns for disease progression and long-term outcomes. Methods: This retrospective study analyzed 1629 pediatric CHB patients from the Fifth Medical Center of Chinese PLA General Hospital, spanning from January 2000 to December 2021. Liver biopsies were performed to assess the severity of liver inflammation and fibrosis, which were graded using the Scheuer scoring system. Key clinical indicators, including age, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT), were evaluated for their predictive value in determining disease severity using restricted cubic spline regression models. Results: Significant nonlinear associations were found between the clinical indicators and liver pathology. Older age was strongly associated with increased risks of moderate to severe inflammation (OR 2.21, 95% CI: 1.34-3.63, p = 0.002) and significant fibrosis (OR 2.22, 95% CI: 1.31-3.77, p = 0.003). Elevated ALT levels (≥80 U/L) were correlated with a higher likelihood of moderate to severe inflammation (OR 1.82, 95% CI: 1.05-3.15, p = 0.033), while higher GGT levels (≥50 U/L) were significantly associated with advanced fibrosis (OR 2.62, 95% CI: 1.72-3.99, p < 0.001). Conclusions: Regular monitoring of clinical indicators such as ALT, AST, and GGT levels plays a critical role in identifying pediatric CHB patients at higher risk of moderate to severe inflammation and significant fibrosis. Our findings highlight the value of integrating age and key biochemical markers into non-invasive diagnostic algorithms for the early detection and management of liver pathology in children.

Elastography-The New Standard in the Assessment of Fibrosis After Pediatric Liver Transplantation?

BACKGROUND

The development of graft fibrosis after pediatric liver transplantation (PLT) remains a major concern as it can lead to graft failure and ultimately graft loss. Elastography is a non-invasive method to assess liver fibrosis, but its role in the posttransplant setting is unclear. The aim of our study was to evaluate shear wave elastography (SWE) in the assessment of liver fibrosis after PLT, including split-liver recipients.

METHODS

We retrospectively analyzed data from PLT recipients who underwent surveillance liver biopsy and concurrent 2D-SWE during the study period from April 2018 to July 2021. Spearman's correlation was used to compare histologic fibrosis stages with liver stiffness measurements (LSM) by 2D-SWE. AUROC analysis was performed to evaluate the performance. One sample t-test was used to compare results with reference values of healthy children.

RESULTS

62 cases were included. 29% showed histologic fibrosis. LSM by 2D-SWE were feasible in all children regardless of age or graft type. There was a significant correlation between LSM and fibrosis stage for all three scoring systems used (Ishak, p = 0.003; METAVIR, p = 0.005; LAF Score, p = 0.003). Patients with a history of biliary complications had increased liver stiffness (p = 0.015). The AUROC of 2D-SWE for predicting significant liver graft fibrosis was 0.81. Liver stiffness after PLT without graft fibrosis was higher than in healthy subjects, but comparable to that in children with chronic liver disease without fibrosis.

CONCLUSION

2D-SWE can reliably detect children with significant liver graft fibrosis, even in split-liver recipients. This study demonstrates the value of a non-invasive tool for fibrosis staging after PLT. 2D-SWE has the potential to improve long-term outcomes after PLT and to reduce the number of surveillance liver biopsies. But elastography is not a substitute for liver biopsy.

Body-Mounted MR-Conditional Robot for Minimally Invasive Liver Intervention

MR-guided microwave ablation (MWA) has proven effective in treating hepatocellular carcinoma (HCC) with small-sized tumors, but the state-of-the-art technique suffers from sub-optimal workflow due to the limited accuracy provided by the manual needle insertions. This paper presents a compact body-mounted MR-conditional robot that can operate in closed-bore MR scanners for accurate needle guidance. The robotic platform consists of two stacked Cartesian XY stages, each with two degrees of freedom, that facilitate needle insertion pose control. The robot is actuated using 3D-printed pneumatic turbines with MR-conditional bevel gear transmission systems. Pneumatic valves and control mechatronics are located inside the MRI control room and are connected to the robot with pneumatic transmission lines and optical fibers. Free-space experiments indicated robot-assisted needle insertion error of 2.6 ± 1.3 mm at an insertion depth of 80 mm. The MR-guided phantom studies were conducted to verify the MR-conditionality and targeting performance of the robot. Future work will focus on the system optimization and validations in animal trials.

Semiautomated electronic medical record based system for monitoring delayed adverse events in pediatric endoscopy and sedation

OBJECTIVE

To develop a semiautomated electronic medical record (EMR) system to track pediatric endoscopic procedural adverse event (AE) at a tertiary referral children's hospital.

METHODS

We developed an automated EMR based query for postprocedure AEs. Main outcome measurements within 30 days of procedure: return to emergency department, return to surgery, unplanned admissions and admissions with longer than intended stays. Events were graded using a recently described classification system for postendoscopy events and tracked for a 36-month period, from January 2017 to December 2019.

RESULTS

Development of a semi-automated system was successful in comprehensive identification of endoscopy and sedation related AE. A total of 193 AEs (2%) were identified in all three categories. Seventy cases (0.7%) were noted to be a direct result of an endoscopic procedure. Of these cases, 31 (44%) were noted to be Grade 3, 5 cases (7%) Grade 4, and no Grade 5 AE occured. Higher rates of AE were observed after therapeutic procedures versus diagnostic (2.6% vs. 0.3%, p = <0.00001). AEs related to sedation occurred in 0.5% of procedures with the majority (84%) reported in patients with American Society of Anesthesia classification of 3 or greater.

CONCLUSIONS

Diagnostic endoscopy remains a safe procedure and risk of both endoscopy and sedation related AE are low. Therapeutic procedures carry a higher risk but are still overwhelmingly safe. Institutional investment in this EMR based system allowed for sustainability and comprehensive tracking of endoscopy related AE.

Expert Consensus on the Prevention and Treatment of Chronic Hepatitis B in Children

The aim of this consensus is to standardize the prevention, diagnosis, and treatment of chronic hepatitis B in children and to achieve the goal of “eliminating viral hepatitis as a major public health threat by 2030” issued by the World Health Organization. Formulated by organized experts of the Chinese Society of Infectious Diseases and Chinese Society of Hepatology, Chinese Medical Association; Group of Infectious Diseases, Chinese Pediatric Society, Chinese Medical Association; and the National Clinical Research Center for Infectious Diseases (Beijing), the consensus provides the latest evidence and recommendations for the prevention, diagnosis, and treatment of chronic hepatitis B in children.

Development of Fibro-PeN, a clinical prediction model for moderate-to-severe fibrosis in children with nonalcoholic fatty liver disease

BACKGROUND AND AIMS

Liver fibrosis is common in children with NAFLD and is an important determinant of outcomes. High-performing noninvasive models to assess fibrosis in children are needed. The objectives of this study were to evaluate the performance of existing pediatric and adult fibrosis prediction models and to develop a clinical prediction rule for identifying moderate-to-severe fibrosis in children with NAFLD.

APPROACH AND RESULTS

We enrolled children with biopsy-proven NAFLD in the Nonalcoholic Steatohepatitis Clinical Research Network within 90 days of liver biopsy. We staged liver fibrosis in consensus using the Nonalcoholic Steatohepatitis Clinical Research Network scoring system. We evaluated existing pediatric and adult models for fibrosis and developed a new pediatric model using the least absolute shrinkage and selection operator with linear and spline terms for discriminating moderate-to-severe fibrosis from none or mild fibrosis. The model was internally validated with 10-fold cross-validation. We evaluated 1055 children with NAFLD, of whom 26% had moderate-to-severe fibrosis. Existing models performed poorly in classifying fibrosis in children, with area under the receiver operator curves (AUC) ranging from 0.57 to 0.64. In contrast, our new model, fibrosis in pediatric NAFLD was derived from fourteen common clinical variables and had an AUC of 0.79 (95% CI: 0.77-0.81) with 72% sensitivity and 76% specificity for identifying moderate-to-severe fibrosis.

