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Lerer R, Barash L, Nafday S, Kogan Liberman D, Ovchinsky N. Evaluation of Newborn Direct Bilirubin As Screening for Cholestatic Liver Disease. JPGN REPORTS 2023; 4:e345. [PMID: 38034462 PMCID: PMC10684158 DOI: 10.1097/pg9.0000000000000345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/24/2023] [Indexed: 12/02/2023]
Abstract
Background Biliary atresia (BA) remains the most common indication for pediatric liver transplantation. Early diagnosis is essential for a favorable long-term prognosis for patients with BA. Preliminary data suggests that measurement of direct bilirubin (DB) in newborns may be an effective screening tool for neonatal cholestasis, particularly BA, allowing for early referral and diagnosis. The objective of our study was to establish a cutoff DB value to predict diagnosis of cholestatic liver disease (CLD) with high sensitivity and specificity, as well as, to evaluate whether newborns with elevated DB received appropriate follow-up in our health system. Methods Baseline data were collected on infants born between 2016 and 2019 who had serum total bilirubin and DB drawn in the nursery, and who continued to follow in our health system. Sensitivity, specificity, and positive and negative predictive values were examined using cutoff values of 0.5, 0.6, and 0.7 mg/dL for identifying infants at risk for CLD. Patients' charts were reviewed to note whether they had follow-up levels drawn by their pediatrician or by the hepatology team within 2 months of age and whether they were diagnosed with CLD. Results Serum total bilirubin and DB levels were drawn from 11 965 infants during their hospitalizations. Three infants from this cohort were diagnosed with CLD: 2 with BA and 1 with Alagille syndrome. DB cutoff values of 0.5, 0.6, and 0.7 mg/dL had sensitivity of 100% and specificity of 96.83% (95% confidence interval [CI], 96.69%-97.53%), 99.08% (95% CI, 98.81%-99.30%), and 99.63% (95% CI, 99.4%-99.7%), respectively. Given that a DB of 0.6 mg/dL had a sensitivity of 100% and specificity of 99%, this value was chosen as the cutoff value to monitor for DB follow-up and diagnosis of CLD. Out of 60 infants who met criteria for DB ≥0.6 mg/dL, only 15 (25%) had a repeat level drawn after nursery discharge; 3 (5%) were eventually diagnosed with CLD. Conclusions A DB cutoff value of 0.6 mg/dL yielded high sensitivity and specificity for identifying patients with CLD. All 3 patients diagnosed with CLD had elevated DB at hospital discharge. The data revealed that the majority (75%) of eligible newborns did not receive follow-up for their elevated DB in the outpatient setting.
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Affiliation(s)
- Rikah Lerer
- From the Division of Gastroenterology, Hepatology, and Nutrition, Cohen Children’s Medical Center, Queens, NY
| | - Lily Barash
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital at Montefiore, Bronx, NY
| | - Suhas Nafday
- Division of Neonatology, Children’s Hospital at Montefiore, Bronx, NY
| | - Debora Kogan Liberman
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital at Montefiore, Bronx, NY
| | - Nadia Ovchinsky
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital at Montefiore, Bronx, NY
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Arshad A, Gardiner J, Ho C, Rees P, Chadda K, Baker A, Sutcliffe AG. Population-based screening methods in biliary atresia: a systematic review and meta-analysis. Arch Dis Child 2023; 108:468-473. [PMID: 36797045 DOI: 10.1136/archdischild-2022-324946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVE The aim of this study was to investigate tested methods of population-based biliary atresia (BA) screening. DESIGN We searched 11 databases between 1 January 1975 and 12 September 2022. Data extraction was independently done by two investigators. MAIN OUTCOME MEASURES Our primary outcomes were: sensitivity and specificity of screening method in BA detection, age at Kasai, BA associated morbidity and mortality, cost-effectiveness of screening. RESULTS Six methods of BA screening were evaluated: stool colour charts (SCCs), conjugated bilirubin measurements, stool colour saturations (SCSs), measurements of urinary sulfated bile acids (USBAs), assessments of blood spot bile acids and blood carnitine measurements.In a meta-analysis, USBA was the most sensitive and specific, with a pooled sensitivity and specificity of 100.0% (95% CI 2.5% to 100.0%) and 99.5% (95% CI 98.9% to 99.8%) (based on one study). This was followed by conjugated bilirubin measurements: 100.0% (95% CI 0.0% to 100.0%) and 99.3% (95% CI 91.9% to 99.9%), SCS: 100.0% (95% CI 0.00% to 100.0%) and 92.4% (95% CI 83.4% to 96.7%), and SCC: 87.9% (95% CI 80.4% to 92.8%) and 99.9% (95% CI 99.9% to 99.9%).SCC reduced the age of Kasai to ~60 days, compared with 36 days for conjugated bilirubin. Both SCC and conjugated bilirubin improved overall and transplant-free survival. The use of SCC was considerably more cost-effective than conjugated bilirubin measurements. CONCLUSION Conjugated bilirubin measurements and SCC are the most researched and demonstrate improved sensitivity and specificity in detecting BA. However, their use is expensive. Further research into conjugated bilirubin measurements, as well as alternative methods of population-based BA screening, is required. PROSPERO REGISTRATION NUMBER CRD42021235133.
