A Novel Model for Predicting the Clearance of Jaundice in Patients With Biliary Atresia After Kasai Procedure

Perioperative effects of dexmedetomidine on renal function in allogeneic kidney transplant patients: a meta-analysis

BACKGROUND

Allogeneic kidney transplantation represents a cornerstone therapeutic strategy for patients diagnosed with end-stage renal disease. The perioperative management of these patients plays a crucial role in ensuring both optimal graft viability and favorable postoperative outcomes. Dexmedetomidine, a highly selective α2-adrenergic agonist, has attracted considerable attention for its potential renoprotective properties, which are attributed to its anti-inflammatory effects, suppression of sympathetic nervous activity, and ability to stabilize hemodynamics. This meta-analysis was undertaken to systematically integrate the current body of evidence regarding the impact of dexmedetomidine on perioperative renal function in recipients of allogeneic kidney transplants.

METHODS

A systematic and comprehensive search of the literature was conducted using multiple databases-PubMed, Embase, Web of Science, Cochrane Library, and the China National Knowledge Infrastructure (CNKI)-up to March 2025. IEligible studies included those involving adult recipients of allogeneic kidney transplants, wherein dexmedetomidine was administered during the perioperative period, and renal function outcomes such as serum creatinine (Cr), blood urea nitrogen (BUN), urine output, or delayed graft function (DGF) were reported. Two reviewers independently extracted data to ensure objectivity and accuracy; disagreements were resolved by discussion. The pooled data were analyzed using a random-effects model. Statistical heterogeneity was quantified using the I2 statistic, while potential publication bias was assessed through funnel plot symmetry. Sensitivity analyses were conducted to evaluate the robustness of the synthesized results.

RESULTS

Eleven studies comprising 1417 patients were included. Compared to controls, dexmedetomidine significantly reduced serum creatinine levels (SMD = - 0.75, 95% CI - 1.18 to - 0.32, p < 0.001; I2 = 84.1%) and BUN levels (SMD = - 0.87, 95% CI - 1.30 to - 0.44, p = 0.001; I2 = 74.5%). Urine output was significantly increased (SMD = 0.98, 95% CI 0.23 to 1.74, p < 0.001; I2 = 90.0%). The incidence of delayed graft function was lower in the dexmedetomidine group (OR = 0.71, 95% CI 0.52 to 0.97, p = 0.616; I2 = 0.0%). Length of hospital stay was also reduced (SMD = - 0.16, 95% CI - 0.29 to - 0.04, p = 0.364; I2 = 5.9%). Sensitivity analyses confirmed the robustness of the results. No significant publication bias was detected.

CONCLUSION

The results of this meta-analysis support the renoprotective potential of dexmedetomidine when administered during the perioperative phase of allogeneic kidney transplantation. Its use is associated with improvements in key renal function markers, such as reductions in serum creatinine and BUN levels, as well as a decreased incidence of delayed graft function. The observed increase in urine output and shortened hospital stay additionally suggest broader perioperative benefits. Taken together, these findings underscore dexmedetomidine's promise as an adjunct pharmacologic agent in the perioperative care of kidney transplant recipients. Further validation through well-designed, large-scale randomized controlled trials remains essential to inform clinical guidelines.

Efficacy of sodium bicarbonate Ringer's solution for perioperative fluid management in infants with biliary atresia: a prospective multicenter study

PURPOSE

To evaluate the efficacy and safety of perioperative sodium bicarbonate Ringer's solution (BRS) in biliary atresia (BA) infants undergoing Kasai portoenterostomy (KPE).

METHODS

This study was conducted in 11 pediatric medical centers across China from 2020 to 2022. Infants were randomly assigned to either the BRS group (n = 64) or the control crystalloids group (n = 56) for perioperative fluid management. Anesthesia and fluid management were standardized. Primary outcomes were arterial blood pH, bicarbonate, and base excess; secondary outcomes included changes in other blood parameters and adverse events.

RESULTS

The baseline characteristics of the two groups were similar. During KPE, BRS more effectively maintained arterial blood pH, bicarbonate, and base excess during KPE with no electrolyte abnormalities. Three days after KPE, the BRS group had lower potassium levels. Drug safety evaluation showed no significant differences, and the incidence of adverse events was comparable.

