ANKRD1 and SPP1 as diagnostic markers and correlated with immune infiltration in biliary atresia

The diagnosis of biliary atresia (BA) remains a clinical challenge, reliable biomarkers that can easily distinguish BA and other forms of intrahepatic cholestasis (IC) are urgently needed.Differentially expressed genes were identified by R software. The least absolute shrinkage and selection operator regression and support vector machine algorithms were used to filter the diagnostic biomarkers of BA. The candidate biomarkers were further validated in another independent cohort of patients with BA and IC. Then CIBERSORT was used for estimating the fractions of immune cell types in BA. Gene set enrichment analyses were conducted and the correlation between diagnostic genes and immune cells was analyzed.A total of 419 differentially expressed genes in BA were detected and 2 genes (secreted phosphoprotein 1 [SPP1] and ankyrin repeat domain [ANKRD1]) among them were selected as diagnostic biomarkers. The SPP1 yielded an area under the curve (AUC) value of 0.798 (95% confidence interval [CI]: 0.742-0.854) to distinguish patients with BA from those with IC, and ANKRD1 exhibited AUC values of 0.686 (95% CI: 0.616-0.754) in discriminating BA patients and those with IC. Further integrating them into one variable resulted in a higher AUC of 0.830 (95% CI: 0.777-0.879). The regulatory T cells, M2 macrophages cells, CD4 memory T cells, and dendritic cells may be involved in the BA process. The ANKRD1 and SPP1 was negatively correlated with regulatory T cells.In conclusion, the ANKRD1 and SPP1 could potentially provide extra guidance in discriminating BA and IC. The immune cell infiltration of BA gives us new insight to explore its pathogenesis.

Perioperative reactive oxygen species in infants with biliary atresia: A retrospective observational study

Biliary atresia (BA) is a devastating cholestatic disorder of infants that presents during the first several months after birth due to an idiopathic obstruction to the bile flow. Without prompt diagnosis, Kasai portoenterostomy, and deliberate follow-ups, the resulting cholestasis leads to progressive hepatic failure. Oxidative stress is an abnormal phenomenon inside cells or tissues caused by a disturbance in the reactive oxygen species (ROS). We aimed to measure perioperative ROS in BA patients.Data are presented as median (25th, 75th percentiles). We evaluated 15 BA patients (age 55 [48, 69] days) and measured ROS; serum superoxide dismutase (SOD), urinary 8-iso prostaglandin F2α (8-iso-PGF2α) and 8-hydroxy-2'-deoxyguanosine (8-OHdG) preoperatively and 30 days later to compare values with serum liver function tests and histologic grades of liver cholestasis. For compared BA patients, 4 normal subjects as control group (age 55 [27, 75] days) measured ROS and serum liver function tests.In BA patients, the preoperative serum SOD was 6.1 IU/mL (4.7, 7.2), urinary 8-iso-PGF2α was 1969 pg/mg Cre (1697, 2374), and urinary 8-OHdG was 37.1 ng/mg Cre (33.1, 53.7). At the postoperative day 30, the serum SOD was 5.2 IU/mL (4.2, 6.7), urinary 8-iso-PGF2α was 1761 pg/mg Cre (1256, 3036), and urinary 8-OHdG was 42.1 ng/mg Cre (29.65, 72.64). In ROS, there were no significant differences between the 2 periods. In control group, urinary 8-iso-PGF2α was significantly lower than that in preoperative BA patient group. However, other ROS were not significant differences between control group and BA patient group. The concentration of urinary 8-iso-PGF2α was positively correlated with total bilirubin and direct bilirubin levels (preoperatively: r = 0.6921, P = .0042 and r = 0.6639, P = .007, postoperatively: r = 0.6036, P = .0172 and r = 0.6464, P = .0092, respectively). The preoperative ROS were not correlated with histologic grades of liver cholestasis. Various factors such as liver inflammation, lipid malabsorption, and tissue disorders due to jaundice might affect the antioxidant activity and elevated urinary 8-iso-PGF2α. However, at least until 30 days later, urinary 8-OHdG as oxidative DNA damage might persist after the operation whether the cholestasis improved or not.

Periportal thickening on magnetic resonance imaging for hepatic fibrosis in infantile cholestasis

BACKGROUND

Untreated neonatal cholestasis can progress to liver cirrhosis and end stage liver disease in infancy due to prolonged hepatocyte and biliary tree injury and may require liver transplantation. Therefore, non-invasive evaluation of hepatic fibrosis is important in infants with cholestasis.

AIM

To investigate the usefulness of periportal thickening (PT) measured on liver magnetic resonance imaging (MRI) for the assessment of hepatic fibrosis in infants with cholestasis including biliary atresia (BA).

METHODS

This retrospective study included infants less than 6 mo who underwent liver MRI and biopsy for the evaluation of infantile cholestasis. PT and spleen size were measured on MRI. Serologic assessment was based on aspartate transaminase to platelet ratio index (APRI). The grade of histopathologic fibrosis was assessed by the METAVIR grading system. Correlation and diagnostic performance of PT, normalized spleen size ratio (SR, using the upper normal size limit), and APRI for diagnosing hepatic fibrosis were obtained by receiver-operating characteristic (ROC) curve analysis.

RESULTS

A total of 155 patients were included, 110 of which were diagnosed with BA. Mean age at the time of MRI was 57.6 ± 34.4 d. There were positive correlations between fibrosis grade and PT and SR, even after adjusting age (all, P < 0.001). For the diagnosis of significant fibrosis (METAVIR grade F2-F4), the area under the ROC curve was 0.899 (95%CI: 0.840–0.941) for PT (cutoff, 4.2 mm), which was higher than 0.741 (95%CI: 0.664–0.808) for SR and 0.712 (95%CI: 0.634–0.782) for APRI (both, P < 0.001). For the diagnosis of cirrhosis (F4), the area under the ROC curve was the highest with SR as 0.790 (95%CI: 0.718–0.852).

CONCLUSION

Liver MRI findings of PT and SR are useful to assess clinically significant hepatic fibrosis (F2 and higher) in infants with cholestasis including BA.

Diagnostic Yield of Newborn Screening for Biliary Atresia Using Direct or Conjugated Bilirubin Measurements

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.

Association of Early Direct Bilirubin Levels and Biliary Atresia Among Neonates

This case series evaluates the direct bilirubin levels in the first days after birth among neonates who were subsequently diagnosed with biliary atresia.

Hepatocyte growth factor levels in livers and serum at Kasai-portoenterostomy are not predictive of clinical outcome in infants with biliary atresia

Biliary atresia (BA) is characterized by progressive destruction of the biliary system leading to liver fibrosis and deterioration of liver function. Serum hepatocyte growth factor (HGF) has been shown to be increased in cirrhotic diseases including BA. The aim of this study was to investigate the prognostic value of HGF levels in sera and liver tissue for the further disease course. A total of 49 serum and liver samples from infants with BA were acquired during Kasai-portoenterostomy (KPE) and analyzed by multiplex immunoassay including HGF, as marker of liver regeneration, and Interleukin 6 (IL-6) as a marker of inflammation. Both mediators showed no correlation with the outcome defined as favorable (survival with native liver (SNL)) or, in contrast, rapid deterioration of liver function requiring transplantation. Our data suggest that the degree of liver regeneration indicated by high levels of HGF within the liver is a dismissible factor in the post-KPE disease course.