CONCLUSION

Existing fibrosis prediction models have limited clinical utility in children with NAFLD. Fibrosis in pediatric NAFLD offers improved performance characteristics for risk stratification by identifying moderate-to-severe fibrosis in children with NAFLD.

Liver fibrosis assessment in pediatric population - can ultrasound elastography be an alternative method to liver biopsy? A systematic review

Liver diseases of various etiologies are becoming increasingly common in the pediatric population. So far, the gold diagnostic standard in these disorders is liver biopsy. This procedure is invasive, painful and requires general anesthesia in this group of patients. Due to the continuous development of new research techniques, such as liver elastography, it is necessary to evaluate them in the context of their diagnostic usefulness. Ultrasound elastography, as a quick and effective method, is being used more and more often in the assessment and monitoring of liver dysfunction in both adults and children. There are several techniques of liver elastography, such as transient elastography, shear wave elastography consisting of various subtypes such as two-dimensional shear wave elastography, acoustic radiation force impulse and point shear wave elastography, which differ in terms of the measurement technique and the achieved results. The purpose of our review was to determine whether techniques of liver elastography could replace liver biopsy. Although now, based on the analyzed papers, elastography cannot replace liver biopsy, in our opinion, the role of this tool in monitoring pediatric patients with liver diseases will grow in the coming years.

Pediatricians' practices and knowledge of metabolic dysfunction-associated steatotic liver disease: An international survey

OBJECTIVE

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of chronic liver disease in children. It is associated with significant intra- and extrahepatic comorbidity. Current guidelines lack consensus, potentially resulting in variation in screening, diagnosis and treatment practices, which may lead to underdiagnosing and/or insufficient treatment. The increasing prevalence of MASLD and associated long-term health risks demand adequate clinical management and consensus in guidelines. This study aims to evaluate the daily practices of pediatricians in screening, diagnosis and treatment of MASLD in children.

METHODS

An online survey with 41 questions (single/multiple response options) was sent to pediatricians (with/without subspecialty) in Europe and Israel, via members of the ESPGHAN Fatty Liver Special Interest Group, between June and November 2022. The 454 pediatricians were included in this study.

RESULTS

51% of pediatricians indicated using any guideline for diagnosis and treatment of MASLD, with 68% reporting to follow recommendations only partially. 63% is of the opinion that guidelines need revision. The majority of pediatricians screen for MASLD with liver function tests and/or abdominal ultrasound. A large variety of treatment options is utilized, including lifestyle management, supplements and probiotics, with a notable 34% of pediatricians prescribing pharmacotherapy. When asked how often pediatricians request a liver biopsy in children with MASLD, 17% indicates they request a liver biopsy in more than 10% of cases.

CONCLUSIONS

There is limited awareness and considerable variation in screening, diagnosis and treatment practices among European pediatricians, and a clear demand for new, uniform guidelines for MASLD in children.

Liver Biopsy Handling of Metabolic-Associated Fatty Liver Disease (MAFLD): the Children's Hospital of Eastern Ontario grossing protocol

Metabolic-(non-alcoholic) associated fatty liver disease (MAFLD/NAFLD) has increasingly become a worldwide epidemic. It has been suggested that renaming NAFLD to MAFLD is critical in identifying patients with advanced fibrosis and poor cardiovascular outcomes. There are concerns that the progression to non-alcoholic steatohepatitis (NASH) may become a constant drive in the future healthcare of children and adolescents. There is a necessity to tackle the emerging risk factors for NASH-associated hepatocellular carcinoma (HCC). In this narrative review, we present the current protocol of liver biopsy separated between pre-analytical, analytical, and post-analytical handling. Genetic association investigations have identified single nucleotide polymorphisms implicated in the progression of MAFLD-HCC, many of which seem to belong to the lipid metabolism pathways. PNPLA3 rs738409 variant, TM6SF2 rs58542926 variant, MBOAT7 rs641738 variant, and GCKR variants seem to be significantly associated with NAFLD disease susceptibility. In disclosing the current comprehensive protocol performed at the Children's Hospital of Eastern Ontario, Ottawa, ON, Canada, we support the most recent Kulkarni-Sarin's pledge to rename NAFLD to MAFLD. Grossing of the liver biopsy is key to identifying histologic, immunophenotypical, and ultrastructure data and properly preserving tissue for molecular genomics data.

Paediatric liver biopsies: A single-centre experience in Erzincan Binali Yıldırım University

Introduction

Liver biopsies are the main method in the diagnosis and treatment of paediatric liver pathologies. Major complication rates of paediatric liver biopsies range from 0% to 6.6% in the literature and minor complication rates range from 0% to 25%. In this study, we aimed to review the complications, indications and results of percutaneous core liver biopsies with paediatric sonography in a tertiary care centre by an interventional radiologist.

Methods

We retrospectively evaluated the results, indications and complications of paediatric liver biopsies performed in our tertiary health centre between January 2017 and December 2020. Biopsies were performed with a 16G semi-automatic needle in 17 patients (29.8%) and with an 18G semi-automatic needle in 40 patients (70.2%). Biopsies were performed only with local anaesthesia in patients older than 12 years; in younger patients, it was performed under general anaesthesia.

Results

Fifty-eight liver biopsies were obtained from 57 children (34 males, 23 females). The most common indications were elevated liver enzymes (33 patients), cholestasis (14 patients), and adiposity and metabolic problems (6 patents). The most common pathological diagnoses were chronic hepatitis (33 patients) and steatosis (10 patients). Major complication in the form of symptomatic subcapsular haematoma developed after liver biopsy performed with 18G needle in only one patient (1.8%).

Conclusions

As previously stated in the literature, percutaneous biopsies performed by interventional radiologists in paediatric patients under the guidance of sonography can be used in diagnosis and treatment; the complication rate is low and it is a safe method.

Quick, Safe, Effective: Ultrasound-Guided Percutaneous Liver Biopsy in the Pediatric Patient

BACKGROUND

Percutaneous liver biopsy has proven to be a valuable tool in the workup of pediatric acute liver failure and the management of post-transplant rejection. However, consensus regarding pre-procedure laboratory values and post-procedure monitoring is lacking.

OBJECTIVE

To characterize the incidence of complications, procedural time, and specimen adequacy for percutaneous liver biopsy in the pediatric patient.

METHODS

Retrospective review of percutaneous liver biopsies at a single institution was performed for a 5-year span. Procedural notes and anesthesia records were sampled for patient weight and procedural factors across a continuous 6-month period, as well as for the subgroup of patients under 24 months of age. A representative continuous subset of pathology reports comprising 376 patients were reviewed for estimation of specimen adequacy.

RESULTS

Eight hundred and sixty-seven ultrasound-guided percutaneous liver biopsies were performed in a 5-year period, 450 of which were in the post-transplant setting with about a 3:1 ratio of split: whole liver transplant. Patient ages ranged from 1 month to 21 years old, with weight ranging from 2.7 to 125 kg. Of the 376 pathology reports available, none were found to be inadequate for evaluation. Two major complications occurred, both of which were biliary leaks in the setting split-liver transplant. There were no incidences of post-procedure hemorrhage. Of the sample reviewed, mean "skin-to-skin" procedure time was under 8.5 min (median of 7 min). Solely among transplant patients, biopsies for split livers averaged 9.2 min, biopsies for whole livers averaged 6.2 min (two-tailed independent t test, p = 0.0426).