CONCLUSION

BRS effectively maintained the acid-base status of BA infants during KPE. With no significant safety concerns, it is suggested that BRS is a suitable option for perioperative fluid management.

Comparison of different Kasai portoenterostomy techniques in the outcomes of biliary atresia: a systematic review and network meta-analysis

BACKGROUND

Biliary atresia (BA) is a progressive disease affecting the bile duct structure and function, leading to poor outcomes without timely surgical intervention. Kasai portoenterostomy (KPE) is a commonly used treatment to restore bile flow. However, the success rate and postoperative outcomes of KPE vary with different surgical techniques, including laparoscopic, robot-assisted, and open approaches.

METHODS

Following the PRISMA guidelines, this study systematically searched PubMed, EMBASE, and Cochrane databases for literature on BA surgical techniques of KPE. Studies comparing two or all three techniques-laparoscopic, robot-assisted, and open-in terms of postoperative outcomes of KPE in BA patients were included. Utilizing the "gemtc" package in R version 4.3.3, NMA was conducted to compare postoperative clearance of jaundice (COJ) among different surgical techniques. We also performed traditional paired meta-analysis in which multiple surgical outcomes were compared.

RESULTS

According to the traditional definition of a successful KPE surgery, in terms of successful postoperative COJ, robotic-assisted Kasai portoenterostomy (RAKPE) shows advantage over open Kasai portoenterostomy (OKPE) and laparoscopic Kasai portoenterostomy (LKPE), while the outcomes between OKPE and LKPE are equivalent. However, statistically speaking, there is no significant difference among the three techniques. LKPE has a longer operation time and less intraoperative bleeding compared to OKPE. There are no statistically significant differences in hospital stay, cholangitis incidence, or liver survival rates at 6 months, 1 year, 2 years, or 5 years.

CONCLUSION

The surgical success rates of KPE with various technical aids are similar, highlighting the need to consider individual patient conditions and cost when choosing a surgical technique. Effective postoperative management is vital for preventing complications and slowing liver fibrosis. Future research should focus on improving surgical techniques and postoperative care to enhance long-term outcomes for BA patients. For those who cannot maintain liver function with KPE, timely LT consideration is crucial.

Relationship between hepatic function recovery and postoperative cholangitis in neonates undergoing hepaticojejunostomy for biliary atresia

OBJECTIVE

To explore the association between hepatic function recovery and the incidence of postoperative cholangitis in neonates with biliary atresia (BA) who underwent hepaticojejunostomy.

METHODS

We conducted a retrospective analysis of medical records from 173 newborns diagnosed with BA and treated with hepaticojejunostomy (Kasai procedure) between February 2020 and October 2022. Participants were categorized into two cohorts: those who developed cholangitis post-surgery (cholangitis group, n=125) and those who did not (non-cholangitis group, n=48). Liver function indices pre- and post-treatment, the extent of postoperative liver function recovery, and jaundice resolution rates were compared. Risk factors for cholangitis development post-surgery were identified using univariate and multifactorial logistic regression analyses.

RESULTS

The cholangitis group exhibited higher surgical weight (P=0.030) and elevated preoperative levels of total bilirubin (TB, P<0.001), direct bilirubin (DB, P<0.001), aspartate aminotransferase (AST, P<0.001), and gamma-glutamyl transferase (GGT, P<0.001). This group also showed better postoperative liver function recovery (P=0.002) and jaundice clearance rates (P=0.003). Logistic regression identified postoperative jaundice clearance (P=0.013), TB (P=0.004), DB (P=0.011), AST (P<0.001), and GGT (P<0.001) as independent risk factors for cholangitis. The nomogram model had a C-index of 0.930 with a goodness-of-fit test p-value of 0.873, and an AUC of 0.930.

CONCLUSION

Postoperative jaundice clearance, TB, DB, AST, and GGT are independent risk factors for cholangitis. The nomogram model offers high predictive accuracy for cholangitis development, aiding early intervention and prognosis improvement in high-risk neonates.