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Affiliation(s)
- Adam Arshad
- Population, Policy & Practice Department, UCL GOS Institute of Child Health, London, UK
| | - Julian Gardiner
- Population, Policy & Practice Department, UCL GOS Institute of Child Health, London, UK
| | - Carmen Ho
- Population, Policy & Practice Department, UCL GOS Institute of Child Health, London, UK
| | - Philippa Rees
- Population, Policy & Practice Department, UCL GOS Institute of Child Health, London, UK
| | - Karan Chadda
- Population, Policy & Practice Department, UCL GOS Institute of Child Health, London, UK
| | - Alastair Baker
- Department of Paediatric Hepatology, Kings College Hospital, London, UK
| | - Alastair G Sutcliffe
- Population, Policy & Practice Department, UCL GOS Institute of Child Health, Institute of Child Health, London, UK
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Hoshino E, Moriwaki K, Morimoto K, Sakai K, Shimohata N, Konomura K, Urayama KY, Suzuki M, Shimozuma K. Cost-Effectiveness Analysis of Universal Screening for Biliary Atresia in Japan. J Pediatr 2023; 253:101-106.e2. [PMID: 36179888 DOI: 10.1016/j.jpeds.2022.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of universal newborn screening using stool color card or direct bilirubin (DB) testing when comparing with no screening for biliary atresia in Japanese setting. STUDY DESIGN A decision analytic Markov microsimulation model was developed to evaluate the universal screening for biliary atresia. Our screening strategies included stool color card, DB, or no screening. The outcomes of all newborns undergoing 3 strategies were simulated to analyze event-free life-years defined as liver transplant-free survival, costs, and incremental cost-effectiveness ratio (ICER) over a 25-year period with an annual discount rate of 2% applied for both costs and outcomes. A 1-way sensitivity analysis was performed to assess the uncertainty. RESULTS There were 941 000 newborn infants in our cohort and 114 cases of biliary atresia. The base case analysis showed that the stool color card strategy was $14 927 337 higher than no screening with an increase in 44 more event-free life-years gained, resulting in an ICER of $339 258 per event-free life-year gained. The DB screening strategy compared with stool color card was $138 994 060 higher with an increase in 271 more event-free life-years gained and an ICER of $512 893 per event-free life-year gained. The DB screening strategy compared with no screening resulted in an ICER of $488 639 per event-free life-year gained. The DB screening resulted in 16 fewer liver transplants than stool color card and stool color card had 2 fewer liver transplants than no screening. CONCLUSIONS Universal screening for biliary atresia could be cost-effective depending on the willingness to pay thresholds for health benefits.
