Current and emerging adjuvant therapies in biliary atresia

Predictors of outcome among children with biliary atresia: a single centre trial

Objective

This study aimed to investigate the predictive role of preoperative gamma-glutamyl transpeptidase (GGT) levels on the prognosis of neonatal biliary atresia (NBA) in patients who underwent the Kasai procedure.

Methods

A retrospective analysis was conducted of patients with NBA who underwent the Kasai procedure at our hospital from 2017 to 2021. Patients were categorized into high (GGT > 300 IU/L) and GGT inadequate (GGT ≤ 300 IU/L) groups based on preoperative GGT levels. The influence of GGT levels on NBA prognosis was evaluated by comparing clinical data, age at operation, jaundice normalization, and survival outcomes between the groups.

Results

A total of 74 patients with NBA were included, with 59 in the high GGT group and 15 in the GGT inadequate group. Ages at the time of the Kasai procedure ranged from 31 to 106 days, with a median of 61 days; the average weight was 4.8 ± 1.1 kg. Two years post-procedure, 56 patients (75.7%) survived with their native liver (P < 0.0001). At 3 months post-procedure, alanine aminotransferase (ALT) levels were significantly higher in the GGT inadequate group compared to the high GGT group (3.5 times vs. 2.3 times the upper limit of normal, P = 0.0259). Significant differences in GGT levels persisted 1-month post-procedure (P = 0.0473). Jaundice clearance was significantly higher in the high GTT group (P = 0.0171) after 6 months. Multivariate logistic regression indicated a substantially higher mortality rate in the GGT inadequate group (P = 0.0452), with no significant age difference at operation (P = 0.8449). Preoperative GGT is a valuable predictor for NBA prognosis (area under the curve (AUC) 0.754, 95% confidence interval CI [0.640-0.847], P = 0.001, specificity 91.1%, and sensitivity 61.1%).

Conclusions

High preoperative GGT levels predict better prognosis in patients with NBA undergoing Kasai operation.

Optimizing Post-Kasai Management in Biliary Atresia: Balancing Native Liver Survival and Transplant Timing

BACKGROUND

 Kasai procedure (KPE) is a palliative intervention in infants with biliary atresia (BA) aiming to restore biliary drainage. While the measure of success in BA is the post-Kasai native liver survival (NLS), BA remains the most frequent indication for liver transplantation in children. While a considerable amount of children fail to clear their jaundice following KPE, resulting in early liver failure and transplantation, some children become jaundice-free after "successful" KPE. However, sequelae of chronic liver disease might affect those children, becoming a later risk for NLS. While liver transplantation is inevitable in the majority of children, various salvage procedures have been recently described to maintain NLS. This article provides a comprehensive overview of procedures performed after KPE to prolong NLS in BA patients from early childhood to late adulthood and discusses their indications and limitations.

METHODS

 A literature-based search for surgical and radiological interventions performed in BA patients after KPE to prolong NLS (salvage procedures) was performed using PubMed. Data from case reports, retrospective studies, and registries were included.

RESULTS

 Fifteen studies included 794 patients who underwent post-KPE salvage procedures. The Oxford Centre for Evidence-Based Medicine levels were IIc to IV.Interventions included redo-Kasai's (n = 710) for cessation of bile flow post-KPE, surgical and radiological procedures (n = 14) for bile lakes, and recurrent cholangitis, shunt surgery (n = 49), and transjugular intrahepatic portosystemic shunt (n = 21) for portal hypertension in BA patients. Age at the time of salvage interventions varied considerably, including redo-Kasai's at 27 days of life and percutaneous biliary interventions in a 35-year-old.

CONCLUSION

 Salvage procedures can maintain NLS after KPE in BA patients with disease sequelae. However, indications remain scarce and liver transplantation is ultimately unavoidable in the majority of patients. While redo-Kasai numbers are globally decreasing with the advances in liver transplantation, procedures for bile lakes and portal hypertension can be viable options for patients with complications but otherwise stable liver function. Discussion on those procedures should be held by multidisciplinary expert teams, involving pediatric hepatologists, pediatric surgeons, and transplant surgeons to elaborate on the potential of maintaining NLS or proceeding with transplantation.

Burden of digestive congenital anomalies among children aged 0-14 years in 204 countries and territories, 1990-2021: results from the Global Burden of Disease Study 2021

OBJECTIVES

We aim to delineate the digestive congenital abnormalities burden in children under 14 years old between 1990 and 2021.

DESIGN

We implemented data from the Global Burden of Disease (GBD) 2021 database to evaluate digestive congenital abnormalities burden with different measures in 204 countries and territories from 1990 to 2021. We present precise estimations with 95% uncertainty intervals. In addition, we computed the estimated annual percentage change (EAPC) to examine the temporal patterns of these indicators.

SETTING

It uses prevalence, deaths and disability-adjusted life years (DALYs) data from the GBD study to analyse this issue.

PARTICIPANTS

Patients with digestive congenital abnormalities diagnosis.

OUTCOMES

Total numbers, age-standardised rates (ASRs) of prevalence, mortality and DALYs and their EAPCs were the main outcomes among children aged 0-14 years.