The systemic immune-inflammation index at kasai portoenterostomy: related to clinical outcomes

BACKGROUND

Systemic Immune-Inflammation Index (SII), known as an easy, economical and useful marker, correlates with the balance of inflammation and immune response. However, the usefulness of SII in biliary atresia (BA) remains unclear. Therefore, we evaluated the relationship of SII level and postoperative clinical outcomes of BA.

METHODS

Retrospective review of 168 patients with BA was conducted with assessments of demographic information, histological findings, laboratory parameters, and clinical outcomes. The LASSO logistic regression analysis was established using the "glmnet" software package to explore the influencing factors related to native liver survival time. Numerical variables were dichotomized based on the receiver operating characteristic (ROC) curve and Youden index yielding the best performance of prediction. R software was used for statistical analysis.

RESULTS

Overall, the 24 month native liver survival rate was 43.5% (73 cases) after Kasai portoenterostomy. LASSO logistic regression analysis show that preoperative malnutrition (OR = 0.032, 95%CI 0.001-0.424), gamma-glutamyltransferase (GGT, OR = 0.994, 95%CI 0.987-0.998), lymphocyte count (LY, OR = 2.426, 95%CI 1.467-4.604), SII (OR = 0.977, 95%CI 0.960-0.989), and liver fibrosis grading (LFG, reference: Grade 1, Grade 3, OR = 0.076, 95%CI 0.007-0.614) were the independent influencing factors for 24 month native liver survival. ROC curve analysis showed that the area under the curve of SII level (0.919) was larger than that of preoperative malnutrition (0.690), LFG (0.759), GGT (0.747), and Ly (0.773). A SII < 140.09 was found to be a significant marker in the prediction of 24-month native liver survival, with 90.41% sensitivity and 93.68% specificity. Furthermore, the rates of 24-month native liver survival (33.1% vs. 72.7%), jaundice clearance (46.8% vs. 75.0%), and good liver function recovery (46.8% vs. 65.9%) were lower in the SII ≥ 140.09 group than that in the SII < 140.09 group (all P < 0.05), but there was no difference in the occurrence of cholangitis (P > 0.05).

CONCLUSION

Preoperative malnutrition, GGT, Ly, SII, and LFG were independent influencing factors for postoperative 24-month native liver survival of BA. The SII level, as a routine haematological marker, has better universality and simplicity and is related to clinical outcomes after Kasai portoenterostomy.

A convenient nomogram for predicting early death or liver transplantation after the Kasai procedure in patients with biliary atresia

PURPOSE

Many patients with biliary atresia (BA) after the Kasai procedure (KP) progress to death or require liver transplantation to achieve long-term survival; however, most cases of death/liver transplantation (D/LT) occur in the early period after KP (usually within 1 year). This study was designed to construct a convenient nomogram for predicting early D/LT in patients with BA after KP.

METHODS

A BA cohort was established in May 2017, and up to May 2023, 112 patients with 1-5 years of follow-up were enrolled in the study and randomly (ratio, 3:1) divided into a training cohort for constructing a nomogram (n = 84) and a validation cohort (n = 28) for externally validating the discrimination and calibration. The training cohort was divided into two groups: the early D/LT group (patients who died or had undergone LT within 1 year after KP [n = 35]) and the control group (patients who survived through the native liver more than 1 year after KP [n = 49]). Multivariate logistic regression and stepwise regression were applied to detect variables with the best predictive ability for the construction of the nomogram. The discrimination and calibration of the nomogram were internally and externally validated.

RESULTS

The Kaplan-Meier (K-M) curve showed an actual 1-year native liver transplantation (NLS) rate of 57.1% and an estimated 2-year NLS rate of 55.2%. By multivariate regression and stepwise regression, age at KP, jaundice clearance (JC) speed 1 month after KP, early-onset PC (initial time < 36.5 days) after KP, sex, aspartate aminotransferase-to-platelet ratio index (APRI), and weight at KP were identified as the independent variables with the best ability to predict early D/LT and were used to construct a nomogram. The developed nomogram based on these independent variables showed relatively good discrimination and calibration according to internal and external validation.