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Affiliation(s)
- Eri Hoshino
- Comprehensive Unit for Health Economic Evidence Review and Decision Support (CHEERS), Research Organization of Science and Technology, Ritsumeikan University, Kyoto, Japan; Graduate School of Public Health, St. Luke's International University, Kyoto, Japan.
| | - Kensuke Moriwaki
- Comprehensive Unit for Health Economic Evidence Review and Decision Support (CHEERS), Research Organization of Science and Technology, Ritsumeikan University, Kyoto, Japan
| | | | - Kotomi Sakai
- Comprehensive Unit for Health Economic Evidence Review and Decision Support (CHEERS), Research Organization of Science and Technology, Ritsumeikan University, Kyoto, Japan
| | - Nobuyuki Shimohata
- Comprehensive Unit for Health Economic Evidence Review and Decision Support (CHEERS), Research Organization of Science and Technology, Ritsumeikan University, Kyoto, Japan
| | - Keiko Konomura
- Center for Outcomes Research and Economic Evaluation for Health (C2H), National Institute of Public Health, Kyoto, Japan
| | - Kevin Y Urayama
- Graduate School of Public Health, St. Luke's International University, Kyoto, Japan; Department of Social Medicine, National Center for Child Health and Development, Kyoto, Japan
| | - Mitsuyoshi Suzuki
- Department of Pediatrics, Faculty of Medicine, Juntendo University, Kyoto, Japan
| | - Kojiro Shimozuma
- Comprehensive Unit for Health Economic Evidence Review and Decision Support (CHEERS), Research Organization of Science and Technology, Ritsumeikan University, Kyoto, Japan
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Biliary Atresia Screening in India-Strategies and Challenges in Implementation. Indian J Pediatr 2022; 89:133-140. [PMID: 34453683 DOI: 10.1007/s12098-021-03862-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 05/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess the utilization of SCC implemented in southern India and the effect on SCC utilization of face-to-face verbal education versus video-based content delivery. METHODS The study included newborns with postnatal age of less than 2 wk at discharge. Mothers were administered SCCs and provided standardized verbal or video health education based on the time-period of enrollment. Home based monitoring of stool color and return of SCC on postnatal day 21 was advised. Telephone surveys were conducted to identify SCC use among families that did not return the SCC by post. RESULTS Of the 2254 newborns enrolled, 1130 were in the verbal-counseling group and 1124 in the video-counseling group. No newborns with pale stools and biliary atresia were identified. SCC return rates were 3.8% and 2.8%. Comparing the verbal and video-counseling groups, there were no differences in the conservative (81.8% vs. 81.5%) and optimistic estimates (97.1% vs. 97.3%) of SCC utilization rates. Mothers with better educational status had higher optimistic estimates of SCC utilization. CONCLUSIONS The use of a validated SCC in Tamil with standardized information delivery leads to good utilization rates in southern India, with video content delivery being as effective as face-to-face verbal content delivery. SCC return by post is not a feasible mode of identification of card use. TRIAL REGISTRATION The study is registered under Clinical Trials Registry - India (CTRI/2018/01/011285).
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Corrado MM, Mack CL. Diagnostic Tools for Early Detection of Biliary Atresia: Is a Newborn Screen Attainable? Clin Liver Dis (Hoboken) 2022; 19:25-28. [PMID: 35106146 PMCID: PMC8785912 DOI: 10.1002/cld.1165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Content available: Audio Recording.
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Affiliation(s)
- Michelle M. Corrado
- AASLD Emerging Liver Scholar, 2020,University of Colorado School of MedicineChildren’s Hospital ColoradoAuroraCO
| | - Cara L. Mack
- University of Colorado School of MedicineChildren’s Hospital ColoradoAuroraCO,Hewit/Andrews Chair in Pediatric Liver DiseaseUniversity of ColoradoSchool of MedicineAuroraCO,Department of PediatricsSection of Pediatric GastroenterologyHepatology & Nutrition Children's Hospital ColoradoDigestive Health Institute‐Pediatric Liver CenterUniversity of Colorado School of MedicineAuroraCO