CONCLUSION

Ultrasound guided percutaneous liver biopsy is fast, useful, and safe in pediatric patients on an outpatient basis with same day discharge.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Pathologic approach to Neonatal cholestasis with a simple scoring system for biliary atresia

A liver biopsy is essential for the diagnostic workup of persistent neonatal cholestasis (NC). The differential diagnosis of NC is broad, including obstructive and non-obstructive causes. In addition, histologic features of certain disorders may be non-specific in the early course of the disease. To evaluate liver biopsies using a practical histopathologic approach for NC and to define a simple scoring system for biliary atresia (BA) for routine clinical practice. From June 2006 to December 2021, liver biopsy specimens from infants with persistent NC were examined by two independent pathologists. The cases diagnosed as BA were correlated with clinical, radiologic, and laboratory data to calculate the final score. Four hundred and fifty-nine cases were enrolled in the study. They had a mean age of 63.94 ± 20.62 days and were followed for a median time of 58 (1-191) months. They included 162 (35.3%) cases of BA. On multivariate analysis, portal edema, ductular proliferation, cholangiolitis, and bile duct/ductular plugs were the histopathologic predictors of BA. A liver biopsy did perform well with a 95.1% sensitivity, 91.6% specificity, 86% PPV, and 97.1% NPV. At a cutoff of 5 of the scoring system, diagnosis of BA could be done with a sensitivity of 95.1% and a specificity of 100%. We have shown detailed histopathologic features of BA with more depth to infants aged ≤ 6 weeks. We have developed a simple scoring system using a combination of liver biopsy with non-invasive methods to increase the diagnostic accuracy of BA.

Noninvasive scores are poorly predictive of histological fibrosis in paediatric fatty liver disease

OBJECTIVES

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in children. Roughly a quarter of paediatric patients with NAFLD develop nonalcoholic steatohepatitis and fibrosis. Here, we evaluated the diagnostic accuracy of previously published noninvasive fibrosis scores to predict liver fibrosis in a large European cohort of paediatric patients with NAFLD.

METHODS

The 457 patients with biopsy-proven NAFLD from 10 specialized centers were included. We assessed diagnostic accuracy for the prediction of any (F ≥ 1), moderate (F ≥ 2) or advanced (F ≥ 3) fibrosis for the AST/platelet ratio (APRI), Fibrosis 4 score (FIB-4), paediatric NAFLD fibrosis score (PNFS) and paediatric NAFLD fibrosis index (PNFI).

RESULTS

Patients covered the full spectrum of fibrosis (F0: n = 103; F1: n = 230; F2: n = 78; F3: n = 44; F4: n = 2). None of the scores were able to accurately distinguish the presence of any fibrosis from no fibrosis. For the detection of moderate fibrosis, area under the receiver operating characteristic curve (AUROC) were: APRI: 0.697, FIB-4: 0.663, PNFI: 0.515, PNFS: 0.665, while for detection of advanced fibrosis AUROCs were: APRI: 0.759, FIB-4: 0.611, PNFI: 0.521, PNFS: 0.712. Fibrosis scores showed no diagnostic benefit over using ALT ≤ 50/ > 50 IU/L as a cut-off.

CONCLUSIONS

Established fibrosis scores lack diagnostic accuracy to replace liver biopsy for staging of fibrosis, giving similar results as compared to using ALT alone. New diagnostic tools are needed for Noninvasive risk-stratification in paediatric NAFLD.

Expert management of congenital portosystemic shunts and their complications

Congenital portosystemic shunts are often associated with systemic complications, the most challenging of which are liver nodules, pulmonary hypertension, endocrine abnormalities, and neurocognitive dysfunction. In the present paper, we offer expert clinical guidance on the management of liver nodules, pulmonary hypertension, and endocrine abnormalities, and we make recommendations regarding shunt closure and follow-up.

Technical Success, Sample Adequacy, and Complications of Pediatric Transjugular Liver Biopsy: A Systematic Review and Meta-Analysis

BACKGROUND

Transjugular liver biopsy (TJLB) procedurally samples liver tissue through the internal jugular vein. It is indicated in the presence of coagulopathies and/or ascites.

AIMS

This meta-analysis aimed to assess the safety and efficacy of TJLB in children.

METHODS

A literature search of several databases was conducted from inception to August 2022. Eligible studies reported pediatric patients (< 18 years old) who underwent TJLB. The pooled proportion was analyzed using a random-effects model. This review was registered in PROSPERO (CRD42022354421).

RESULTS

From 921 initial studies screened, eight met the eligibility criteria, with a total of 361 pediatric patients who underwent 374 TJLBs. All eight studies reported pooled rates of technical success at 99.1% (95% CI 0.982, 1.001; I2 = 0%) and histological adequacy of sampling at 97.5% (95% CI 0.954, 0.995; I2 = 27.66%). A total of 49 complications were reported across six studies, the most common being bleeding from the entry site (38.78%), fevers for less than 24 h (12.24%), red blood cells transfusion requirement (10.2%), supraventricular tachycardia (8.16%), and pain requiring analgesia (8.16%).

CONCLUSION

Pediatric TJLB demonstrates high rates of technical success and adequate liver core biopsy samples, with a low rate of complications. These results suggest that TJLB is an effective method for diagnostic yield and postprocedural outcomes, especially in patients with preexisting coagulopathies and ascites where percutaneous liver biopsy is contraindicated. Additional studies evaluating larger groups of pediatric patients may provide further support for the use of TJLB in this population.

Critical elements of pediatric liver cancer surgery

The appropriate management of pediatric liver malignancies, primarily hepatoblastoma and hepatocellular carcinoma, requires an in depth understanding of contemporary preoperative risk stratification, experience with advanced hepatobiliary surgery, and a good relationship with one's local or regional liver transplant center. While chemotherapy regimens have become more effective, operative indications more well-defined, and overall survival improved, the complexity of liver surgery in small children provides ample opportunity for protocol violation, inadequate resection, and iatrogenic morbidity. These guidelines represent the distillation of contemporary literature and expert opinion as a means to provide a framework for preoperative planning and intraoperative decision-making for the pediatric surgeon.

Pediatric liver cirrhosis interventional procedures: from biopsy to transjugular intrahepatic portosystemic shunt

Cirrhosis is a complex diffuse process whereby the architecture of the liver is replaced by abnormal nodules because of the presence of fibrosis. Several pediatric diseases such as extrahepatic portal vein obstruction, biliary atresia, alpha-1-antitrypsin deficit and autoimmune hepatitis can lead to cirrhosis and portal hypertension in children. In this article the authors describe interventional radiology procedures that can facilitate the diagnosis and treatment of diseases associated with liver cirrhosis and portal hypertension in the pediatric population. These procedures include image-guided liver biopsy, mesenteric-intrahepatic left portal vein shunts, balloon-occluded retrograde transvenous obliteration, transjugular intrahepatic portosystemic shunts and splenic embolization.

Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD)

Nonalcoholic fatty liver disease (NAFLD) is a major cause of chronic liver disease globally and in India. The already high burden of NAFLD in India is expected to further increase in the future in parallel with the ongoing epidemics of obesity and type 2 diabetes mellitus. Given the high prevalence of NAFLD in the community, it is crucial to identify those at risk of progressive liver disease to streamline referral and guide proper management. Existing guidelines on NAFLD by various international societies fail to capture the entire landscape of NAFLD in India and are often difficult to incorporate in clinical practice due to fundamental differences in sociocultural aspects and health infrastructure available in India. A lot of progress has been made in the field of NAFLD in the 7 years since the initial position paper by the Indian National Association for the Study of Liver on NAFLD in 2015. Further, the ongoing debate on the nomenclature of NAFLD is creating undue confusion among clinical practitioners. The ensuing comprehensive review provides consensus-based, guidance statements on the nomenclature, diagnosis, and treatment of NAFLD that are practically implementable in the Indian setting.

Prevalence and Significance of Autoantibody Seropositivity in Children with Wilson's Disease

Autoantibodies occur in healthy subjects as well as in children with Wilson's disease (WD), but their prevalence and significance are unknown. Thus, we aimed to assess the prevalence of autoantibodies and autoimmune markers, and their relationship to liver injury in WD children. The study included 74 WD and 75 healthy children as a control group. Patients with WD underwent transient elastography (TE) examinations, as well as determination of liver function tests, copper metabolism markers, and serum immunoglobulins (Ig). In the sera of the WD patients and controls, anti-nuclear (ANA), anti-smooth muscle, anti-mitochondrial, anti-parietal cell, anti-liver/kidney microsomal, anti-neutrophil cytoplasmic autoantibodies, and specific celiac antibodies were determined. Among the autoantibodies, only the prevalence of ANA in children with WD was higher than in the controls. There was no significant relationship between the presence of autoantibodies and liver steatosis or stiffness after TE. However, advanced liver stiffness (E > 8.2 kPa) was related to IgA, IgG, and gamma globulin production. The type of treatment did not influence the prevalence of autoantibodies. Our results suggest that autoimmune disturbances in WD might not be directly related to liver damage as expressed by steatosis and/or liver stiffness after TE.

The Ultrastructure of Hepatic Stellate Cell-Macrophage Intercellular Crosstalk as a New Morphological Insight into Phenomenon of Fibrogenesis in Pediatric Autoimmune Hepatitis

The aim of the study was the pioneering retrospective ultrastructural evaluation of respective forms of hepatic stellate cells (HSCs) and analysis of their crosstalk with other adjacent nonparenchymal cells (NPCs), especially Kupffer cells/macrophages (KCs/MPs), in pediatric autoimmune hepatitis (AIH).

METHODS

Ultrastructural assessment of the HSC population and NPCs was performed in transmission electron microscopy (TEM) using pretreatment liver biopsies from 25 children (8 boys and 17 girls) aged 4-17 with clinic-pathologically diagnosed untreated AIH.

RESULTS

Submicroscopic evaluation allowed easy identification of numerous HSCs in the form of transitory cells, i.e., T-HSCs, accompanied by signs of fibrosis. T-HSCs included cells with features of activation initiation (iHSCs) and activation perpetuation (pHSCs), indicating high HSC activation plasticity. The pHSCs were markedly elongated and mainly showed a distinct loss of lipid cytoplasmic material, expanded and dilated channels of granular endoplasmic reticulum, and linear bundles of microfilaments beneath the cell membrane. They were surrounded by usually mature collagen fibers. Frequently activated KCs/MPs adhered directly to T-HSCs. Between them, tight intercellular junctions were formed by means of point desmosomes.

CONCLUSIONS

Our qualitative TEM observations indicate a key role of T-HSCs in liver fibrogenesis in pediatric AIH, with the essential involvement of activated KCs/MPs that directly adhere to them. Tight intercellular junctions, being the ultrastructural exponent of the specific cellular mechanisms of the crosstalk between NPCs, can play a vital role in hepatic collagen fibroplasia. A better understanding of HSC population morphology at the ultrastructural level in AIH seems important not only to improve the disease morphological diagnostics but to also provide new insights into therapeutic interventions for the phenomenon of liver fibrogenesis.

Relative Enhancement in Gadoxetate Disodium-Enhanced Liver MRI as an Imaging Biomarker in the Diagnosis of Non-Alcoholic Fatty Liver Disease in Pediatric Obesity

Relative enhancement (RE) in gadoxetate disodium (Gd-EOB-DTPA)-enhanced MRI is a reliable, non-invasive method for the evaluation and differentiation between simple steatosis and non-alcoholic steatohepatitis in adults. This study evaluated the diagnostic accuracy of RE in Gd-EOB-DTPA-enhanced liver MRI and hepatic fat fraction (HFF) in unenhanced liver MRI and ultrasound (US) for non-alcoholic fatty liver disease (NAFLD) screening in pediatric obesity. Seventy-four liver US and MRIs from 68 pediatric patients (13.07 ± 2.95 years) with obesity (BMI > BMI-for-age + 2SD) were reviewed with regard to imaging biomarkers (liver size, volume, echogenicity, HFF, and RE in Gd-EOB-DTPA-enhanced MRIs, and spleen size), blood biomarkers, and BMI. The agreement between the steatosis grade, according to HFF in MRI and the echogenicity in US, was moderate. Alanine aminotransferase correlated better with the imaging biomarkers in MRI than with those in US. BMI correlated better with liver size and volume on MRI than in US. In patients with RE < 1, blood biomarkers correlated better with RE than those in the whole sample, with a significant association between gamma-glutamyltransferase and RE (p = 0.033). In conclusion, the relative enhancement and hepatic fat fraction can be considered as non-invasive tools for the screening and follow-up of NAFLD in pediatric obesity, superior to echogenicity on ultrasound.

Wilson Disease and Alpha1-Antitrypsin Deficiency: A Review of Non-Invasive Diagnostic Tests

Wilson disease and alpha1-antitrypsin deficiency are two rare genetic diseases that may impact predominantly the liver and/or the brain, and the liver and/or the lung, respectively. The early diagnosis of these diseases is important in order to initiate a specific treatment, when available, ideally before irreversible organ damage, but also to initiate family screening. This review focuses on the non-invasive diagnostic tests available for clinicians in both diseases. These tests are crucial at diagnosis to reduce the potential diagnostic delay and assess organ involvement. They also play a pivotal role during follow-up to monitor disease progression and evaluate treatment efficacy of current or emerging therapies.

Noninvasive Prediction of Advanced Fibrosis in Pediatric Liver Disease-Discriminatory Performance of 2D Shear Wave Elastography, Transient Elastography and Magnetic Resonance Elastography in Comparison to Histopathology

Background: Elastography can be measured with different imaging techniques and is increasingly used for noninvasive assessment of hepatic fibrosis. Little is known about the performance, and interrelation of different elastographic techniques, in prediction of hepatic fibrosis in pediatric liver disease. Objectives: We aimed to determine the discriminatory value for advanced fibrosis (Metavir F3-4) and evaluate the applicability of 2D shear wave ultrasound elastography (USe), Transient Elastography (TE) and Magnetic Resonance elastography (MRe) in pediatric liver disease. Methods: In patients with pediatric liver disease aged 0−19 years, USe, TE and MRe were compared with histopathological fibrosis stage. Multivariate logistic regression models for advanced fibrosis were considered. Discriminative performance was assessed by the area under the receiver operating characteristic curve and the Brier Score. Primary analyses included complete cases. Multiple imputation was used as sensitivity analysis. Results: In 93 histologically evaluated patients USe, TE and MRe were performed 89, 93 and 61 times respectively. With increased liver stiffness values, significantly increased odds for presenting F3-4 were seen in individual models for ALT < 470 U/L, whereas the effect for ALT > 470 U/L was non-significant. Area under the curve and Brier Score for discrimination of advanced fibrosis were 0.798 (0.661−0.935) and 0.115 (0.064−0.166); 0.862 (0.758−0.966) and 0.118 (0.065−0.171); 0.896 (0.798−0.994) and 0.098 (0.049−0.148) for USe, TE and MRe respectively. No significant increase in discriminatory ability was found when combining elastographic modalities. Conclusions: In pediatric liver disease, USe, TE and MRe had a good discriminatory ability for assessment of advanced liver fibrosis, although TE and MRe performed best. In most children with pediatric liver disease, TE is a reliable and easily applicable measure.

