Adjuvant therapy in biliary atresia: hopelessly optimistic or potential for change?

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.

Delphi Method Analysis and Consensus of Prevalent Distinctive Practices for Biliary Atresia Management after Kasai Portoenterostomy

Background

Extrahepatic biliary atresia (BA) is seen in infants, with an incidence of 1 in 15,000 live births. The presentation is progressive jaundice, dark-colored urine, and clay-colored stools. Kasai portoenterostomy (KPE) is the commonly performed surgical procedure in these patients. Postoperatively, phenobarbitone, ursodeoxycholic acid (UDCA), steroids, and other drugs are given to improve bile drainage and prevent inflammation and fibrosis. However, a definitive protocol regarding the need for different drugs, dosage, and duration varies across individual surgeons and centers. No universally accepted protocol exists for postoperative management after KPE.

Aim

The aim of this study was to know the prevailing postoperative management of BA by subject experts and use the Delphi process to know if the experts want to change their practice based on the results from the survey.

Material and Methods

A questionnaire was made after discussing with two experts in the field of BA. The questionnaire was mailed to 25 subject experts. The first survey data were analyzed and shared with all responders. In the second survey, change in the management based on the results from the first survey was assessed.

Results

The Delphi questionnaire was answered by 17 experts. Postoperatively, prophylactic antibiotics are prescribed for 6-12 weeks by around 40% and >12 weeks by 30% of respondents. Phenobarbitone is prescribed for <3 months by nearly 50%. UDCA is prescribed for <3 months, ≤6 months, and 6 months-1 year by 47.1%, 23.5%, and 23.5% responders, respectively. Nearly 50% prescribe steroids (mostly prednisolone), and among them, two-thirds prescribe it for 6-12 weeks. Approximately 60% give antiviral drugs to children who are cytomegalovirus immunoglobulin M positive. In our survey, 50% of experts perform 5-10 KPE per year, and 25% each perform 10-15 and >15 KPE per year. The second survey noted that a significant percentage of responders want to change their practice according to consensus.

Conclusion

From our Delphi survey, an overview of the postoperative management of BA could be made. However, multicentric studies are required for uniform protocol on the postoperative management of BA.

Advances in the Treatment of Neonatal Biliary Disease

This article discusses current standard of care in neonatal biliary disease, particularly management of biliary atresia and choledochal cysts. It highlights surgical considerations, guidelines for adjuvant therapies, and promising therapeutic options that are under investigation.

Association between Kasai portoenterostomy at low caseload centres and transplant complications in children with biliary atresia

BACKGROUND

Kasai portoenterostomy (KPE) is the preferred treatment for biliary atresia (BA) patients. It has been shown that the center caseload of KPE impacts on native liver survival. We aimed to define the impact of KPE caseload on complications at the time of liver transplantation (LT).

METHODS

Retrospective data collection of LT for BA performed in our tertiary center between 2010 and 2018. The patients were grouped according to the caseload of the center that performed KPE: Group A (≥5 KPE/year) and Group B (<5 KPE/year). We analyzed total transplant time (TTT), hepatectomy time, amount of plasma and red blood cell (RBC) transfusions, occurrence of bowel perforations at LT.

RESULTS

Among 115 patients, Group A (n 44) and Group B (n 71) were comparable for age, sex, PELD score, TTT. The groups differed for: median hepatectomy time (57 min, IQR = 50-67; vs 65, IQR 55-89, p = 0.045); RBC transfusions (95 ml, IQR 0-250; vs 200 ml, IQR 70-500, p = 0.017); bowel perforations (0/44 vs 15/71, p = 0.001). One-year graft loss in Group A vs Group B was 1/44 vs 7/71 (p = 0.239), whereas deaths were 0/44 vs 5/71 respectively (p = 0.183); 5/15 patients who had a perforation eventually lost the graft.

CONCLUSIONS

This study found an association between KPE performed in low caseload center and the incidence of complications at LT. These patients tend to have a worse outcome. The centralization of KPE to referral center represents an advantage at the time of LT.