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Liu F, Yeung F, Chung PHY. The outcome of Kasai portoenterostomy after day 70 of life. Front Pediatr 2022; 10:1015806. [PMID: 36340701 PMCID: PMC9634416 DOI: 10.3389/fped.2022.1015806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The age at Kasai portoenterostomy (KPE) was reported to correlate with the prognosis of patients with biliary atresia (BA) and that a late KPE is bounded to be failure. Herewith, we reported the outcome of patients receiving KPE after day 70 of life. In addition, the prognostic indicators were evaluated. MATERIALS AND METHODS This was a retrospective analysis and all BA patients receiving KPE after day 70 of life in a tertiary centre between 1980 and 2018 were evaluated. RESULTS A total of 164 KPE procedures were performed during the study period and 62 cases were done after day 70 of life which were included in this study. The median follow up period of these patients was 10.6 years (range: 4.5 to 41.5 years). Thirty-nine patients (62.9%) patients were able to achieve jaundice clearance at 6 months after KPE. The NLS rate was 53.2% (n = 33) as recorded at the time of writing. There was no statistical difference in the age at KPE between native liver survivors and patients requiring liver transplant. For complications among the native liver survivors (n = 33), portal hypertension and recurrent cholangitis were found in 63.6% and 30.3% of these patients. There was also no significant difference in the age at KPE between those who developed portal hypertension and recurrent cholangitis (p = 0.451 and p = 0.173 respectively). Regarding the prognostic indicators in predicting NLS, pre-KPE bilirubin, alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) were significantly higher among patients requiring liver transplant (p = 0.012, =0.011 and =0.017 respectively). The bilirubin level at 6 months after KPE was also higher among patients who required liver transplant (p = 0.016). CONCLUSION More than half of the BA patients can survive for 10 years with their native liver despite KPE was performed after day 70 of life. However, they have a higher chance to develop BA-related complications. The level of pre-KPE bilirubin and ductal enzymes as well as post-KPE bilirubin are prognostic indicators to predict NLS.
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Affiliation(s)
- Fangran Liu
- Division of Paediatric Surgery, Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, China
| | - Fanny Yeung
- Division of Paediatric Surgery, Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, China
| | - Patrick Ho Yu Chung
- Division of Paediatric Surgery, Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, China
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Rabbani T, Guthery SL, Himes R, Shneider BL, Harpavat S. Newborn Screening for Biliary Atresia: a Review of Current Methods. Curr Gastroenterol Rep 2021; 23:28. [PMID: 34817690 DOI: 10.1007/s11894-021-00825-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Biliary atresia is a serious neonatal liver disease due to obstructed bile ducts that has better outcomes when detected and treated in the first 30-45 days of life. This review examines different methods to screen newborns for biliary atresia as well as discusses observations from ongoing screening programs implemented in parts of the United States. RECENT FINDINGS Screening strategies for biliary atresia include detecting persistent jaundice, examining stool color, testing fractionated bilirubin levels, or measuring bile acid levels from dried blood spot cards. The stool color card program is the most widely used screening strategy worldwide. An alternative approach under investigation in the United States measures fractionated bilirubin levels, which are abnormal in newborns with biliary atresia. Fractionated bilirubin screening programs require laboratories to derive reference ranges, nurseries to implement universal testing, and healthcare systems to develop infrastructure that identifies and acts upon abnormal results. Biliary atresia meets the disease-specific criteria for newborn screening. Current studies focus on developing a strategy which also meets all test-specific criteria. Such a strategy, if implemented uniformly, has the potential to accelerate treatment and reduce biliary atresia's large liver transplant burden.
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Affiliation(s)
- Tebyan Rabbani
- Department of Pediatrics, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Stephen L Guthery
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Utah and Intermountain Primary Children's Hospital, Salt Lake City, UT, USA
| | - Ryan Himes
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Ochsner Health, New Orleans, LA, USA
| | - Benjamin L Shneider
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine and Texas Children's Hospital, 6621 Fannin Street, CCC 1010, Houston, TX, 77030, USA
| | - Sanjiv Harpavat
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine and Texas Children's Hospital, 6621 Fannin Street, CCC 1010, Houston, TX, 77030, USA.