Rotational thromboelastometry-guided blood component use in cirrhotic children undergoing invasive procedures: Randomized controlled trial

BACKGROUND & AIMS

This randomized controlled trial (RCT) was conducted with the aim to evaluate the efficacy and safety of using ROTEM-based transfusion strategy in cirrhotic children undergoing invasive procedures.

METHODS

This was an open-label, RCT which included (i) children under 18 years of age with liver cirrhosis; (ii) INR between 1.5 and 2.5; and/or (iii) platelet count between 20 × 10⁹ /L and 50 × 10⁹ /L (for procedures other than liver biopsy) and between 40 × 10⁹ /L and 60 × 10⁹ /L (for liver biopsy); and (iv) listed for invasive procedures. Stratified randomization was done for children undergoing liver biopsies. Patients randomized to the ROTEM and conventional groups received blood component transfusion using predefined criteria.

RESULTS

A total of 423 invasive procedures were screened for inclusion of which 60 were randomized (30 in each group with comparable baseline parameters). The volume of total blood components, fresh frozen plasma (FFP) and platelets transfused was significantly lower in ROTEM as compared to conventional group. Only 46.7% of children in ROTEM group received a blood component compared to 100% in conventional group (p < .001). The requirement of FFP (ROTEM: 43.3%, Conventional: 83.3%, p = .001) was significantly lower in the patients receiving ROTEM-guided transfusions. There was no difference in procedure-related bleed and transfusion-related complications between the two groups. ROTEM was cost-effective (p = .002) despite the additional cost of the test.

CONCLUSION

ROTEM-based transfusion strategies result in lower blood component transfusion in cirrhotic children undergoing invasive procedures without an increase in risk of procedure-related bleed. ROTEM-guided transfusion strategy is cost-effective.

Consensus on the management of complications of cirrhosis of the liver in pediatrics

The Asociación Mexicana de Hepatología A.C. carried out the Consensus on the Management of Complications of Cirrhosis of the Liver in Pediatrics to provide physicians with useful information for treating said complications. A group of pediatric gastroenterologists and experts in nutrition, nephrology, and infectious diseases participated and reviewed the medical literature. The Delphi method was applied to obtain the level of agreement on the statements that were formulated. The statements were sent to the participants to be analyzed and voted upon, after which they were discussed in virtual sessions, and the final versions were produced. The aim of the consensus results was to issue indications for the management of pediatric patients with liver cirrhosis, to prevent or control complications.

Drug-induced Liver Injury in Pediatrics

Drug-induced liver injury (DILI) is a rare, underdiagnosed cause of liver disease in children. The incidence of DILI in the pediatric population is unknown but it represents around 10% of all DILI cases. The most common hepatotoxic drugs in children are antibiotics and antiepileptics. DILI is classified as intrinsic or idiosyncratic and it presents mostly with 2 patterns of injury: hepatocellular or cholestatic. Diagnosis can be done with help of the Roussel Uclaf Causality Assessment Method (RUCAM) casualty assessment. The mainstay of treatment is prompt withdrawal of the suspect drug.

Use of shear wave elastography for the diagnosis and follow-up of biliary atresia: A meta-analysis

BACKGROUND

Timely differentiation of biliary atresia (BA) from other infantile cholestatic diseases can impact patient outcomes. Additionally, non-invasive staging of fibrosis after Kasai hepatoportoenterostomy has not been widely standardized. Shear wave elastography is an ultrasound modality that detects changes in tissue stiffness. The authors propose that the utility of elastography in BA can be elucidated through meta-analysis of existing studies.

AIM

To assess the utility of elastography in: (1) BA diagnosis, and (2) post-Kasai fibrosis surveillance.

METHODS

A literature search identified articles that evaluated elastography for BA diagnosis and for post-Kasai follow-up. Twenty studies met criteria for meta-analysis: Eleven for diagnosis and nine for follow-up post-Kasai. Estimated diagnostic odds ratio (DOR), sensitivity, and specificity of elastography were calculated through a random-effects model using Meta-DiSc software.

RESULTS

Mean liver stiffness in BA infants at diagnosis was significantly higher than in non-BA, with overall DOR 24.61, sensitivity 83%, and specificity 79%. Post-Kasai, mean liver stiffness was significantly higher in BA patients with varices than in patients without, with DOR 16.36, sensitivity 85%, and specificity 76%. Elastography differentiated stage F4 fibrosis from F0-F3 with DOR of 70.03, sensitivity 96%, and specificity 89%. Elastography also differentiated F3-F4 fibrosis from F0-F2 with DOR of 24.68, sensitivity 85%, and specificity 81%.

CONCLUSION

Elastography has potential as a non-invasive modality for BA diagnosis and surveillance post-Kasai. This paper’s limitations include inter-study method heterogeneity and small sample sizes. Future, standardized, multi-center studies are recommended.

Epidemiology and Natural History of Childhood-Acquired Chronic Hepatitis C: A Single-Center Long-Term Prospective Study

OBJECTIVES

To prospectively describe the epidemiology and long-term outcome of childhood-acquired hepatitis C virus (HCV) infection in a large cohort of children followed at a single center.

METHODS

All children with chronic HCV infection followed at the Liver Unit of our tertiary Hospital in Florence (Italy) from January 1, 1988, to September 30, 2021, were included in the analysis.

RESULTS

The final sample consisted of 163 children (median age at enrollment 4 years, interquartile range (IQR): 10; median age at last follow-up 14 years, IQR: 7). The median duration of follow-up was 86 months (IQR: 112). One hundred twenty-five children were vertically infected and 26 acquired the infection horizontally. Twenty-six of the 125 children who were vertically infected (20.8%) underwent spontaneous clearance of HCV RNA at a median age of 4 years (IQR: 2), whereas all the others remained persistently viremic. One patient was diagnosed with cirrhosis; 2 presented clinically detectable extrahepatic manifestations (chronic urticaria). Thirty-two children (19.6%) received antiviral therapy: 8 out of 32 (25%) were treated with pegylated-interferon alfa-2b [sustained virological response (SVR) 24 weeks after the end of treatment in 7/8]; 24 out of 32 (75%) were treated with direct-acting antivirals (SVR 12 weeks after the end of treatment in 23/24).

CONCLUSIONS

The present study describes the largest cohort of children with chronic HCV infection prospectively evaluated with a long follow-up at a single center. HCV infection in children is often a chronic infection that can be cured with modern antiviral therapy. Early treatment could prevent the development of advanced liver disease.

Shear wave elastography options in the integrated assessment of liver parenchyma in children

Introduction. Chronic liver diseases in children are accompanied by fibrocirrhotic transformation of the organ. Modern ultrasound diagnostic procedures offer a method that can differentiate between the fibrous and unchanged tissues. The paper includes the results of a study of liver stiffness in healthy children using shear wave elastography. The method presented in the article can come to an active use in the non-invasive detection of fibrosis as part of the integrated assessment of liver in pediatric practice. Aim. To study the stiffness of unchanged liver in children of different gender and age groups.