Diagnostic Accuracy of Serum Matrix Metalloproteinase-7 for Biliary Atresia

The diagnosis of biliary atresia (BA) remains a clinical challenge because affected infants have signs, symptoms, and serum liver biochemistry that are also seen in those with other causes of neonatal cholestasis (non-BA). However, an early diagnosis and prompt surgical treatment are required to improve clinical outcome. Recently, the relative abundance of serum matrix metalloproteinase-7 (MMP-7) was suggested to have discriminatory features for infants with BA. To test the hypothesis that elevated serum concentration of MMP-7 is highly diagnostic for BA, we determined the normal serum concentration of MMP-7 in healthy control infants, and then in 135 consecutive infants being evaluated for cholestasis. The median concentration for MMP-7 was 2.86 ng/mL (interquartile range, IQR: 1.32-5.32) in normal controls, 11.47 ng/mL (IQR: 8.54-24.55) for non-BA, and 121.1 ng/mL (IQR: 85.42-224.4) for BA (P < 0.0001). The area under the curve of MMP-7 for the diagnosis of BA was 0.9900 with a cutoff value of 52.85 ng/mL; the diagnostic sensitivity and specificity were 98.67% and 95.00%, respectively, with a negative predictive value of 98.28%. Conclusion: Serum MMP-7 assay has high sensitivity and specificity to differentiate BA from other neonatal cholestasis, and may be a reliable biomarker for BA.

Effect of combined ursodeoxycholic acid and glucocorticoid on the outcome of Kasai procedure: A systematic review and meta-analysis

INTRODUCTION

Multiple studies have investigated the effect of ursodeoxycholic acid (UDCA) or glucocorticoid (GC) on the outcome of the hepatoportoenterostomy (Kasai procedure) in patients with biliary atresia (BA). However, the combined effect of these drugs (UDCA + GC) is little understood.

METHODS

This meta-analysis specifically evaluated the effect of UDCA + GC after the Kasai procedure in patients with BA. A comprehensive literature search was conducted for all relevant articles in the electronic databases Medline, PubMed, Cochrane, Excerpta Medica Database (EMBASE), China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database on Disc (CBM-disc), and Vendor Information Pages (VIP).

RESULTS

Eight studies with BA patients were finally included in our meta-analysis. The 8 identified studies consisted of 3 case-control, 3 cohort, and 2 randomized controlled trials (RCTs) with overall 530 subjects (144, 152, and 234 subjects, respectively). Among them, 312 patients were treated with UDCA + GC, while 218 received placebo or other intervention. The meta-analysis indicated that groups that received UDCA + GC had significantly lower rates of postoperative jaundice relative to the controls (pooled, odds ratio [OR] = 2.41; 95% confidence interval [CI] 1.44-4.04; Z = 3.34; P = .0008), while rates of cholangitis were similar (pooled, OR = 0.87; 95% CI 0.43-1.74; Z = 0.40; P = .69).

CONCLUSIONS

Combined UDCA and GC intervention was superior to that of the control in accelerating the clearance of serum bilirubin in patients with BA after the Kasai procedure. However, this conclusion requires further confirmation using RCTs of high methodological quality.

Clinical Features and Genetic Analysis of Pediatric Patients with Alagille Syndrome Presenting Initially with Liver Function Abnormalities

Alagille syndrome (AGS) is a multisystem disorder and caused by mutations in JAG1 or NOTCH2 gene. The diagnosis of AGS is hampered by its highly variable clinical manifestations. We performed a retrospective analysis on 16 children diagnosed as having AGS in recent five years in our hospital. Cholestasis was seen in 15 patients (93.8%), heart disease in 12 (75%), characteristic facies in 7 (43.8%), and butterfly vertebrae in 7 (43.8%). Ophthalmology examination was not performed on all the patients. Further, serum biochemical parameters were compared between AGS and 16 biliary atresia (BA) patients who were confirmed by surgery. Elevated liver enzymes were seen in all the patients. Serum total cholesterol (TC) (P=0.0007), alanine aminotransferase (ALT) (P=0.0056), aspartate aminotransferase (AST) (P=0.0114), gamma-glutamyl transferase (GGT) (P=0.035) and total bile acid (TBA) levels (P=0.042) were significantly elevated in AGS patients compared to those in BA cases. However, there were no significant differences in serum total bilirubin (TB), conjugated bilirubin (CB) and albumin (ALB) between the two groups. We identified 14 different JAG1 gene variations and 1 NOTCH2 gene mutation in 16 Chinese AGS patients. Our study suggested clinical features of AGS are highly variable and not all patients meet the classical diagnostic criteria. It was suggested that hypercholesterolaemia and significantly elevated GGT, TBA and ALT may be helpful to diagnose AGS. Genetic testing is integral in the diagnosis of AGS.

Autoimmune liver disease-related autoantibodies in patients with biliary atresia

AIM

To investigate the prevalence and clinical significance of autoimmune liver disease (ALD)-related autoantibodies in patients with biliary atresia (BA).

METHODS

Sera of 124 BA patients and 140 age-matched non-BA controls were assayed for detection of the following autoantibodies: ALD profile and specific anti-nuclear antibodies (ANAs), by line-blot assay; ANA and anti-neutrophil cytoplasmic antibody (ANCA), by indirect immunofluorescence assay; specific ANCAs and anti-M2-3E, by enzyme linked immunosorbent assay. Associations of these autoantibodies with the clinical features of BA (i.e., cytomegalovirus infection, degree of liver fibrosis, and short-term prognosis of Kasai procedure) were evaluated by Spearman’s correlation coefficient.

RESULTS

The overall positive rate of serum autoantibodies in preoperative BA patients was 56.5%. ALD profile assay showed that the positive reaction to primary biliary cholangitis-related autoantibodies in BA patients was higher than that to autoimmune hepatitis-related autoantibodies. Among these autoantibodies, anti-BPO was detected more frequently in the BA patients than in the controls (14.8% vs 2.2%, P < 0.05). Accordingly, 32 (25.8%) of the 124 BA patients also showed a high positive reaction for anti-M2-3E. By comparison, the controls had a remarkably lower frequency of anti-M2-3E (P < 0.05), with 6/92 (8.6%) of patients with other liver diseases and 2/48 (4.2%) of healthy controls. The prevalence of ANA in BA patients was 11.3%, which was higher than that in disease controls (3.3%, P < 0.05), but the reactivity to specific ANAs was only 8.2%. The prevalence of ANCAs (ANCA or specific ANCAs) in BA patients was also remarkably higher than that in the healthy controls (37.9% vs 6.3%, P < 0.05), but showed no difference from that in patients with other cholestasis. ANCA positivity was closely associated with the occurrence of postoperative cholangitis (r = 0.61, P < 0.05), whereas none of the autoantibodies showed a correlation to cytomegalovirus infection or the stages of liver fibrosis.