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Madadi-Sanjani O, Kuebler JF, Uecker M, Pfister ED, Baumann U, Kunze-Hullmann B, Blaser J, Buck T, Petersen C. Province-Wide Stool Color Card Screening for Biliary Atresia in Lower-Saxony: Experiences with Passive Distribution Strategies and Results. Int J Neonatal Screen 2021; 7:ijns7040075. [PMID: 34842600 PMCID: PMC8629020 DOI: 10.3390/ijns7040075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Stool color card (SCC) screenings for biliary atresia (BA) have shown to improve Kasai timing and outcome significantly. Both obligatory and non-obligatory screenings with passive distribution strategies have proven to be effective. Therefore, we have initiated a voluntary SCC program and aim to describe our experience. METHODS Since 2017 we supply all maternity wards in Lower-Saxony with SCC. Attending pediatricians and parents of BA infants were contacted via questionnaires and asked for their evaluation of the SCC screening. RESULTS 85.2% of attending pediatricians support the SCC screening, but only 78.1% considered the initiative useful. In their clinical routine, only 67% of visiting parents report to have received an SCC at the maternity hospital. In the group of parents of BA infants, only 54% (7/13) had received an SCC. Out of those seven parents, only one had referred their child to a children's hospital based on pathological SCC results. The lack of SCC education in the maternity hospitals was made responsible by parents. Within three years, only one infant with BA was identified through the SCC. CONCLUSIONS Our voluntary SCC screening shows serious limitations with inacceptable distribution of SCCs and low acceptance of attending pediatricians. SCC programs in decentralized health care systems without educational campaigns, standardized diagnostic and treatment algorithms and the definition of reference centers are additional burdens for local health care providers without the promised benefit.
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Affiliation(s)
- Omid Madadi-Sanjani
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany; (J.F.K.); (M.U.); (C.P.)
- Correspondence: ; Tel.: +49-511-5329053; Fax: +49-511-5328095
| | - Joachim F. Kuebler
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany; (J.F.K.); (M.U.); (C.P.)
| | - Marie Uecker
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany; (J.F.K.); (M.U.); (C.P.)
| | - Eva-Doreen Pfister
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (E.-D.P.); (U.B.)
| | - Ulrich Baumann
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, 30625 Hannover, Germany; (E.-D.P.); (U.B.)
- Liver Unit, Birmingham Women’s and Children’s Hospital, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B4 6NH, UK
| | - Berit Kunze-Hullmann
- Leberkrankes Kind e.V., National German Patient Organization for Diseases of the Liver in Children, 20038 Hamburg, Germany;
| | - Jochen Blaser
- Representative Office of Lower Saxony, Techniker Krankenkasse (Health Insurance), 30159 Hannover, Germany;
| | - Thomas Buck
- Medical Association of Lower Saxony, Representative Office of Hannover, 30625 Hannover, Germany;
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany; (J.F.K.); (M.U.); (C.P.)
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Abstract
Biliary atresia (BA) is a common cause of surgical jaundice during the neonatal period. It is currently considered as a spectrum of diseases with a common final pathology characterized by obliteration of the extrahepatic biliary tract and the absence of normally branching intrahepatic ducts. Though it is a global disease that can be found in all ethnicities there are some clear differences between BA arising in the East and the West. This is likely to be related to different genetic, environmental and cultural factors. BA is more frequently found in Far Eastern infants (both Chinese and Japanese) though the syndromic associations are much less common. Many Eastern countries have national screening programmes not seen in the West possibly due to debate over its cost effectiveness in countries where incidence is low. Kasai portoenterostomy (KPE) is considered as the primary treatment of BA but its outcome still remains unsatisfactory across the region. Given the complexity of BA, it is unlikely that strategic advances could be made by the sole effort of individual countries and we believe that collaboration between the East and West is the way forward.
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Karpen SJ. Pediatric Cholestasis: Epidemiology, Genetics, Diagnosis, and Current Management. Clin Liver Dis (Hoboken) 2020; 15:115-119. [PMID: 32685137 PMCID: PMC7346681 DOI: 10.1002/cld.895] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/23/2019] [Indexed: 02/04/2023] Open
Abstract
Watch a video presentation of this article Watch an interview with the author Answer questions and earn CME.