Materials and methods. Shear wave elastography was performed in 200 healthy children aged 3 to 18 years (103 girls and 97 boys) using Aixplorer apparatus (Supersonic Imagine, France), in three age subgroups: a 3- to 6-year-old group (n = 103), a 7- to 11-year-old group (n = 52), and a 12- to 18-year-old group (n = 45). The measurements were taken in different segments of the right lobe of the liver, in the area free from the vascular structures, fixing the zone of scanning at the depth of 3-5 cm from the capsule. Not less than 10 measurements were made, which enabled to calculate the mean value of liver elasticity.

Results. The study identified the liver stiffness measurement normal range in a group of healthy children. Significant differences in liver stiffness were obtained by comparing the values of 3- to 6- year-old and 7- to 11-year-old groups (P = 0.001); 3- to 6-year-old and 12- to 18-year-old groups (P = 0.001); there were no statistically significant differences in the stiffness values depending on gender (P = 0.345).

Conclusions. Young modulus values obtained may be used as normative. The use of shear wave elastography enhances the accuracy of the conventional ultrasound examination in identifying patients with liver disease.

Pediatric Acute Liver Failure: A Clinicopathological Perspective

Pediatric acute liver failure (PALF) is a life-threatening disorder characterized by acute hepatocellular injury occurring in children without recognized underlying liver disease. The clinicopathologic evaluation of PALF requires a different approach from that in adults. The diagnostic considerations differ depending on the age, personal and family history, geographical region, and clinical presentation. Distinct entities such as gestational alloimmune liver disease, herpes simplex virus infection, and metabolic disorders should be considered in neonates with acute liver failure, while acetaminophen toxicity and autoimmune hepatitis are more frequently seen in older children and adolescents. An identified cause for PALF despite a negative complete evaluation (indeterminate) is lacking in 30 to 50% of cases. Although not routinely performed in the setting of PALF, liver biopsy may be helpful in assessing the etiology, potential mechanisms of injury, determining the appropriateness of liver transplantation, and prognostication of the patients. In this article, we review the clinicopathologic characteristics of PALF with an emphasis on general approach of pathologic evaluation and histopathologic characteristic of selected entities.

Diagnostic performance of 2D-shear wave elastography and serum fibrosis markers for evaluation of hepatic graft fibrosis in pediatric liver-inclusive transplant recipients: A prospective pilot study

BACKGROUND

Liver biopsy is the gold standard for hepatic fibrosis staging, but it is invasive and has potential severe complications. We aimed to determine the diagnostic performance of 2D-SWE and serum markers to predict significant hepatic graft fibrosis (≥F2) in pediatric liver-inclusive transplant recipients.

METHODS

This prospective, cross-sectional pilot study included children younger than 19 years who had received a LT or LSBT and underwent a liver biopsy performed for clinical indications. LS was measured using 2D-SWE. The AUROC was calculated to evaluate the diagnostic performance of 2D-SWE and biomarkers (AST/ALT ratio, APRI, FIB4) for predicting significant fibrosis.

RESULTS

Twenty-two children (13 males, 8 LSBT) were included. Eighteen (81.8%) children received a whole liver graft. Thirteen (59.1%) patients had hepatic fibrosis (≥F1) and four (18.2%) had significant fibrosis. The AUROCs of AST/ALT ratio, APRI, and FIB4 for predicting significant hepatic graft fibrosis were 0.71 (p = .29), 0.85 (p = .0001), and 0.76 (p = .03), respectively. When FIB4 was calculated using the hepatic graft's age, its AUROC improved to 0.85 (p < .0001). The AUROC of 2D-SWE for predicting significant hepatic graft fibrosis was 0.80 (p = .046). When 2D-SWE was combined with APRI or FIB4, its AUROC improved to 0.82 (p = .08) and 0.87 (p = .002), respectively.

CONCLUSIONS

APRI and FIB4 can accurately predict significant hepatic graft fibrosis. 2D-SWE may serve as a valuable adjunct tool to detect significant graft fibrosis, especially when combined with these serum markers.

Hematological and biochemical characteristics and diagnostic imaging results in acute T cell-mediated rejection after pediatric liver transplantation

BACKGROUND

Liver biopsy is the gold standard for diagnosing TCMR after LT. However, complications caused by liver biopsy may occur especially during the immediate post-transplantation period and other effective methods for predicting TCMR have not been established. Thus, we investigated whether hematological and biochemical characteristics and Doppler ultrasonography findings are associated with acute TCMR.

METHODS

A multiple logistic regression analysis was performed to identify the prognostic factors of acute TCMR, defined as a RAI ≥4. Then, a ROC curve analysis was conducted to evaluate for diagnostic performance. The relationship between prognostic factors and each histological category of RAI was investigated.

RESULTS

Eighty-nine liver biopsies were performed on 85 patients between January 2012 and December 2019. The RAI of 62 (69.7%) liver biopsies was ≥4. AEC (×10⁴ /μl), direct bilirubin level (mg/dl), and MHVV (cm/s) were found to be associated with acute TCMR (OR: 4.96, 95% CI: 1.44-17.0, p = .011; OR: 1.41, 95% CI: 1.04-1.91, p = .025; OR: 1.05, 95% CI: 1.02-1.08, p < .001, respectively). The area under the ROC curves for predicting acute TCMR was 0.86 (95% CI: 0.78-0.94). There was a correlation between AEC, direct bilirubin level, and MHVV as well as the severity of RAI.

CONCLUSIONS

AEC, direct bilirubin level, and MHVV were the independent risk factors for acute TCMR. This study could provide information regarding the identification of patients requiring liver biopsy.

Expression of Protein SOX9 in Biliary Atresia

OBJECTIVES

Biliary atresia (BA) is still an enigmatic disease. Deeper knowledge of its pathophysiology could help develop better treatments. SOX9 regulates bile duct development, liver regeneration and fibrosis; therefore, it could be determinant in characterizing BA liver damage. Aim: To study if there is a SOX9 expression pattern in liver biopsies from BA patients.

METHODS

Liver biopsies from BA patients (group BA), from age-matched infants without primary hepatic disease (group Control), and from patients with other liver conditions (group OLC) were compared. Expression of SOX9 was checked for: amount, intensity of immunoreaction, localization within ductular structures, perifibrotic epithelial cells, and lobular cells. The scores were added to create a scale from 0 to 11 that allowed group comparison. SOX9 Scale and liver survival were also looked for a correlation.

RESULTS

All BA cases had a score >4, while all controls scored <4. OLC livers scored 1 to 8 (3.5 ± 2.0) (P < 0.001 between all groups). A cut-off at 4 had 100% sensitivity and 88.24% specificity to differentiate BA from Controls and from OLC (area under receiver operating characteristic curve: 0.9989 (95% confidence interval: 0.9964-1.000). Strong expression of SOX9 was observed mainly in the nuclei of proliferated ductules of portal spaces and fibrotic bridges. SOX9 Scale score could not be related to liver survival in this study.

CONCLUSION

In BA livers, SOX9 is mainly expressed in reactive ductular epithelium, following a pattern significantly different from that seen in non-BA patients; thus, SOX9 Scale may have a role in the diagnosis of BA.

Incidence of Complications from Percutaneous Biopsy in Chronic Liver Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Approaches to liver biopsy have changed over the past decade in patients with chronic liver disease.

AIMS

We conducted a systematic review and meta-analysis on the incidence of all complications and technical failure associated with percutaneous liver biopsy.