CONCLUSION

High prevalence of autoantibodies in the BA developmental process strongly reveals the autoimmune-mediated pathogenesis. Serological ANCA positivity may be a useful predictive biomarker of postoperative cholangitis.

Chronic liver disease is universal in children with biliary atresia living with native liver

AIM

To examine the medical status of children with biliary atresia (BA) surviving with native livers.

METHODS

In this cross-sectional review, data collected included complications of chronic liver disease (CLD) (cholangitis in the preceding 12 mo, portal hypertension, variceal bleeding, fractures, hepatopulmonary syndrome, portopulmonary hypertension) and laboratory indices (white cell and platelet counts, total bilirubin, albumin, international normalized ratio, alanine aminotransferase, aspartate aminotransferase, γ-glutamyl transpeptidase). Ideal medical outcome was defined as absence of clinical evidence of CLD or abnormal laboratory indices.

RESULTS

Fifty-two children [females = 32, 62%; median age 7.4 years, n = 35 (67%) older than 5 years] with BA (median age at surgery 60 d, range of 30 to 148 d) survived with native liver. Common complications of CLD noted were portal hypertension (40%, n = 21; 2 younger than 5 years), cholangitis (36%) and bleeding varices (25%, n = 13; 1 younger than 5 years). Fifteen (29%) had no clinical complications of CLD and three (6%) had normal laboratory indices. Ideal medical outcome was only seen in 1 patient (2%).

CONCLUSION

Clinical or laboratory evidence of CLD are present in 98% of children with BA living with native livers after hepatoportoenterostomy. Portal hypertension and variceal bleeding may be seen in children younger than 5 years of age, underscoring the importance of medical surveillance for complications of BA starting at a young age.

Prognostic factors indicating survival with native liver after Kasai procedure for biliary atresia

BACKGROUND

The number of the bile ducts in the portal canal/measured surface area of the portal canal (BDP ratio) indicates prognosis in biliary atresia (BA), as does an elevated cytokeratin 7 positivity percentage (PCK7). We compared these two markers.

METHODS

We reviewed 32 BA cases undergoing Kasai operation from 1976 to 2016 with >5 portal canals in biopsy samples. Group I required liver transplantation or died within a year of operation (n = 8). Group II survived with their native liver (n = 24). We determined the BDP ratio (10²/mm²) and PCK7 (%), subdividing patients into three groups by their age at operation: Group A ≤60 days (n = 6, 1 Group I), 60< Group B ≤90days (n = 16, 5 Group I), Group C >90 days (n = 10, 2 Group I).

RESULTS

PCK7 (%) was 2.71 ± 1.87 in Group I and 4.25 ± 2.56 in Group II (p = 0.13). BDP ratio (10²/mm²) was 1.19 ± 0.424 in Group I and 1.64 ± 0.534 in Group II (p = 0.04). Both markers were higher in Group C than in Group A or B (p < 0.01).

CONCLUSION

The BDP ratio is a better prognostic indicator than PCK7 in BA.

Function and Regulation of MicroRNAs and Their Potential as Biomarkers in Paediatric Liver Disease

MicroRNAs (miRNAs) are short non-coding RNAs involved in biological and pathological processes of every cell type, including liver cells. Transcribed from specific genes, miRNA precursors are processed in the cytoplasm into mature miRNAs and as part of the RNA-induced silencing complex (RISC) complex binds to messenger RNA (mRNA) by imperfect complementarity. This leads to the regulation of gene expression at a post-transcriptional level. The function of a number of different miRNAs in fibrogenesis associated with the progression of chronic liver disease has recently been elucidated. Furthermore, miRNAs have been shown to be both disease-and tissue-specific and are stable in the circulation, which has led to increasing investigation on their utility as biomarkers for the diagnosis of chronic liver diseases, including those in children. Here, we review the current knowledge on the biogenesis of microRNA, the mechanisms of translational repression and the use of miRNA as circulatory biomarkers in chronic paediatric liver diseases including cystic fibrosis associated liver disease, biliary atresia and viral hepatitis B.

Role of CD56-expressing immature biliary epithelial cells in biliary atresia

AIM: To analyze the clinical and pathological parameters and expression of the neural cell adhesion molecule (CD56) in patients with biliary atresia (BA).

METHODS: Established clinical laboratory markers of hepatic function, including enzyme activity, protein synthesis, and bilirubin metabolism, were evaluated in patients with BA and compared with those in patients with choledochal cysts and neonatal hepatitis. Pathological changes in tissue morphology and fibrosis were examined by histological and tissue collagen staining. Immunohistochemical staining for the biliary epithelial cell markers CD56 and CK19 together with the Notch signaling related molecules Notch1 and Notch2 was performed in the context of alterations in the structure of intrahepatic biliary ducts.

RESULTS: Differences in some clinical laboratory parameters among the three diseases examined were observed, but they did not correlate with the pathological classification of fibrosis in BA. Immunohistochemical staining showed the presence of CD56-positive immature bile ducts in most patients (74.5%) with BA but not in patients with choledochal cysts or neonatal hepatitis. The number of CD56-expressing cells correlated with disease severity, with more positive cells present in the later stages of liver damage (81.8% vs 18.2%). Furthermore, bile plugs were mainly found in CD56-positive immature biliary ducts. Notch signaling was a key regulatory pathway in biliary duct formation and played a role in tissue fibrosis. Notch1 was co-expressed in CD56-positive cells, whereas Notch2 was found exclusively in blood vessels in the portal area of patients with BA.

CONCLUSION: The maturation of biliary epithelial cells and the expression of Notch may play a role in the pathogenesis of BA.

[Abnormal Serum Total Protein Measurement by Lipoprotein-X in an Infant with Biliary Atresia]

Lipoprotein-X (LP-X) in cholestatic jaundice causes abnormal reaction in assays for low-density lipoprotein-cholesterol, but the effects on other test items are unknown. Here, we report an infant with biliary atresia showing abnormal reaction in total serum protein assay using the biuret method, and lipoprotein-X (LP-X) was then detected. In this 11-month-old female infant, jaundice was observed at 2 months old, and a diagnosis of biliary atresia was made. On biochemical tests at 12 months old, the total serum protein concentrations detected by the biuret method were very high, and the response curve and linearity of dilution were abnormal. LP-X was detected by agar electrophoresis. In addition and recovery experiments with normal serum fractionation of the patient's LP-X-rich lipoprotein fraction prepared by ultracentrifugation, normal γ-globulin fractionation showed an abnormal reaction by the biuret method. In infants with biliary atresia, we showed that the total serum protein assay by the biuret method was influenced by LP-X-rich lipoprotein, which may be caused by abnormal reaction of LP-X and γ-globulin. [Case Report].