MINI ABSTRACT

We studied the impact of Kasai portoenterostomy (KPE) caseload on complications at the time of liver transplantation (LT), in 115 patients. We found an association between KPE performed in low caseload center and increased bowel perforations and blood transfusions. We suggest to centralize to experienced center all children requiring KPE.

Centralization of Biliary Atresia: Has Germany Learned Its Lessons?

INTRODUCTION

 The majority of pediatric surgeons and hepatologists recommend the centralization of biliary atresia (BA) treatment within experienced liver units. We aimed to investigate whether voluntary self-restriction and acceptance of the need for this change in practice changed the BA referral policy in Germany during the last decade.

MATERIALS AND METHODS

 In cooperation with pediatric surgeons, gastroenterologists or hepatologists, and pediatric liver transplant units, the 2-year follow-up data of infants with BA born in Germany between 2010 and 2014 were collected using www.bard-online.com or pseudonymized data transfer. Results were compared with our previous analysis of the outcome data of infants with BA born between 2001 and 2005 in Germany.

RESULT

 Overall, 173 infants with BA were identified, of whom 160 underwent Kasai portoenterostomy (KPE; 92.5%) and 13 (7.5%) underwent primary liver transplantation at 21 German centers. At 2-year follow-up, overall survival was 87.7% (vs. 81.9% in 2001-2005 [p = 0.19]), survival with native liver post-KPE was 29.2% (vs. 22.8% in 2001-2005 [p = 0.24]), and jaundice-free survival with native liver post-KPE was 24.0% (vs. 20.1% in 2001-2005 [p = 0.5]). Compared with the 2001-2005 analysis, all criteria showed improvement but the differences are statistically not significant.

CONCLUSION

 Our observation shows that KPE management requires improvement in Germany. Centralization of BA patients to German reference liver units is not yet mandatory. However, European and national efforts with regard to the centralization of rare diseases support our common endeavor in this direction.

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.

Gut Microbiome: A Potential Modifiable Risk Factor in Biliary Atresia

Biliary atresia (BA) is a fibro-obliterative condition of the biliary tree, presenting in infancy. The bilioenteric conduit formed at Kasai portoenterostomy (KPE), achieves restoration of bile flow in approximately 60% of infants. Even if the operation is successful, cirrhosis and its associated complications are, however, common. BA remains the leading cause for liver transplantation (LT) in children. Antibiotic, choleretic, and steroid therapy post-KPE have not convincingly reduced LT rates. Advances in molecular technology have enabled characterisation of the encoded genes of the gut microbiota (gut microbiome). The gut microbiome plays an important role in host metabolism, nutrition, and immune function, with alterations in its diversity and/or composition, known as dysbiosis, being described in disease states, including liver disease. Liver-gut microbiome exploration in adulthood largely focuses on nonalcoholic liver disease, cirrhosis (mainly alcohol- or viral-based aetiology) and cholestatic liver diseases (eg, primary sclerosing cholangitis), with microbial signatures correlating to disease severity. Investigation of the gut microbiota in BA had been limited to culture-based methodology, but molecular studies are emerging, and although in their infancy, highlight a potential pathogenic role for Enterobacteriaceae and Streptococcus, and a potential beneficial role for Bifidobacteria. Bacterial translocation, and the production of gut microbiome-derived metabolites, are key host-microbiome-mechanistic pathways in liver disease pathogenesis. Microbiome-targeted therapeutics for liver disease are in development, with faecal microbiota transplantation showing promise in cirrhosis. Could the gut microbiome be a novel modifiable risk factor in BA, reducing the need for LT?

Does the Treatment After Kasai Procedure Influence Biliary Atresia Outcome and Native Liver Survival?

OBJECTIVES

Biliary atresia (BA) is a rare and progressive idiopathic disease affecting the biliary tract that can lead to end-stage liver disease. The main treatment is Kasai portoenterostomy (KP). The use of adjuvant therapy (AT; prophylactic antibiotics and steroids) after KP aims to prevent cholangitis and reduce the need for liver transplantation (LT), but there is a lack of evidence on their effectiveness. We investigated the impact of significant changes in the post-KP protocol on the overall outcomes of BA.

METHODS

We enrolled 43 consecutive infants undergoing KP at Bambino Gesù Children's Hospital between July 2012 and October 2018. We compared AT (AT group; n=25) against no treatment (AT-free group; n = 18).