METHODS

We systematically searched PubMed and the Cochrane Library for cohort studies reporting on complications resulting from liver biopsy published between 2010 and 2020. Studies on participants of any age and sex, who underwent any percutaneous biopsy for non-focal liver disease, were selected. All events except mild pain, minor hematoma, vasovagal episodes, fever and fistula were defined as major complications. Random-effect model meta-analyses with and without covariates were performed, to examine the effect of publication year, patient characteristics, outcome collection, and biopsy type on incidences.

RESULTS

We identified 30 studies reporting on complications resulting from percutaneous liver biopsy procedures (n = 64,356). Incidence of major complications was 2.44% (95% CI 0.85, 6.75), with mortality at 0.01% (95% CI 0.00, 0.11), hospitalization at 0.65% (95% CI 0.38, 1.11), major bleeding at 0.48% (95% CI 0.22, 1.06), and moderate/severe pain at 0.34% (95% CI 0.08, 1.37). Minor complications at 9.53% (95% CI 3.68, 22.5) were mainly pain at 12.9% (95% CI 5.34, 27.9). Technical failure was high at 0.91% (95% CI 0.27, 3.00). Decreasing patient age significantly increased incidence of hospitalization and major bleeding (P < 0.0001). Hospitalization incidence also significantly increased with disease severity.

CONCLUSIONS

Incidence of major (2.4%) and minor (9.5%) complications, and technical failure (0.91%) in percutaneous liver biopsies continues.

Prospective assessment of liver stiffness by shear wave elastography in childhood obesity: a pilot study

PURPOSE

The increased incidence of childhood obesity and related non-alcoholic fatty liver disease (NAFLD) has determined the need to identify a non-invasive technique to diagnose and monitor NAFLD. Two-dimensional shear wave elastography (2D-SWE) has emerged as a reliable, non-invasive, tool to evaluate liver tissue elasticity in clinical practice. Aims of this study were to longitudinally evaluate 2D-SWE changes in relation to weight loss, metabolic profile, and body composition modifications and to investigate the correlation between 2D-SWE variation and clinical and biochemical indices of cardio-metabolic risk in obese children.

METHODS

Thirty-three children underwent anthropometric, bioimpedenziometric, fasting biochemical assessments, ultrasound, and SWE evaluations, at baseline (V0) and after a 12-months of follow-up (V12). Diet and physical activity programs have been prescribed to all patients according to European Society of Endocrinology and Pediatric Endocrine Society recommendations. Adherence to the prescribed diet and physical activity program was checked every 3 months during the 12-month of follow-up. Variation of all parameters was evaluated in intragroup and intergroup comparison analysis in children, who had not lost weight (Group A) and those who had lost weight (Group B) at V12. Study population was also analyzed dividing it into two groups with respect to 2D-SWE liver elasticity value ≤10.6 kPa or >10.6 kPa.

RESULTS

A significant reduction of mean 2D-SWE value was demonstrated both in the entire cohort (p = 0.002) and in Group B children (p = 0.004). Intragroup comparison analysis, between V0 and V12, documented a significant decrease of 2D-SWE and BMI SDS and a significant improvement of metabolic profile (decrease of HOMA-IR, HbA1c, oral glucose tolerance test 120-min glucose and insulin, triglycerides, triglycerides/HDL-ratio, transaminases, uric acid, and increase of Matsuda-index and HDL) in children of Group B but not in those of Group A. Intergroup comparison analysis showed significant differences for BMI, BMI SDS, transaminases and several parameters of glucose and lipid metabolism, between Group A and Group B children after 12-months of follow-up. No significant differences were documented with regard to clinical and biochemical variables by dividing the population in accordance with the 2D-SWE cut-off of 10.6 kPa.

CONCLUSIONS

These results suggested a relation between weight loss, metabolic profile improvement and 2D-SWE value reduction. SWE could play a significant role in the non-invasive assessment of NAFLD in children and adolescents with obesity.

Percutaneous Core Needle Biopsy: Considerations in the Pediatric Patient

Image-guided percutaneous biopsy is the cornerstone of solid tissue diagnosis. The ability to safely sample tissue in locations that previously required surgery or necessitated empiric therapy has allowed for more personalized treatment options, as well as more rapid development of novel therapeutics. In children, these same advantages are accompanied by a smaller margin for error and rapidly expanding indications. The intent of this review is to outline the role of image-guided biopsy in the management of childhood disease, how this role is changing, and the practical aspects of managing and performing pediatric biopsies.

Serum concentration of fatty acids in children with obesity and nonalcoholic fatty liver disease

OBJECTIVES

It has been suggested that circulating fatty acids (FAs) take part in the pathogenesis of nonalcoholic fatty liver disease (NAFLD) in children with obesity. The aims of this study were to evaluate the serum FA concentration in this pediatric population.

METHODS

The prospective study included 80 children with obesity and suspected liver disease. Patients with viral hepatitis, autoimmune, toxic, and selected metabolic liver diseases were excluded. Criteria for NAFLD diagnosis included liver steatosis in ultrasound as well as elevated alanine transaminase (ALT) serum activity. The total intrahepatic lipid content (TILC) was assessed by magnetic resonance proton spectroscopy (1H-MRS). Fasting serum FA concentrations were measured in all children using gas-liquid chromatography.

RESULTS

NAFLD was diagnosed in 31 children. Total FA concentration was significantly higher (P < 0.01) in all obese children as well as in obese children with NAFLD compared with controls. In children with NAFLD, a significant, positive correlation was found between total FA concentration and cholesterol (R = 0.47, P < 0.01), triacylglycerols (R = 0.78, P < 0.001), and insulin (R = 0.45, P < 0.011). In a group of children with obesity, TILC correlated positively with saturated FA concentration (R = 0.23, P < 0.05).

CONCLUSION

Data from the present study do support the hypothesis that FAs are potentially involved in the pathogenesis of NAFLD in children with obesity.

Ultrasound-guided percutaneous liver biopsy in children. Five-year experience at a tertiary care center

INTRODUCTION AND AIMS

Percutaneous liver biopsy with histopathologic analysis is a valuable tool for the diagnosis, prognosis, and treatment evaluation of liver diseases. Its ultrasound-guided performance is useful, making the procedure safer and reducing the risk for complications and hospital stay. Our aim was to describe the indications, histopathologic study, and complications associated with the performance of ultrasound-guided percutaneous liver biopsy in pediatric patients.

MATERIAL AND METHODS

The study included 102 ultrasound-guided percutaneous liver biopsies performed on patients <16 years of age, within the time frame of January 2014 and December 2019. The information was obtained from electronic files and histopathologic studies and the data were analyzed through descriptive statistics.

RESULTS

A total of 102 procedures were carried out on 99 patients. Mean patient age was 72 months and 58.8% of the patients were female. Over 65% of the indications for liver biopsy included autoimmune hepatitis (23.5%), elevated liver enzymes (21.5%), and chronic liver disease (20.5%). Four patients presented with immediate complications (3.9%), three of which were major (2.9%), concurring with that reported in the international literature.

CONCLUSIONS

Our study corroborates the importance of ultrasound-guided liver biopsy in the diagnosis and follow-up of pediatric patients. The procedure also had a low complication rate of only 3.9%.