CONCLUSION

Most D/LTs were early D/LTs that occurred within 1 year after KP. The established nomogram based on predictors, including sex, weight at the KP, the APRI, age at the KP, JC speed 1 month after the KP, and early PC, may be useful for predicting early D/LT and may be helpful for counseling BA patients about patient prognosis after KP. This study was retrospectively registered at ClinicalTrials.gov (NCT05909033) in June 2023.

Predictive model containing gene signature and shear wave elastography to predict patient outcomes after Kasai surgery in biliary atresia

AIMS

Infants with biliary atresia (BA) are treated with Kasai portoenterostomy (KPE) surgery, but many BA patients need subsequent salvage liver transplants. The aim of this study is to develop a comprehensive gene-clinical model based on two-dimensional shear wave elastography (2DSWE), liver gene expression, and other clinical parameters to predict response to KPE for BA patients.

METHODS

Differentially expressed gene patterns between liver samples of BA (n = 102) and non-BA control (n = 14) were identified using RNA sequencing analysis. Biliary atresia patients were then randomly assigned to training and validation cohorts. Gene classifier based on the differentially expressed genes was built in the training cohort. Nomogram models with and without gene classifier were further constructed and validated for predicting native liver survival of BA patients. The utility of the nomograms was compared by C-index.

RESULTS

Using the least absolute shrinkage and selection operator model, we generated a nine-gene prognostic classifier. The nomogram based on the nine-gene classifier, age, preoperative 2DSWE, and albumin had the better C-index compared to gene classifier alone in the training cohort (0.83 [0.76-0.90] vs. 0.69 [0.61-0.77], p = 0.003) and the validation cohort (0.74 [0.67-0.82] vs. 0.62 [0.55-0.70], p = 0.001). Using risk scores developed from the nomogram, the 12-month survival rates of BA patients with native liver were 35.7% (95% confidence interval [CI], 22.7-56.3) in the high-risk group and 80.8% (95% CI, 63.4-100.0) in the low-risk group in the validation cohort.

CONCLUSIONS

The comprehensive genetic-clinical nomogram based on preoperative 2DSWE, liver gene expression, and other clinical parameters can accurately predict response to KPE.

[New advances in the diagnosis and treatment of biliary atresia]

The diagnosis of biliary atresia (BA) is mainly based on clinical manifestations, screening, and related biochemistry tests. In recent years, the development of blood biomarkers and the improvement in ultrasound examination have made it possible for BA to be diagnosed at a younger age. In particular, matrix metalloproteinase-7 shows high sensitivity and specificity and has a higher diagnostic efficiency than existing biochemical parameters, thereby holding a promise for clinical application. Sound touch elastography can increase the diagnostic efficiency for BA in terms of diagnosis and prognostic evaluation. Surgery is still the only method for the treatment of BA at present, with the preferred surgical treatment regimen of Kasai portoenterostomy combined with pharmacotherapies for alleviating infection and inflammation, and the patients who fail Kasai portoenterostomy or have liver dysfunction may require liver transplantation to save their lives. Therefore, the current research on BA should focus on the biomarkers for early diagnosis, specifically targeted drugs, and drugs for preventing progressive liver fibrosis. This article reviews the current diagnosis and treatment methods for BA and discusses the potential research directions.

Low gamma-glutamyl transpeptidase levels at presentation are associated with severity of liver illness and poor outcome in biliary atresia

OBJECTIVE

To investigate the clinical features and prognosis of biliary atresia (BA) with normal or minimally elevated gamma-glutamyl transpeptidase (GGT).

METHODS

The clinical data of patients with BA in our hospital between 2012 and 2017 were retrospectively studied. The patients were divided into a low-GGT group (GGT ≤ 300 IU/L) and a high-GGT group (GGT > 300 IU/L) according to the preoperative GGT level. The perioperative clinical parameters, the postoperative jaundice clearance within 6 months, and the 2-year native liver survival were compared among the groups.