RESULTS

No significant differences in anthropometric and laboratory parameters were shown between the 2 groups at baseline and every study evaluation (1, 3, and 6 months). The incidences of clinical complications of liver disease were similar. Six months post-KP, the achievement of serum total bilirubin ≤1.5 mg/dL and satisfactory Pediatric End-Stage Liver Disease scores were not significantly different between the 2 groups. Cholangitis was observed in 30% of patients in the first 6 months postoperatively: 33% and 28% in the AT-free and AT groups, respectively (P = 0.18). Survival to LT listing at 12 months and without LT at 24 months were not significantly different between the 2 groups (P > 0.05).

CONCLUSIONS

AT after KP confirmed conflicting results; therefore, multicentered, prospective, randomized control studies are needed to better understand its utility after KP, especially in the multidrug resistance spread era.

Bilirubin level 1 week after hepatoportoenterostomy predicts native liver survival in biliary atresia

BACKGROUND

To determine a very early predictive biomarker after hepatoportoenterostomy (HPE) for the prediction of native liver survival in biliary atresia (BA) patients.

METHODS

A retrospective chart review was conducted of BA patients in our hospital between August 2000 and April 2019. The serum total bilirubin (T-bil), direct bilirubin, and gamma-glutamyl transferase level 1 week after HPE were analyzed. The clinical outcome predictors were investigated.

RESULTS

A total of 90 BA patients were recruited. Receiver operating characteristic curve analysis showed that a post-HPE 1-week T-bil level ≤4.85 mg/dL predicted jaundice-free after HPE (P = 0.02). BA patients with a post-HPE 1-week T-bil ≤4.85 mg/dL were more likely to be jaundice-free within 3 months of HPE (odds ratio = 3.53; P = 0.006). Kaplan-Meier plot analysis showed that the likelihood of native liver survival and jaundice-free native liver survival were significantly higher in BA subjects with a post-HPE 1-week T-bil ≤4.85 mg/dL than in other subjects (P = 0.01 and 0.01, respectively).

CONCLUSIONS

The serum post-HPE 1-week T-bil level may predict the long-term outcome in BA patients. A post-HPE 1-week T-bil ≤4.85 mg/dL correlated with better native liver survival and jaundice-free native liver survival in BA patients.

Innate Immunity and Pathogenesis of Biliary Atresia

Biliary atresia (BA) is a devastating fibro-inflammatory disease characterized by the obstruction of extrahepatic and intrahepatic bile ducts in infants that can have fatal consequences, when not treated in a timely manner. It is the most common indication of pediatric liver transplantation worldwide and the development of new therapies, to alleviate the need of surgical intervention, has been hindered due to its complexity and lack of understanding of the disease pathogenesis. For that reason, significant efforts have been made toward the development of experimental models and strategies to understand the etiology and disease mechanisms and to identify novel therapeutic targets. The only characterized model of BA, using a Rhesus Rotavirus Type A infection of newborn BALB/c mice, has enabled the identification of key cellular and molecular targets involved in epithelial injury and duct obstruction. However, the establishment of an unleashed chronic inflammation followed by a progressive pathological wound healing process remains poorly understood. Like T cells, macrophages can adopt different functional programs [pro-inflammatory (M1) and resolutive (M2) macrophages] and influence the surrounding cytokine environment and the cell response to injury. In this review, we provide an overview of the immunopathogenesis of BA, discuss the implication of innate immunity in the disease pathogenesis and highlight their suitability as therapeutic targets.