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Affiliation(s)
- Saul J. Karpen
- Department of PediatricsDivision of Pediatric Gastroenterology, Hepatology and NutritionEmory University School of Medicine/Children's Healthcare of AtlantaAtlantaGA
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Direct Health Care Costs, Health Services Utilization, and Outcomes of Biliary Atresia: A Population-based Cohort Study. J Pediatr Gastroenterol Nutr 2020; 70:436-443. [PMID: 31834111 DOI: 10.1097/mpg.0000000000002582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Biliary atresia (BA) is the most common reason for liver transplant in childhood, and outcomes worsen with older age at hepatoportoenterostomy (HPE). We determined direct health care costs in children with BA, compared to controls in a population-based cohort of children in Ontario, Canada. METHODS We used health administrative data to identify all children diagnosed with BA between 2002 and 2016 (n = 121) and matched controls (n = 602). We determined annual direct healthcare costs, and rates of health services utilization, liver transplantation, death, portal hypertension, cirrhosis, esophageal varices, and major upper gastrointestinal bleeding requiring hospitalization. Multivariable regression models determined the association between age at HPE, risk of liver transplant, and direct costs. RESULTS Incidence of BA was 6.07 (4.99-7.15) per 100,000 live births. The annual median (interquartile range) direct health care costs were higher in BA cases ($4210; interquartile range $1091-$16,765) compared to controls ($283; $112-$634). Compared to age at HPE <45 days, there was no significant association between direct costs and HPE ≥90 days (rate ratio 1.24, 95% confidence interval [CI] 0.78-1.97) or 45 to 90 days (rate ratio 1.05, 95% CI 0.73-1.50). Age at HPE ≥90 days was significantly associated with risk of undergoing liver transplant compared to age <45 days (hazard ratio 5.27, 95% CI 2.45-11.34). Direct costs were higher in patients with BA who underwent liver transplantation compared to those who did not ($39,476±$84,367 vs $22,579 ± $67,913). CONCLUSIONS Direct ealth care costs were high in patients with BA, especially in those who underwent liver transplantation. Age at HPE was associated with risk of liver transplantation, but not direct health care costs, utilization, or other risk outcomes.
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Harpavat S, Garcia-Prats JA, Anaya C, Brandt ML, Lupo PJ, Finegold MJ, Obuobi A, ElHennawy AA, Jarriel WS, Shneider BL. Diagnostic Yield of Newborn Screening for Biliary Atresia Using Direct or Conjugated Bilirubin Measurements. JAMA 2020; 323:1141-1150. [PMID: 32207797 PMCID: PMC7093763 DOI: 10.1001/jama.2020.0837] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Treating biliary atresia in newborns earlier can delay or prevent the need for liver transplant; however, treatment typically occurs later because biliary atresia is difficult to detect during its early stages. OBJECTIVE To determine the diagnostic yield of newborn screening for biliary atresia with direct or conjugated bilirubin measurements and to evaluate the association of screening implementation with clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional screening study of 124 385 infants born at 14 Texas hospitals between January 2015 and June 2018; and a pre-post study of 43 infants who underwent the Kasai portoenterostomy as treatment for biliary atresia at the region's largest pediatric hepatology center before (January 2008-June 2011) or after (January 2015-June 2018) screening implementation. Final follow-up occurred on July 15, 2019. EXPOSURES Two-stage screening with direct or conjugated bilirubin measurements. In stage 1, all newborns were tested within the first 60 hours of life, with a positive screening result defined as bilirubin levels exceeding derived 95th percentile reference intervals. In stage 2, infants who had a positive screening result in stage 1 were retested at or before the 2-week well-child visit, with a positive screening result defined as bilirubin levels greater than the stage 1 result or greater than 1 mg/dL. MAIN OUTCOMES AND MEASURES The primary outcomes of the screening study were sensitivity, specificity, positive predictive value, and negative predictive value based on infants testing positive in both stages. The reference standard was biliary atresia diagnosed at the region's pediatric hepatology centers. The primary outcome of the pre-post study was the age infants underwent the Kasai portoenterostomy for treatment of biliary atresia. RESULTS Of 124 385 newborns in the screening study, 49.2% were female, 87.6% were of term gestational age, 70.0% were white, and 48.1% were Hispanic. Screening identified the 7 known infants with biliary atresia with a sensitivity of 100% (95% CI, 56.1%-100.0%), a specificity of 99.9% (95% CI, 99.9%-99.9%), a positive predictive value of 5.9% (95% CI, 2.6%-12.2%), and a negative predictive value of 100.0% (95% CI, 100.0%-100.0%). In the pre-post study, 24 infants were treated before screening implementation and 19 infants were treated after screening implementation (including 6 of 7 from the screening study, 7 from screening at nonstudy hospitals, and 6 from referrals because of clinical symptoms). The age infants underwent the Kasai portoenterostomy was significantly younger after screening was implemented (mean age, 56 days [SD, 19 days] before screening implementation vs 36 days [SD, 22 days] after screening implementation; between-group difference, 19 days [95% CI, 7-32 days]; P = .004). CONCLUSIONS AND RELEVANCE Newborn screening with direct or conjugated bilirubin measurements detected all known infants with biliary atresia in the study population, although the 95% CI around the sensitivity estimate was wide and the study design did not ensure complete ascertainment of false-negative results. Research is needed in larger populations to obtain more precise estimates of diagnostic yield and to better understand the clinical outcomes and cost-effectiveness of this screening approach.