The correlation between plasma cytokine levels in jaundice-free children with biliary atresia

BACKGROUND

T helper (Th) cell cytokines modulate inflammation and play a role in biliary atresia (BA). The aim of the study is a cross-sectional assessment of the levels of Th cytokines in the jaundice-free post Kasai procedure patients.

METHODS

There were 40 jaundice-free patients with BA and 28 normal controls enrolled. Patients were divided into 3 groups, including normal liver function, impaired liver function, and portal hypertension. Plasma concentration of Th1 [interferon-γ (INF-γ), interleukin (IL)-2], Th2 (IL-4, IL-10), Th3 [transforming growth factor-β1 (TGF-β1)], Th17 (IL-17) cytokines, and stromal cell-derived factor-1α (SDF-1α) were investigated.

RESULTS

The IFN-γ level was significantly higher in the BA patients with impaired liver function and portal hypertension than controls (P<0.0001 and P<0.0001, respectively). There was a significantly increase of TGF-ß1 in all BA groups compared with controls (P=0.003). The reduction of SDF-1α expression was found in BA groups (P<0.0001). IL-10 levels significantly correlated with aspartate aminotransferase to platelet ratio index (r=0.496, P=0.001). For the cytokine correlations, there were no correlations of Th1, Th2 and Th17 cytokine with the other measured cytokines, but TGF-ß1 was negatively correlated with SDF-1α levels (r=-0.327, P=0.039).

CONCLUSIONS

IFN-γ and IL-10 are likely to be involved in the disease progression in BA. Besides, TGF-β1 is found to be a suppression marker associated with SDF-1α levels and reduced production of TGF-β1 may be associated with the disease progression.

APRi predicts native liver survival by reflecting portal fibrogenesis and hepatic neovascularization at the time of portoenterostomy in biliary atresia

BACKGROUND

Aspartate aminotransferase-to-platelet ratio index (APRi) may be useful noninvasive prognostic tool in biliary atresia (BA). We studied whether APRi predicts native liver survival and parallels biochemical and immunohistological signs of liver injury and fibrogenesis at the time of Kasai portoenterostomy (PE).

METHODS

Serum and liver specimens were obtained at PE from 29 BA patients for liver biochemistry including APRi, histology and immunohistochemical analysis of collagen 1, α-SMA and CD34. APRi values were related to native liver survival and other clinical data as well as serum liver biochemistry, liver histology and immunohistochemistry at PE.

RESULTS

Median age at PE was 63 (range 7-141) days and median APRi was 0.92 (0.13-6.39). APRi had strong positive correlations with patient age (r=0.684, p<0.001) and biochemical signs of hepatocyte injury and cholestasis. APRi showed no significant correlations with Metavir (r=0.336, p=0.223) or Ishak (r=0.289, p=0.262) global fibrosis scores nor with liver collagen 1 expression (r=0.260, p=0.222). In contrast, portal fibrosis score (r=0.515, p=0.013), predominantly portal α-SMA expression (r=0.519, p=0.015) and amount CD34-positive microvessels in the centrizonal region (r=0.604, p=0.004) correlated positively with APRi. Patients (n=10) who underwent liver transplantation had significantly higher APRi at presentation (1.34 vs. 0.77, p=0.017) compared to those who survived with native liver (n=19).

CONCLUSIONS

APRi correlates with portal fibrosis, expression of α-SMA and the amount of CD34-positive microvessels, suggesting that APRi predicts native liver survival by reflecting portal myofibroblastic cell activation, fibrogenesis and associated neovascularization.

Increased conjugated bilirubin is sufficient to initiate screening for biliary atresia

INTRODUCTION

Biliary atresia is the leading cause of liver transplantation in children. It affects 1:15,000 in Denmark. With a national birth rate of 60,000, four children are born every year with biliary atresia. Early correction of biliary obstruction is essential to prevent fatal biliary cirrhosis. The Danish Health and Medicines Authority (DHMA) demands diagnostic evaluation of children with elevated level of serum bilirubin after two weeks of age. Biliary atresia has to be excluded if conjugated bilirubin level is above than 20 μmol/l, and/or more than 20% of total bilirubin. This percentage value has caused diagnostic trouble over the years. The objective of the present study was to investigate the possibility of changing the recommendations.

METHODS

This was a retrospective analysis of the medical records of children operated for biliary atresia in the 1993-2012 period.

RESULTS

During the period, 73 patients where operated with a portoenterostomy ad modum Kasai. Patients older than 84 days at the time of operation were excluded, 54 patients were available for analysis. Conjugated bilirubin in μmol/l and the percentage value were significantly above the DHMA threshold limit: mean 129.7 μmol/l (42-334 μmol/l) and 73% (28-97%), respectively.

CONCLUSION

The total amount of conjugated bilirubin above 20 μmol/l is sufficient to require further evaluation for biliary atresia. The percentage value is unnecessary and may cause confusion.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Telomere Length in Peripheral Blood Leukocytes Is Associated with Severity of Biliary Atresia

Objective

The purpose of this study was to investigate the association of telomere length in peripheral blood leukocytes with the severity of biliary atresia (BA).

Methods

One hundred and fourteen BA patients and 114 age-matched healthy controls were enrolled. Relative telomere length (RTL) was assessed using a quantitative real-time polymerase chain reaction. Multivariate regression analysis was used to estimate RTL as an independent risk factor of BA. Receiver operating characteristic curve analysis was used to calculate the accuracy of biomarkers in the prediction of liver cirrhosis.

Results

BA patients had significantly shorter telomeres than healthy controls (p < 0.0001). The RTL in BA patients with jaundice was considerably lower than that of patients without jaundice (p = 0.005). Moreover, RTL was markedly shorter in patients with cirrhosis (F4), as compared to patients with mild fibrosis (F2) and non-fibrosis (F0-F1, p < 0.0001). Logistic regression analysis indicated that short RTL was associated with a higher risk of liver cirrhosis in BA. Tertile analysis showed a dose-response effect for this association (p trend < 0.0001). Additionally, RTL in BA children revealed a negative correlation with age (r = -0.50, p < 0.001). We noted an association between reduction of RTL and liver stiffness scores, adjusted for age and gender (b = -0.01, p < 0.0001). Short RTL can be employed to distinguish cirrhosis patients from non-cirrhosis patients (AUC = 0.78). Further analysis showed a linear correlation between leukocyte RTL and liver RTL in BA patients (r = 0.83, p < 0.001).

Conclusion

The findings of this study provide evidence that telomere shortening is associated with an elevated risk of liver cirrhosis in BA.

Validation of aspartate aminotransferase to platelet ratio for diagnosis of liver fibrosis and prediction of postoperative prognosis in infants with biliary atresia

AIM: To validate the value of aspartate aminotransferase to platelet ratio index (APRI) in assessment of liver fibrosis and prediction of postoperative prognosis of biliary atresia (BA) infants from Mainland China.