Ursodeoxycholic acid use is associated with significant risk of morbidity and mortality in infants with cholestasis: A strobe compliant study

The off-label use of medications is a "right" for pediatricians, owing to lack of enough safety and effectiveness drug trials in pediatric age group. Pediatricians have to rely on their personal judicial use of medications in children.We studied off-label use of ursodeoxycholic acid (UDCA) retrospectively during 2005 to 2015 among those who attended the Pediatic Hepatology Unit, Cairo University.We analyzed data of 779 neonates and infants with cholestasis. 15% dropped out. Males comprised 374 (56.5%). Cholestasis was due to surgical causes in 129 (19.5%), neonatal hepatitis in 445 (67.2%), and paucity of intrahepatic bile ducts in 88 (13.3%). Three hundred sixty (54.4%) received UDCA (15-30 mg/kg/d), and 302 (45.6%) did not. Both groups were matched as regards causes and severity of cholestasis. Those who received UDCA had worse outcome (P < .001), and more complications (P < .001). A total of 73.1% (221) achieved cure without UDCA compared to only 45.8% (165) of those on UDCA (P < .001).UDCA is not effective and not safe in Egyptian neonates and infants with cholestasis. UDCA use compromises chance of cure, and is associated with serious morbidity, progression of disease, and death. UDCA off-label use mortality was absolutely preventable. Off- label use of UDCA in neonates and children should be utterly prohibited. Information of use of off-label medications, effectiveness, and safety, should be recorded, analyzed, and made available within context of Off-label Use Registry Studies with informed consent of parents.

Error traps and culture of safety in biliary atresia

Biliary atresia is a progressive inflammatory sclerosing disease of the bile ducts in the neonatal liver. Without surgical intervention these patients are destined to succumb to the disease. The development of the hepatoportoenterostomy in 1959 and liver transplantation in 1963 ushered a new era of success treating these patients. While many surgical modifications and adjuncts to treatment have been attempted over the last 50 years, the mainstay of treatment to give the child the best chance at prolonged survival with the native liver is a properly performed operation, in a timely fashion, with minimal post-operative complications. This review presents the authors current practice guideline to achieve these goals.

Biliary atresia: a scientometric analysis of the global research architecture and scientific developments

Biliary atresia (BA) is a rare cholangiopathy of largely unknown etiology and unpredictable outcome. There has been an increasing number of BA-related publications, which may challenge researchers to determine their actual scientific value. This study aimed to evaluate the global research activity and developments relating to BA using a combination of scientometric methodologies and visualization tools. A comprehensive search strategy for the Web of Science™ database was designed to obtain bibliographic data on scientific BA publications for the timespan 1900-2018. Research output of countries, institutions, individual authors and collaborative networks was analyzed. Semi-qualitative research measures including citation rate and h-index were assessed. Choropleth mapping and network diagrams were used to visualize results. In total, 4,459 publications on BA were identified (88.5% in English), originating from 63 countries. The largest number was published by the USA (n = 991; 22.2%), Japan (n = 667; 15.0%) and the UK (n = 294; 6.6%). The USA combined the highest number of cooperation articles (n = 140). The most productive collaborative network was established between the USA and Canada (n = 17). Scientific papers from the UK received the highest average citation rate (16.7), whereas the USA had the highest country-specific h-index (59). Eighty-eight (2.0%) items were published under the auspices of multicenter consortiums and registries. The most productive institutions and authors were based in the USA, the UK, Japan, France, Canada and Taiwan. BA-related research has constantly been progressing, becoming more multidisciplinary but with main research endeavors concentrated in a few high-income countries. Studies into pathogenesis of BA remain uncommon, but are sorely needed to foster true scientific progress with this rare disease. Hence, international collaborative and translational research should be strengthened to allow further evolution in this field.

Immune Status in Children Before Liver Transplantation-A Cross-Sectional Analysis Within the ChilsSFree Multicentre Cohort Study

Background: Both, markers of cellular immunity and serum cytokines have been proposed as potential biomarkers for graft rejection after liver transplantation. However, no good prognostic model is available for the prediction of acute cellular rejection. The impact of underlying disease and demographic factors on immune status before pediatric liver transplantation (pLTx) is still poorly understood. We investigated expression of immune markers before pLTx, in order to better understand the pre-transplant immune status. Improved knowledge of the impact of pre-transplant variables may enhance our understanding of immunological changes post pLTx in the future.

Methods: This is a cross-sectional analysis of data from the ChilSFree study, a European multicentre cohort study investigating the longitudinal patterns of immune response before and after pLTx. Immune cell counts and soluble immune markers were measured in 155 children 1–30 days before pLTx by TruCount analysis and BioPlex assays. Results were logarithmised due to skewed distributions and then compared according to age, sex, and diagnosis using t-tests, ANOVAs, and Tukey post-hoc tests. The association between immune markers at time of pLTx and patients' age was assessed using a fractional polynomial approach. Multivariable regression models were used to assess the relative contribution of each factor.