Celiac Disease in Conjunction with Hereditary Fructose Intolerance as a Rare Cause of Liver Steatosis with Mild Hypertransaminasemia-A Case Report

Celiac disease (CD) has been associated with several genetic and autoimmune disorders, but its association with hereditary fructose intolerance (HFI) is very rare. The possibility of an association between CD and HFI should be considered, especially in patients with a lack of improvement after a gluten-free diet. Children with HFI often present with a wide range of symptoms, however, data about a strong aversion to fruits and sweets may be helpful to establish the diagnosis. The diagnosis of HFI should be confirmed in genetic testing. Both CD and HFI may present with liver steatosis with hypertransaminasemia. In patients with these two disorders, the dietary restrictions of gluten and fructose improve clinical symptoms and protect them from secondary complications. We report the case of a child with the concurrence of these two disorders.

Maternal obesity increases the risk and severity of NAFLD in offspring

BACKGROUND & AIMS

Maternal obesity has been linked to the development of cardiovascular disease and diabetes in offspring, but its relationship to non-alcoholic fatty liver disease (NAFLD) is unclear.

METHODS

Through the nationwide ESPRESSO cohort study we identified all individuals ≤25 years of age in Sweden with biopsy-verified NAFLD diagnosed between 1992 and 2016 (n = 165). These were matched by age, sex, and calendar year with up to 5 controls (n = 717). Through linkage with the nationwide Swedish Medical Birth Register (MBR) we retrieved data on maternal early-pregnancy BMI, and possible confounders, in order to calculate adjusted odds ratios (aORs) for NAFLD in offspring.

RESULTS

Maternal BMI was associated with NAFLD in offspring: underweight (aOR 0.84; 95% CI 0.14-5.15), normal weight (reference, aOR 1), overweight (aOR 1.51; 0.95-2.40), and obese (aOR 3.26; 1.72-6.19) women. Severe NAFLD (biopsy-proven fibrosis or cirrhosis) was also more common in offspring of overweight (aOR 1.94; 95% CI 0.96-3.90) and obese (aOR 3.67; 95% CI 1.61-8.38) mothers. Associations were similar after adjusting for maternal pre-eclampsia and gestational diabetes. Socio-economic parameters (smoking, mother born outside the Nordic countries and less than 10 years of basic education) were also associated with NAFLD in offspring but did not materially alter the effect size of maternal BMI in a multivariable model.

CONCLUSIONS

This nationwide study found a strong association between maternal overweight/obesity and future NAFLD in offspring. Adjusting for socio-economic and metabolic parameters in the mother did not affect this finding, suggesting that maternal obesity is an independent risk factor for NAFLD in offspring.

LAY SUMMARY

In a study of all young persons in Sweden with a liver biopsy consistent with fatty liver, the authors found that compared to matched controls, the risk of fatty liver was much higher in those with obese mothers. This was independent of available confounders and suggests that the high prevalence of obesity in younger persons might lead to a higher risk of fatty liver in their offspring.

Safety, Feasibility, Yield, Diagnostic and Prognostic Implications of Transjugular Liver Biopsy in Children and Adolescents

OBJECTIVES

The objectives of the study were to evaluate the indications, feasibility, complications and clinical implications of transjugular liver biopsy (TJLB) in children.

METHODS

Data of all TJLB performed in children <18 years old was retrieved from the computerized hospital information system. TJLB was done using a 19 G quick-core needle biopsy system with 20 mm throw length. Hepatic venous pressure gradient was additionally measured in children with portal hypertension. A single pathologist reviewed all the biopsies again and provided structured information.

RESULTS

A total of 102 children, including 5 with acute liver failure underwent TJLB with technical success in 101 (99%). A mean of 2.3 ± 0.9 passes (range: 1-5) was taken for the biopsy. The most common indications for TJLB in our cohort were elevated international normalized ratio >1.5 (66, 64.7%), ascites (46, 45.1%) and thrombocytopenia (platelet count < 60,000/mm3) (42, 41.2%). Mean size of the tissue received was 14.5 ± 5.6 mm with an average of 10.2 ± 4.7 portal tracts. Only one child developed major (category D) complication (hemobilia) and 12 (11.8%) developed minor complications post-procedure. Etiological diagnosis could be made in a total of 64 (63.9%) children undergoing TJLB, the most common diagnosis being autoimmune hepatitis (n = 31), non-cirrhotic portal fibrosis (n = 16) and drug-induced liver injury (n = 4).

CONCLUSION

TJLB is well tolerated, feasible and helps make a diagnosis in close to 64% children allowing timely medical and/or surgical intervention. It is especially useful for diagnosis of autoimmune liver diseases, drug-induced liver injury and non-cirrhotic portal fibrosis.

Pediatric vs. adult NAFLD to MAFLD transition: a welcome but tangled path

The term non-alcoholic fatty liver disease (NAFLD) appears unfitting both in adults and in children. As obesity and metabolic syndrome play a relevant pathogenic role, an international group of adults’ liver disease experts has proposed to rename this condition metabolic (dysfunction)-associated fatty liver disease (MAFLD). While this new more appropriate and useful definition has mostly been met with good reactions in adults, it may present a tangled path in pediatrics. Here we further stress the recommendations of the North American and the European Societies for Pediatric Gastroenterology, Hepatology and Nutrition that a hyperechogenic liver in a child affected by obesity or overweight with chronically elevated liver enzymes should not be assumed to have NAFLD only. Especially in those patients who are not in the classic age range or who have particularly severe laboratory anomalies, other genetic, metabolic (inborn errors of metabolism, IEM), endocrine, intestinal and hepatic pediatric-onset conditions, should in fact be excluded, particularly when response to a weight loss trial is not available. The term pediatric fatty liver disease (PeFLD) with three subtypes (1. contextual diagnosis of an IEM; 2. Metabolic (dysfunction)-associated fatty liver; 3. unknown cause of fatty liver) has recently been proposed aiming to separate true MAFLD from IEM and/or the other above mentioned conditions, which may be rare when considered individually but represent a large group when considered collectively. Although the cost-effectiveness ratio of this attitude is still indeterminate, it is likely that the advantage of the early identification of a specifically treatable pediatric-onset liver disease associated to/mimicking MAFLD would be rewarding.

Ultrastructural Profile Combined with Immunohistochemistry of a Hepatic Progenitor Cell Line in Pediatric Autoimmune Hepatitis: New Insights into the Morphological Pattern of the Disease

Considering that the heterogenic population of a hepatic progenitor cell line (HPCL) can play a vital role in autoimmune hepatitis (AIH), we decided to conduct pioneering retrospective evaluation of these cells in pediatric AIH by means of transmission electron microscopy (TEM). The aim of the study was to assess the ultrastructure of the HPCL in children with untreated AIH. Ultrastructural analysis of the HPCL population, preceded by immunohistochemical staining for cytokeratin 7 (CK7), was performed using pretreatment liver biopsies from 23 children with clinicopathologically diagnosed AIH. Immunohistochemical assessment for CK7 allowed detection of proliferating immature epithelial cells differentiating towards periportal and intralobular intermediate hepatocytes without marked formation of ductular reactions in AIH children. Using TEM, we distinguished three morphological types of HPCs: I—the most undifferentiated progenitor cells; III—intermediate hepatocyte-like cells; II—intermediate bile duct cells. Most frequent were the cells differentiating towards hepatocytes, most rare—those differentiating towards cholangiocytes. The results indicate that an HPCL may be an important source of hepatocyte regeneration. Ultrastructural analyses of the HPCL population, combined with immunohistochemistry for CK7, might be a useful tool to evaluate liver cell regeneration, including fibrogenesis, and may help better understand the morphological pattern of the disease, in pediatric AIH. Frequent appearance of an HPCL in the vicinity of fibrotic foci, often accompanied by hyperactive Kupffer cells and transitional hepatic stellate cells, may indicate their significant involvement in liver fibrogenesis.