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Affiliation(s)
- Sanjiv Harpavat
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston
| | - Joseph A. Garcia-Prats
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston
| | - Carlos Anaya
- University of Texas Rio Grande Valley School of Medicine and Doctors Hospital at Renaissance, Edinburg
| | - Mary L. Brandt
- Department of Surgery, Baylor College of Medicine and Texas Children’s Hospital, Houston
| | - Philip J. Lupo
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston
| | | | - Alice Obuobi
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston
| | - Adel A. ElHennawy
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston
| | | | - Benjamin L. Shneider
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston
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13
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Madadi-Sanjani O, Blaser J, Voigt G, Kuebler JF, Petersen C. Home-based color card screening for biliary atresia: the first steps for implementation of a nationwide newborn screening in Germany. Pediatr Surg Int 2019; 35:1217-1222. [PMID: 31346695 DOI: 10.1007/s00383-019-04526-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Biliary atresia is a rare neonatal disease and the most common indication for pediatric liver transplantation. Kasai portoenterostomy is the initial treatment, aiming to prevent liver transplantation. Beyond age at Kasai, few prognostic factors are known. Multiple countries have established screening methods to reduce the age at Kasai and recent analysis shows significant better outcomes for screening cohorts. In 2016, we established a decentralized stool color card screening in Lower Saxony and we present our first 2 years of experiences. METHODS In cooperation with a major German health insurance company and the Medical Association of Lower Saxony, we established the screening project, printed 120,000 color cards, and distributed them to all maternity hospitals. Program advertises were printed in newspapers and medical journals. After the first year, the project was evaluated. Thirty maternity hospitals and local practitioners were contacted via telephone, Internet, intranet, and pediatric journals. RESULTS One out of seventy-six maternity hospitals (1.3%) refused to participate in the screening. 30 hospitals (40%) were contacted and 93.5% of the interviewed staff reported that stool color cards were handed out regularly and discussed with the parents. Only 20% of local practitioners assessed neonatal cholestasis to be a relevant problem during daily practice, and 55% regarded a stool color card screening to be useful. CONCLUSIONS In the second year, we extended the screening project to outpatient maternity clinics. Based on the responses of local practitioners, we regard the voluntary screening as insufficient and we have contacted the Federal Joint Committee for the initiation of a nationwide obligatory stool color card screening.
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Affiliation(s)
- Omid Madadi-Sanjani
- Center of Pediatric Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - J Blaser
- Representative Office of Lower Saxony, Techniker Krankenkasse (Health Insurance), Hannover, Germany
| | - G Voigt
- Medical Association of Lower Saxony, Representative Office of Hannover, Hannover, Germany
| | - J F Kuebler
- Center of Pediatric Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - C Petersen
- Center of Pediatric Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Biliary Atresia as a Disease Starting In Utero: Implications for Treatment, Diagnosis, and Pathogenesis. J Pediatr Gastroenterol Nutr 2019; 69:396-403. [PMID: 31335837 PMCID: PMC6942669 DOI: 10.1097/mpg.0000000000002450] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biliary atresia (BA) is the most common reason for pediatric liver transplant. BA's varied presentation, natural history, and treatment with the Kasai portoenterostomy have been well described; however, when BA starts relative to birth has not been clearly defined. In this review, we discuss laboratory, imaging, and clinical data which suggest that most if not all forms of BA may start before birth. This early onset has implications in terms of delivering treatments earlier and identifying possible factors underlying BA's etiology.
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