Results: Sex had no effect on immune status. We found strong evidence for age-specific differences in the immune status. The majority of immune markers decreased in a log-linear way with increasing age. T and B cells showed a sharp increase within the first months of life followed by a log-linear decline in older age groups. Several immune markers were strongly associated with underlying diagnoses. The effects of age and underlying disease remained virtually unchanged when adjusting for each other in multivariable models.

Discussion: We show for the first time that age and diagnosis are major independent determinants of cellular and soluble immune marker levels in children with end-stage liver disease. These results need to be considered for future research on predictive immune monitoring after pLTx.

Ten-Year Experience in the Prevention of Post-Kasai Cholangitis

BACKGROUND

Cholangitis is the most common complication after the Kasai procedure. It can be life-threatening and may affect long- and short-term outcomes of children with biliary atresia. We summarize our experiences in the prevention of early-onset cholangitis.

PATIENTS AND METHODS

From January 2002 to March 2013, children with biliary atresia (BA) who underwent the Kasai procedure in the General Surgical Department were included in a retrospective cohort study. These patients were divided into group A (therapy 1) and group B (therapy 2) depending on the infection prevention protocol and occurrences of cholangitis within the six months after surgery were recorded. Two hundred eighteen children were included in this cohort study. Seventy-six children (35 females and 41 males) were included in group A. One hundred forty-two children (65 females and 77 males) were included in group B. Therapy 1 was our primary protocol and included a third-generation cephalosporin, metronidazole, and human immunoglobulin. Therapy 2 was a modification of therapy 1 that involved imipenem-cilastatin and human immunoglobulin. Statistical analyses were performed. A p value below 0.05 was regarded as significant.

RESULTS

In group A, 45 children developed cholangitis within the six months after the Kasai procedure. In group B, 14 of these children experienced post-operative cholangitis. A χ² analysis was used to examine the difference in the incidence of cholangitis between groups A and B. There was a substantial difference in the morbidity of post-operative cholangitis between groups A and B (59.2% vs. 9.9%, p = 0.000).

CONCLUSION

Cholangitis in the early period after a Kasai procedure can be prevented effectively with an advanced prophylactic protocol.

Vitamin A can ameliorate fibrosis of liver in an established rat model of biliary atresia and Kasai portoenterostomy

BACKGROUND

Antifibrosis therapy may prevent progressive liver fibrosis after successful Kasai portoenterostomy (KPE) in biliary atresia (BA) patients. The aim of this study is to evaluate the efficacy of antifibrosis therapy in a rat model of BA and KPE.

METHODS

BA model was created on three-week-old Sprague-Dawley rats by intrabiliary alcohol injection as previously described, and KPE was performed at postoperative week (POW) 5 by cystoenterostomy. Liver biopsies were performed at the time of BA creation, during KPE, POW 9, and at sacrifice (POW 17). Prednisolone (0.1 mg/100 g/day, group 1, n = 20), Vitamin A (0.5 mg/100 g/day, group 2, n = 20), and ursodeoxycholic acid (UDCA, 1.5 mg/100 g/day, group 3, n = 20) were respectively given to three groups after KPE and continued daily until sacrifice. Histological evaluation of fibrosis and immunohistochemistry stains for 8 fibrosis markers were compared to the control group (without medication, n = 10).

RESULTS

Among the four markers, namely ɑ-smooth muscle actin (ɑ-SMA), glial fibrillary acidic protein (GFAP), tumor growth factor β1 (TGFβ1) receptors 1 and 2, which showed persistently high expression after successful KPE in the examined 8 markers, only the expression of ɑ-SMA was significantly reduced in all treatment groups at POW17. However, the fibrosis grade at POW 17 was only significantly reduced in group 2 in comparison with the control group (Vitamin A vs. control group, Ishak score 3 vs. 1.8, p < 0.05).

CONCLUSION

In our rat model of BA with KPE, Vitamin A was effective in reducing liver fibrosis, and the mechanisms deserve further study.