METHODS: Medical records of 153 BA infants who were hospitalized from January 2010 to June 2013 were reviewed. The efficacy of APRI for diagnosis of liver fibrosis was assessed using the receiver operator characteristic (ROC) curve compared to the pathological Metavir fibrosis score of the liver wedge specimens of 91 BA infants. The prognostic value of preoperative APRI for jaundice persistence, liver injury, and occurrence of cholangitis within 6 mo after KP was studied based on the follow-up data of 48 BA infants.

RESULTS: APRI was significantly correlated with Metavir scores (r_s = 0.433; P < 0.05). The mean APRI value was 0.76 in no/mild fibrosis group (Metavir score F0-F1), 1.29 in significant fibrosis group (F2-F3), and 2.51 in cirrhosis group (F4) (P < 0.001). The area under the ROC curve (AUC) of APRI for diagnosing significant fibrosis and cirrhosis was 0.75 (P < 0.001) and 0.81 (P = 0.001), respectively. The APRI cut-off of 0.95 was 60.6% sensitive and 76.0% specific for significant fibrosis diagnosis, and a threshold of 1.66 was 70.6% sensitive and 82.7% specific for cirrhosis. The preoperative APRI in infants who maintained jaundice around 6 mo after KP was higher than that in those who did not (1.86 ± 2.13 vs 0.87 ± 0.48, P < 0.05). The AUC of APRI for prediction of postoperative jaundice occurrence was 0.67. A cut-off value of 0.60 showed a sensitivity of 66.7% and a specificity of 83.3% for the prediction of jaundice persistence. Preoperative APRI had no significant association with later liver injury or occurrence of cholangitis.

CONCLUSION: Our study demonstrated that APRI could diagnose significant liver fibrosis, especially cirrhosis in BA infants, and the elevated preoperative APRI predicts jaundice persistence after KP.

Identification of the plasma metabolomics as early diagnostic markers between biliary atresia and neonatal hepatitis syndrome

Early detection is the most effective way to improve the clinical outcome of biliary atresia (BA). Emerging metabolomics provides a powerful platform for discovering novel biomarkers and biochemical pathways to improve early diagnosis. The aim of this study is to find the potential biomarkers to distinguish BA from neonatal hepatitis syndrome (NHS) by using a metabolomics method. We comprehensively analyzed the serum metabolites in a total of 124 blood samples from patients with BA or neonatal hepatitis syndrome (NHS) and from normal individuals using advanced metabolomic approaches, and found that the levels of glutarylcarnitine (C5DC) significantly increased in the BA group while the levels of threonine (Thr) significantly rose in the NHS group comparing with the other groups. The levels of glutamic acid (Glu) in the BA group were significantly elevated compared to those in the NHS group, but still lower than the hyperbilirubinemia and normal controls. The levels of propionyl carnitine (C3), isovaleryl carnitine (C5) and glutamine (Gln) were reduced in the BA group compared to those in the NHS group, but still higher than the hyperbilirubinemia and normal controls. This study demonstrates the possibility of metabolomics as non-invasive biomarkers for the early detection of BA and also provides new insight into pathophysiologic mechanisms for BA.

Elevated bile acids in newborns with Biliary Atresia (BA)

Biliary Atresia (BA), a result from inflammatory destruction of the intrahepatic and extrahepatic bile ducts, is a severe hepatobiliary disorder unique to infancy. Early diagnosis and Kasai operation greatly improve the outcome of BA patients, which encourages the development of early screening methods. Using HPLC coupled tandem mass spectrometry, we detected primary bile acids content in dried blood spots obtained from 8 BA infants, 17 neonatal jaundice and 292 comparison infants at 3–4 days of life. Taurocholate (TC) was significantly elevated in biliary atresia infants (0.98±0.62 µmol/L) compared to neonatal jaundice (0.47±0.30 µmol/L) and comparison infants (0.43±0.40 µmol/L), with p = 0.0231 and p = 0.0016 respectively. The area under receiver operating characteristic (ROC) curve for TC to discriminate BA and comparison infants was 0.82 (95% confidence interval: 0.72–0.92). A cutoff of 0.63 µmol/L produced a sensitivity of 79.1% and specificity of 62.5%. The concentrations of total bile acids were also raised significantly in BA compared to comparison infants (6.62±3.89 µmol/L vs 3.81±3.06 µmol/L, p = 0.0162), with the area under ROC curve of 0.75 (95% confidence interval: 0.61–0.89). No significant difference was found between the bile acids of neonatal jaundice and that of comparison infants. The early increase of bile acids indicates the presentation of BA in the immediate newborn period and the possibility of TC as newborn screening marker.

Portal venous pressure in biliary atresia

Biliary atresia (BA) is characterized by a variable degree of fibrosis within the liver, causing portal hypertension sometimes evident at the time of presentation.

AIM

The aims of this study are to measure portal venous pressure (PVP) at time of Kasai portoenterostomy (KP) and to investigate the value of surrogate indices.

METHODS

At the time of KP and before any liver manipulation, an attempt was made to recanalize the umbilical vein, allowing a catheter to be sited. Preoperative noninvasive variables included maximum splenic diameter (on ultrasound); platelet count, aspartate aminotransferase, and bilirubin; and the aspartate aminotransferase/platelet index ratio (APRi). Clearance of jaundice was defined as achieving a bilirubin of less than 20 μmol/L. Data are quoted as median (range). Nonparametric statistical tests were used, and P < .05 was regarded as significant.

RESULTS

Portal venous pressure measurements were available in 61 infants, who underwent a KP during the period February 2007 to October 2010. Median age at KP was 52 (19-151) days. Median PVP was 9 (3-26) mm Hg and was significantly lower in those with isolated (n = 47) BA vs cytomegalovirus-associated BA (n = 6) (8 vs 17 mm Hg; P = .02). Overall, PVP correlated with spleen size (r(s) = 0.38; P < .0001), APRi (r(s) = 0.5; P < .0001), bilirubin (r(s) = 0.38; P = .001), and age at KP (r(s) = 0.33; P = .0004). Thirty-three infants (56%) cleared their jaundice (to <20 μmol/L). There was no significant difference in median PVP (7 vs 9.5 mm Hg; P = .1) between these groups. To date, 6 children have undergone endoscopy, with 2 requiring intervention for significant varices. Neither infant at time of KP had elevated PVP (3 and 9 mm Hg).

CONCLUSIONS

Portal venous pressure is a key variable in the assessment of the BA liver, and differences can be shown depending on underlying cause (eg, cytomegalovirus status). Furthermore, it has modest correlation with noninvasive indices (eg, spleen size and APRi) but appears of limited use when used as prognostic index of outcome and indeed in the later development of varices.

Serum IL-6 and IL-8 in infants with biliary atresia in comparison to intrahepatic cholestasis

BACKGROUND

Biliary atresia (BA) is an idiopathic progressive inflammation and fibrosclerosis of the extra and intrahepatic bile ducts.