RESULTS

In 2021, 2206.79 thousand prevalent cases were reported worldwide, with digestive congenital anomalies accounting for 47.16 thousand deaths and 4324.56 thousand DALYs among children aged 0-14 years. Digestive congenital anomalies prevalence was mitigated by 8.15% between 1990 and 2021, with the global ASR of prevalence declining to 40.09 per 100 000. Digestive congenital anomalies mortality was mitigated by 35.35% between 1990 and 2021, with an ASR of deaths declining to 0.77 per 100 000. The worldwide burden of digestive congenital anomalies decreased by 34.96% in terms of DALYs from 1990 to 2021, with an ASR of 70.44 DALYs per 100 000 population. There was a significant hindrance in the prevalence, particularly among older children. The likelihood of digestive congenital abnormalities peaked during infancy (2-4 years) in all regions.

CONCLUSION

We highlight promising global declines in the digestive congenital anomalies burden among children over the past 32 years. Prevalence, deaths and DALYs associated with these anomalies have shown consistent decreases, although regional variations persist. These findings offer crucial insights for shaping effective prevention and management strategies for paediatric digestive congenital anomalies.

CircUTRN24/miR-483-3p/IGF-1 Regulates Autophagy Mediated Liver Fibrosis in Biliary Atresia

Biliary atresia (BA) is a rare neonatal cholestatic disease that presents with a marked bile duct reaction and rapid fibrotic development. Our earlier research has shown that circUTRN24 is highly elevated in BA, but the exact molecular mechanism is still unknown. This study attempted to investigate whether circUTRN24 induces BA liver fibrosis through regulation of autophagy and to elucidate its molecular mechanism. Using TGF-β-treated hepatic stellate cells (HSC) LX-2, we created a liver fibrosis model. qRT-PCR was used to analyze the expression of circUTRN24, miR-483-3p, and IGF-1. Western blot analysis was used to assess the expression of IGF-1, HSC activation-related proteins, and autophagy-related proteins. The TGF-β-induced LX-2 cell fibrosis model was then supplemented with circUTRN24 siRNA, miR-483-3p mimics, and the autophagy activator Rapamycin, and functional rescue tests were carried out to investigate the role of circUTRN24, miR-483-3p, and autophagy in BA liver fibrosis. Using a luciferase reporter assay, a direct interaction between miR-483-3p and circUTRN24 or IGF-1 was discovered. With the increase of TGF-β treatment concentration, circUTRN24 expression also gradually increased, as did HSC activation and autophagy-related protein. si-circUTRN24 significantly decreased circUTRN24 expression and inhibited HSC activation and autophagy, which was reversed by Rapamycin. Through bioinformatics prediction and validation, we found circUTRN24 might act through miR-483-3p targeting IGF-1 in the autophagy-related mTOR pathway. Furthermore, miR-483-3p mimics significantly increased miR-483-3p expression and inhibited HSC activation and autophagy, which were reversed by Rapamycin. Functional rescue experiments showed that si-circUTRN24 inhibited circUTRN24 and IGF-1 expressions and promoted miR-483-3p expression, while the miR-483-3p inhibitor abolished these effects. These findings imply that circUTRN24/miR-483-3p/IGF-1 axis mediated LX-2 cell fibrosis by regulating autophagy.

Inflammation drives pathogenesis of early intestinal failure-associated liver disease

Patients with intestinal failure who receive long-term parenteral nutrition (PN) often develop intestinal failure-associated liver disease (IFALD). Although there are identified risk factors, the early pathogenesis is poorly understood and treatment options are limited. Here, we perform a transcriptomic analysis of liver tissue in a large animal IFALD model to generate mechanistic insights and identify therapeutic targets. Preterm Yorkshire piglets were provided PN or bottle-fed with sow-milk replacer for 14 days. Compared to bottle-fed controls, piglets receiving PN developed biochemical cholestasis by day of life 15 (total bilirubin 0.2 vs. 2.9 mg/dL, P = 0.01). RNA-Seq of liver tissue was performed. Ingenuity Pathway Analysis identified 747 differentially expressed genes (343 upregulated and 404 downregulated) with an adjusted P < 0.05 and a fold-change of > |1|. Enriched canonical pathways were identified, demonstrating broad activation of inflammatory pathways and inhibition of cell cycle progression. Potential therapeutics including infliximab, glucocorticoids, statins, and obeticholic acid were identified as predicted upstream master regulators that may reverse the PN-induced gene dysregulation. The early driver of IFALD in neonates may be inflammation with an immature liver; identified therapeutics that target the inflammatory response in the liver should be investigated as potential treatments.

Alterations of gut microbiota in infants with biliary atresia identified by 16S rRNA-sequencing

BACKGROUND

Biliary atresia (BA) is a severe neonatal disease with progressive intra- and extra-hepatic bile ducts inflammation and hepatic fibrosis. Characterization of gut microbiome profiles in infants with biliary atresia can provide valuable information and potential disease biomarkers. Our study aims to explore the relationship between gut microbiota and biliary atresia.

METHODS

16 S ribosomal RNA (rRNA) gene sequencing was carried out to identify the differences in composition and diversity of gut microbiota between infants with BA and healthy subjects. A total of 31 infants with biliary atresia and 20 healthy subjects were recruited.

RESULTS

The composition of gut microbiota in BA group was significantly different with the normal control group (P < 0.05) and the abundance ratio of Klebsiella/Bifidobacterium showed great potential for identification of BA (P < 0.01). In addition, the differential bacterial taxa were involved in lipid and vitamins metabolism.

CONCLUSION

Our results could provide potential non-invasive biomarker for identification of biliary atresia and contribute to the treatment in terms of ameliorating microbiota dysbiosis.