LEVEL OF EVIDENCE

Basic science.

Does the identity of the bacteria matter in post-Kasai cholangitis? A comparison between simple and intractable cholangitis

PURPOSE

This study compared the bacteriology and clinical outcomes between simple (SC) and intractable cholangitis (IC) after Kasai operation.

METHODS

Post-Kasai patients (n = 192) from 1980 to 2015 were retrospectively reviewed. The results of blood culture and clinical outcomes between the patients with SC and IC were compared.

MAIN RESULTS

A total of 102 cholangitic episodes in 68 patients were analyzed (SC vs IC = 76 vs 26). There were more IC episodes within the first year of Kasai operation (SC vs IC = 36.8% vs 61.5%, p = 0.022). The most common bacteria identified in SC and IC groups were Escherichia Coli and Staphylococcus aureus. Until the latest follow up, the native liver survival rates in patients with SC and IC were 75.0% and 50.0% (p = 0.89). Among the patients with IC, the native liver survival rate was significantly better in those with a positive culture (100% vs 20%, p = 0.001).

CONCLUSION

Intractable cholangitis is a common complication within the first year of Kasai operation and may be caused by a different spectrum of organisms. The identification of the bacteria by blood culturing may result in a better treatment outcome.

LEVEL OF EVIDENCE

Level III.

Biliary Atresia: Clinical and Research Challenges for the Twenty-First Century

Biliary atresia (BA) is a fibroinflammatory disease of the intrahepatic and extrahepatic biliary tree. Surgical hepatic portoenterostomy (HPE) may restore bile drainage, but progression of the intrahepatic disease results in complications of portal hypertension and advanced cirrhosis in most children. Recognizing that further progress in the field is unlikely without a better understanding of the underlying cause(s) and pathogenesis of the disease, the National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsored a research workshop focused on innovative and promising approaches and on identifying future areas of research. Investigators discussed recent advances using gestational ultrasound and results of newborn BA screening with serum direct (conjugated) bilirubin that support a prenatal onset of biliary injury. Experimental and human studies implicate the toxic properties of environmental toxins (e.g., biliatresone) and of viruses (e.g., cytomegalovirus) to the biliary system. Among host factors, sequence variants in genes related to biliary development and ciliopathies, a notable lack of a cholangiocyte glycocalyx and of submucosal collagen bundles in the neonatal extrahepatic bile ducts, and an innate proinflammatory bias of the neonatal immune system contribute to an increased susceptibility to damage and obstruction following epithelial injury. These advances form the foundation for a future research agenda focused on identifying the environmental and host factor(s) that cause BA, the potential use of population screening, studies of the mechanisms of prominent fibrosis in young infants, determinations of clinical surrogates of disease progression, and the design of clinical trials that target subgroups of patients with initial drainage following HPE. (Hepatology 2018; 00:000-000).

Intravenous immunoglobulin for the treatment of intractable cholangitis after Kasai portoenterostomy in biliary atresia patients

OBJECTIVE

To assess the efficacy of intravenous immunoglobulin (IVIG) as add-on treatment for intractable cholangitis (IC) after Kasai portoenterostomy (KPE) in biliary atresia (BA) patients.

METHODS

113 BA patients who had one or more episodes of cholangitis after KPE were recruited in this study. According to whether response to routine conservative treatment, all patients were divided into IC group and simple cholangitis (SC) group. Meanwhile, patients with IC subdivided into IVIG group and control group according to whether application of IVIG.

RESULTS

The IC group had higher serum procalcitonin (PCT) (P = 0.014), C-reactive protein (CRP) (P = 0.023), and γ-Gltamyltranspeptidase (γ-GGT) (P = 0.031) level than the SC group. The IVIG group had shorter duration of fever after treatment (P = 0.011) and length of hospital stay (P = 0.018) than the control group. The time until recurrent episode of cholangitis was significant longer in IVIG group than in control group (P = 0.019).

CONCLUSIONS

IVIG as add-on treatment may be an effective treatment for the cholangitis acute episode, and we conclude by calling for more prospective studies to attest to the role of IVIG in the treatment of cholangitis.