AIM

To measure the serum levels of IL-6 and IL-8 in biliary atresia and correlate with clinical outcome.

METHODS

Sixty children were included, 20 with BA (group 1), 20 with intrahepatic cholestasis (group 2) and 20 normal children as controls. Complete blood count (CBC), liver function tests, serum IL-6 and IL-8 were analyzed in all the three groups.

RESULTS

Mean serum IL-6 and IL-8 levels were significantly higher in group 1 (394.7 +/- 40.2 and 111.2 +/- 9.7 pg/dl, respectively) than group 2 (175.5 +/- 33.1 and 53.5 +/- 8.2 pg/dl, respectively) (p=0.0 for both). Both IL-6 and IL-8 were significantly higher in both the disease groups compared to controls (30.4 +/- 8.8 and 13.7 +/- 4.1 pg/dl, respectively). IL-8 showed a significant positive correlation with lymphocytes and significant negative correlation with albumin in group 1. Higher IL-6 was found in patients with BA with severe fibrosis than in patients with mild fibrosis while higher IL-8 was found in children with persistent jaundice than those free from jaundice in group 1.

CONCLUSION

Serum IL-6 and IL8 are high in patients with BA indicating ongoing inflammation. They may serve to determine disease severity and may predict the progression to liver fibrosis in these cases.

[Value of the liver function test in differential diagnosis of infantile hepatitis syndrome and biliary atresia]

OBJECTIVE

This study aimed to investigate the value of the liver function test in the differential diagnosis of infantile hepatitis syndrome (IHS) and biliary atresia (BA) by analyzing seven conventional serological markers in this test using receiver operating characteristic (ROC) curves.

METHODS

Serum levels of seven conventional serological markers: alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (gamma-GT), alkaline phosphatase (ALP), total bilirubin (TB), conjugated bilirubin (CB) and serum albumin (ALB) were measured in 103 children with IHS and 60 children with BA. ROC curves were used to evaluate the sensitivity, specificity, positive and predictive values and optimal cut-off. The united tests (parallel test and serial test) of gamma-GT, TB and CB were performed to elevate diagnostic efficiency.

RESULTS

Compared with the IHS group, the BA group had significantly increased serum ALT, AST, gamma-GT, TB and CB levels (p<0.01). The area under ROC (AUCROC) of AST, gamma-GT, CB and TB was 0.77, 0.881, 0.841 and 0.87, respectively. gamma-GT showed the highest AUCROC, specificity, positive predictive value and positive likelihood ratio in the diagnosis of BA, followed by CB, TB and AST in turn. The negative predictive value of CB was the highest, followed by TB. The negative likelihood ratio of CB was the lowest but its Youden index was the highest. The Youden index of gamma-GT and TB was lower than that of CB. After the parallel tests, the sensitivity and negative predictive value of gamma-GT, CB and TB increased to 100%. After the serial tests, the specificity of gamma-GT, CB and TB increased to 90.4% and the positive predictive value increased to 87.5%.

CONCLUSIONS

The measurement of gamma-GT, TB and CB levels are valuable in the differential diagnosis of BA and IHS. An imaging examination is required in the parallel test positive patients.

Different polyunsaturated fatty acid profiles in patients with biliary atresia after successful Kasai operation and liver transplantation

BACKGROUND

Although Kasai operation eliminates jaundice in patients with biliary atresia, inflammation at Glisson's area persists and fibrosis advances slowly to liver cirrhosis. Profiles of polyunsaturated fatty acids, on which metabolic products have an immunoregulative effect, were investigated in this study.

METHODS

Blood samples were obtained from patients including 21 jaundice-free patients with biliary atresia after Kasai operation (native liver group) and 18 patients in whom Kasai operation failed and liver transplantation was performed (transplantation group). All of these patients are without any complications for more than 6 months. Blood samples from 18 patients with inguinal hernia were assigned as normal controls (control group). Profiles of fatty acids in whole serum lipids were measured using gas chromatography. The n-3/n-6 ratio of polyunsaturated fatty acids was compared among the three groups.

RESULTS

The n-3/n-6 ratio was 0.114 in the native liver group, which was significantly lower than 0.145 in the transplantation group (P = 0.009) and 0.158 in the control group (P = 0.004). There was no significant difference between the transplantation and control groups (P = 0.83).

RESULTS

The n-3/n-6 ratio was abnormal after Kasai operation despite normal liver function. This seems to be one factor of persisting inflammation in Glisson's area.

High levels of serum basic fibroblast growth factor in children with biliary atresia

BACKGROUND/AIMS

The purpose of this study was to investigate the relationship between basic fibroblast growth factor (bFGF) and clinical outcome in biliary atresia (BA) patients after surgical treatment.

METHODOLOGY

Sixty-five pediatric patients with BA post Kasai operation and 12 healthy children were recruited. The patients were categorized into 2 groups according to their serum levels of total bilirubin (TB < 2, no jaundice vs. TB > or = 2mg/dL, persistent jaundice) and alanine aminotransferase (ALT < 100 vs. ALT > or = 100 U/L). The serum bFGF levels were determined by enzyme-linked immunosorbent assay.

RESULTS

The mean serum bFGF level of the BA patients was higher than that of normal controls (14.2 +/- 1.6 vs. 9.0 +/- 2.2 pg/mL, p < 0.03). Serum bFGF levels in the persistent jaundice group were significantly higher than those without jaundice (17.6 +/- 3.1 vs. 11.9 +/- 1.5 pg/mL, p < 0.04). Additionally, patients with serum ALT > or = 100 U/L had higher serum levels of bFGF than those with serum ALT < 100 U/L (19.0 +/- 2.4 vs. 8.9 +/- 1.6 pg/mL, p < 0.0005). In the no jaundice group, serum bFGF levels were significantly elevated in the patients with portal hypertension (PH) compared with those without PH (15.8 +/- 2.2 vs. 8.6 +/- 1.9 pg/mL, p < 0.02).

CONCLUSIONS

The significant elevation in bFGF levels is associated with the presence of PH and the severity of hepatic damage. bFGF may play a role in the pathogenesis of progressive inflammation and the perpetuation of PH in BA patients after Kasai procedure.