RESULTS

A total of 1,998 children were included in this study, namely, 496 in the low-GGT group and 1,502 in the high-GGT group. The ages and weights at the surgery in the low-GGT group were significantly lower than those in the high-GGT group (64.71 ± 21.35 vs. 68.64 ± 22.42 days, P = 0.001; 4.67 ± 1.03 vs. 4.89 ± 0.98 kg, P < 0.001). The levels of serum ALP, ALT, and AST in the low-GGT group were significantly higher than those in the high-GGT group before and 2 weeks after the surgery (ALP: 647.52 ± 244.10 vs. 594.14 ± 228.33 U/L, P < 0.001; ALT: 119.62 ± 97.14 vs. 96.01 ± 66.28 U/L, P < 0.001; AST: 218.00 ± 173.82 vs. 160.71 ± 96.32 U/L; P < 0.001). The INR of the low-GGT group was higher than that of the high-GGT group (1.05 ± 0.34 vs. 0.98 ± 0.20, P < 0.001), while FIB was lower than the high-GGT group (2.54 ± 0.67 vs. 2.73 ± 1.44 g/L; P = 0.006). The decreasing amplitude of TB and DB within 2 weeks after surgery in the low-GGT group was smaller than those in the high-GGT group (TB: 51.62 ± 71.22 vs. 61.67 ± 53.99 μmol/L, P = 0.003; DB: 33.22 ± 35.57 vs. 40.20 ± 35.93 μmol/L, P < 0.001). The jaundice clearance rate in the low-GGT group was significantly lower than that in the high-GGT group at 1, 3, and 6 months after surgery (17.70 vs. 26.05%; 35.17 vs. 48.58%; 38.62 vs. 54.64%, P < 0.001). In addition, the 2-year native liver survival rate in the low-GGT group was significantly lower than that of the high-GGT group (52.5 vs. 66.3%, P < 0.001 HR 1.80, 95% CI 1.38-2.33).

CONCLUSION

Compared to patients with high GGT, patients with normal or minimally elevated pre-operative GGT in BA were found to have poorer pre-operative liver function parameters, and post-operatively had lower jaundice clearance rates and worse 2-year native liver survival. This suggests a lower GGT at presentation in biliary atresia could be a sign of more severe liver injury.

A nomogram model based on preoperative grey-scale US features and routine serum biomarkers to predict the outcome of infants with biliary atresia after Kasai portoenterostomy

OBJECTIVE

To establish a nomogram to predict the outcome of biliary atresia (BA) infants 3-months post- Kasai portoenterostomy (KPE).

METHODS

BA Infants who underwent KPE from two hospitals were included in the training (n = 161) and validation cohorts (n = 64). A logistic regression equation (Equation A) for predicting the serum total bilirubin (TBIL) level 3-month post-KPE was established in the training cohort. Then, a nomogram was developed based on Equation A in the training cohort and validated in the validation cohort. Moreover, a new equation (Equation B) was generated based on the nomogram and the size of the enlarged hilar lymph nodes (LNs) in the validation cohort. The predictive performance of the nomogram was evaluated by the receiver operating characteristic (ROC) curve and by calculating the area under the ROC curve (AUC), sensitivity, specificity, and positive (PPV) and negative (NPV) prediction values.

RESULTS

A nomogram based on gallbladder morphology and serum levels of TBIL and total protein (TP) was established with AUC (95%CI) of 0.673 (0.595, 0.745) and 0.647 (0.518, 0.763), sensitivity (95%CI) of 71.4% (62.1%,79.6%) and 81.8% (59.7%,94.8%), specificity (95%CI) of 63.3% (48.3%,76.6%) and 47.6% (32.0%,63.6%), PPV (95%CI) of 81.6% (72.5%,88.9%) and 45.0% (29.3%,61.5%), and NPV (95%CI) 49.2% (36.4%,62.1%) and 83.3% (62.6%,95.3%), respectively, in the training and validation cohorts. Furthermore, in the validation cohort, the AUC (95%CI) of Equation B was 0.798 (95%CI: 0.679, 0.888), which was significantly higher than that of the nomogram (P = 0.042).

CONCLUSION

A nomogram based on the pre-KPE gallbladder morphology, TBIL, and TP to predict the outcome of BA 3-months post-KPE is established. Moreover, the addition of the size of the enlarged hilar LNs into the nomogram further improves its predictive value.