Insulin-like growth factor-1 (IGF-1) in children with postoperative biliary atresia: a cross-sectional study

Biliary atresia is the leading cause of chronic infantile cholestasis which eventually leads to cirrhosis. Re-establishment of biliary drainage by Kasai portoenterostomy and liver transplantation for end-stage liver disease has favorably altered the clinical outcome. However, growth failure, one of the major complications of chronic liver disease, remains a major problem. The aim of the study is to evaluate growth, nutritional status and serum growth factor IGF-1 in children with biliary atresia after Kasai operation and at comparing these data between the groups with successful and unsuccessful operation. Fifty-four children with postoperative biliary atresia were evaluated for their clinical outcome, height, blood biochemistry related nutritional status and serum IGF-1. Height and serum IGF-1 were expressed as standard deviation score (SDS) to minimize the influence of age. With 44.4% of the enrolled patients the operation had been unsuccessful and jaundice persisted. The mean age of children with jaundice in comparison with the jaundice free groups was not significantly different (42.0 and 49.9 months, p = 0.458). In jaundice-free patients, hematocrit, serum albumin, calcium and phosphorus were normal and significantly higher. In the successful Kasai group, the height SDS and serum IGF-1 SDS were within the normal range and significantly higher (height SDS 0.2 +/-1.0 vs. -0.9 +/- 1.2, p < 0.01 and IGF-1 SDS 0.5 +/- 2.2 vs. -1.3 +/- 1.0, p < 0.01). The mean IGF-1 SDS in the failed Kasai group was less than -1. Children with good outcome of postoperative biliary atresia showed better growth, better nutritional status and higher serum IGF-1 levels when compared to those with unsuccessful operation.

Hepatobiliary scintigraphy after Kasai procedure for biliary atresia: clinical correlation and prognostic value

BACKGROUND/PURPOSE

Kasai portoenterostomy (KP) is regarded as first-line treatment for biliary atresia, although its postoperative course is often unpredictable. Hepatobiliary scintigraphy using technetium-labeled iminodiacetic acid derivatives offers a dynamic, objective assessment both of parenchymal liver function and restored biliary excretion. The value of postoperative radionuclide scans was assessed prospectively in a large population of post-KP infants.

METHODS

Radionuclide scans consisted of an intravenous dose of 20 MBq of 99mTc mebrofenin iminodiacetic acid and subsequent gamma camera imaging. Four scan variables were evaluated: the hepatic extraction fraction (HEF; ie, initial liver uptake divided by the peak vascular uptake), the half-life of tracer excretion (TEX), the shape of the excretion curve, and the presence of activity in the Roux loop at 4 hours postinjection. All infants had type 3 biliary atresia with a median age at KP of 59 days (24-120 days). To assess predictive value, outcome (clearance of jaundice and need for transplant) was assessed at 6 months (for 1-week scan) and 2 years (for 6-month scan).

RESULTS

Eighty-seven infants underwent a radionuclide scan at 1 week post-KP. The median HEF was 34% (10%-90%). No relationship could be identified between HEF (P = .2) or excretion curve shape (P = .9) and outcome (at 6 months), and there were too few examples of a measurable TEX to allow meaningful comparison. The only predictive element at this time point was Roux loop activity (positive predictive value, 79%; negative predictive value, 53%; for "good" isotope bowel activity). Forty-four infants completed a second scan at 6 months. Median HEF increased from a baseline of 37% (11%-90%) to 64% (8%-100%) (P < .0001), although there was no significant intercorrelation (P = .12). The most predictive variables (of outcome at 2 years) were curve shape (positive predictive value, = 95%, negative predictive value, 82%) and TEX, and the least predictive was now Roux loop activity.

CONCLUSIONS

Early (at 7 days) hepatic scintigraphy is not predictive of poor outcome in general, although Roux loop activity does indicate later success. Later hepatic scintigraphy (at 6 months) allows a detailed assessment of dynamic liver function with biliary excretion variables predictive of outcome in the medium term.

Characterization of plasma proteome in biliary atresia

BACKGROUND

Biliary atresia (BA) is a disorder during infancy with unknown etiology in which progression frequently leads to liver cirrhosis. Plasma proteome is characterized in this study.

METHODS

Twelve paired plasma samples from 6 children with BA who received surgical correction at early stage and then liver transplantation at late stage of liver cirrhosis were studied. Plasma samples from 2 subjects without liver disorder were used as normal reference for 2-dimensional gel electrophoresis and for identification of protein spots by mass spectrometric analysis. Plasma samples from another 3 normal subjects (with a total of 5) were used for nephelometric quantification of immunoglobulin kappa light chain in comparison with patients' samples.

RESULTS

Among the protein spots detected, ranging from 6 to 200 kDa mass with pIs of 3-10, significant up-regulation of immunoglobulin kappa light chain was found at the late stage of BA, which was subsequently confirmed by nephelometric analysis. Conversely, significant decrease of apolipoprotein (Apo) A-I and C-II, haptoglobin alpha2 and beta chain, and transthyretin were detected during the progression of BA.

CONCLUSIONS

Increased immunoglobulin kappa light chain detected in late-stage BA characterizes adverse immune modulation in this disorder. Decreased apolipoproteins, haptoglobin and transthyretin levels might be potential markers of progressive liver injury, fibrosis and defective lipid metabolism in BA.

The role of monocyte chemoattractant protein-1 in biliary atresia

BACKGROUND

The aim of this study was to explain the role of monocyte chemoattractant protein-1 (MCP-1) in biliary atresia (BA).

METHODS

Concentrations of serum MCP-1 and collagen type IV were measured in 38 patients with BA by using commercially available kits. MCP-1 was also assessed in liver biopsy specimens by using immunohistochemistry. Subjects were classified into groups. Group 1 comprised BA patients with normal liver function (n = 13), group II comprised BA patients with moderate liver dysfunction (n = 18), group III comprised BA patients older than 20 years awaiting liver transplantation (n = 7), and the control group comprised age-matched patients without evidence of liver disease (n = 23).

RESULTS

Serum MCP-1 levels were significantly increased in group II compared with group I (P < .0001) and the control group (P < .0001). Serum MCP-1 levels in group III were lower than in the control group (P < .0001). There was a significant linear correlation between serum MCP-1 levels and type IV collagen levels in group II. Group II subjects with portal hypertension (PH) had higher MCP-1 levels than those without PH (P = .0009). Biopsy specimens showed MCP-1 was expressed mainly on biliary epithelial cells, vascular endothelial cells, and hepatocytes in group II.

CONCLUSIONS

These findings suggest that MCP-1 probably plays a significant role in the development of progressive liver fibrosis in BA.

The significance of serum hepatocyte growth factor levels in planning follow-up of postoperative jaundice-free patients with biliary atresia

PURPOSE

The aim of this study was to clarify the significance of serum hepatocyte growth factor (HGF), interleukin (IL)-6, and IL-1 receptor antagonist (ra) levels in the evaluation of disease status in jaundice-free survivors with biliary atresia after Kasai operation.

PATIENTS AND METHODS

Serum concentrations of HGF, IL-6, and IL-ra were measured in 31 long-term jaundice-free patients with biliary atresia after Kasai operation and 29 controls. Patients were divided into 4 groups: group A (n = 8), normal liver function; group B (n = 9), mild liver dysfunction without portal hypertension; group C (n = 9), moderate liver dysfunction with controllable portal hypertension; and group D (n = 5), receiving liver transplantation.

RESULTS

Serum IL-6 levels were significantly higher in patients than in controls. There was no difference in serum IL-6 levels among groups B, C, and D. Serum IL-1ra levels were elevated according to liver dysfunction. Serum HGF levels in group D were significantly higher than in controls and the other groups. Serum hyaluronic acid levels were positively correlated with serum levels of IL-1ra and HGF.

CONCLUSIONS

Elevation of serum IL-1ra and HGF levels correlated with the progression of liver fibrosis and dysfunction. In particular, serum HGF levels could be used as a predictor for requiring liver transplantation.

Comparison of different diagnostic methods in infants with Cholestasis

AIM: To evaluate different methods in differentiating idiopathic neonatal hepatitis from biliary atresia.

METHODS: Sixty-five infants with cholestatic jaundice and final diagnosis of idiopathic neonatal hepatitis and biliary atresia were studied prospectively from September 2003 to March 2006. A thorough history and physical examination were undertaken and the liver enzymes were examined. All cases underwent abdominal ultrasonography, hepatobiliary scintigraphy, and percutaneous liver biopsy. The accuracy, sensitivity, specificity and predictive values of these various methods were compared.

RESULTS: There were 34 girls and 31 boys, among them 46 subjects had idiopathic neonatal hepatitis (age, 61 ± 17 d) and 19 had biliary atresia (age, 64 ± 18 d). The mean age at onset of jaundice was significantly lower in cases of biliary atresia when compared to idiopathic neonatal hepatitis cases (9 ± 13 d vs 20 ± 21 d; P = 0.032). The diagnostic accuracy of different methods was as follows: liver biopsy, 96.9%; clinical evaluation, 70.8%; ultrasonography, 69.2%; hepatobiliary scintigraphy, 58.5%; and liver enzymes, 50.8%.

CONCLUSION: Our results indicate that clinical evaluation by an experienced pediatric hepatologist and a biopsy of the liver are considered as the most reliable methods to differentiate idiopathic neonatal hepatitis and biliary atresia.

Association of serum levels of tissue inhibitors of metalloproteinase-1 with clinical outcome in children with biliary atresia

The purpose of this study was to determine the possible role of serum levels of tissue inhibitors of metalloproteinase-1 (TIMP-1) in the pathogenesis of the progressive inflammation and fibrosis in biliary atresia (BA). Serum concentrations of TIMP-1 were measured in 57 BA patients and 15 healthy controls using commercially available enzyme-linked immunosorbent assays. The mean ages of the BA patients and the controls were 6.1 +/- 0.6 and 6.7 +/- 1.1 years, respectively. The patients were categorized into two groups according to their clinical outcomes: patients with jaundice (total bilirubin > or = 2 mg/dl) and patients without jaundice (total bilirubin < 2 mg/dl). In our study, serum levels of TIMP-1 were significantly higher in the BA patients than in healthy subjects (4.8 +/- 0.4 vs. 3.5 +/- 0.3 ng/ml, respectively; p < 0.05). Additionally, serum levels of TIMP-1 significantly increased in the BA patients with jaundice in comparison to those without jaundice (6.3 +/- 0.7 vs. 3.1 +/- 0.3 ng/ml, respectively; p = 0.001). Patients with persistent jaundice had lower levels of albumin but had greater levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and gamma glutamyl transpeptidase compared with patients without jaundice. Furthermore, patients with portal hypertension (PH) had higher TIMP-1 levels than those without PH (5.3 +/- 0.4 vs. 1.9 +/- 0.3 ng/ml, respectively; p < 0.001). It is concluded that serum levels of TIMP-1 increased in patients with BA. The significant increase in TIMP-1 levels is related to the presence of PH and the severity of jaundice. The elevated TIMP-1 levels may reflect the degree of hepatic fibrosis and development of PH. The data suggest that TIMP-1 may play a role in the pathophysiology of post-Kasai BA.

Elevated serum nitric oxide metabolites in biliary atresia

Biliary atresia (BA) remains one of the most intractable liver diseases in children. The aim of this study was to investigate the possible roles of nitric oxide (NO) in BA. Serum levels of nitrite and nitrate (NO production) were determined using a colorimetric method from 65 post-operative BA patients and 12 healthy children. The patients were categorized into two groups according to their jaundice status, and serum alanine aminotransferase (ALT, a marker for liver injury). Unpaired t tests were used. Data are expressed as mean and SD in terms of mumol/l. Age and gender between BA patients and controls were comparable. Serum NO metabolites of BA patients was higher than the controls (79.77+/-21.22 vs. 65.75+/-9.44, P=0.001). Subgroup analysis revealed that there was no difference in serum nitrate/nitrite levels of BA patients without jaundice compared to those with jaundice (78.85+/-23.23 vs. 80.90+/-18.76, P=0.70). However, patients with serum ALT> or =100 IU/l had higher levels of serum NO metabolites compared to those with serum ALT<100 IU/l. In conclusion, NO production was elevated in BA patients compared to normal controls. Serum NO was associated with serum ALT levels, but not with jaundice status, in BA patients. These suggest that NO plays a role in the pathophysiology of liver injury in post-operative BA.

Concentrations of copper and zinc in liver and serum samples in biliary atresia patients at different stages of traditional surgeries

Many patients with biliary atresia (BA) have impaired metabolism of copper (Cu) and zinc (Zn) because of the obstruction of bile ducts. An excessive Cu accumulation is cytotoxic and results in fibrosis in hepatic tissues. Since Zn works antagonistically to Cu, lower Zn concentrations may deteriorate liver damage. In the 1980's, we performed a series of surgeries on BA patients for the construction and alteration of the bile flow route, which is the major excretion route for Cu. We obtained liver and serum samples at each surgery, and measured Cu and Zn concentrations by inductively coupled plasma atomic emission spectrometry. Hepatic Cu concentration decreased with the improvement of cholestasis after the establishment of bile excretion. Conversely, when cholestasis persisted or recurred, increases in hepatic and serum Cu concentrations were noted. Hepatic Zn concentration was lower than previously reported normal values. High hepatic and serum Cu concentrations due to persistent or recurrent cholestasis and low hepatic Zn concentration may deteriorate hepatic fibrosis and liver cirrhosis.

Kidney Volume and Plasma Hepatocyte Growth Factor–Transforming Growth Factor β1 Ratio Among Children With Biliary Atresia Before and After Liver Transplantation: The Reversibility of Nephromegaly

BACKGROUND

We previously showed a positive correlation between nephromegaly and plasma hepatocyte growth factor (HGF)/transforming growth factor beta1 (TGF-beta1) ratio in children with biliary atresia. The purpose of this study is to examine the possible reversibility of nephromegaly in patients with biliary atresia.

METHODS

We evaluated kidney volume in 13 patients with biliary atresia before and after liver transplantation, 6 patients with hepatoblastoma, and 26 healthy children. Plasma HGF and TGF-beta1 levels were determined for all children.

RESULTS

We noted significant nephromegaly in children with biliary atresia before liver transplantation compared with healthy children and children after liver transplantation (P < 0.001 and P = 0.006 for intercepts, P = 0.064 and P = 0.753 for slopes by analysis of covariance, respectively). The highest plasma HGF levels and HGF/TGF-beta1 ratios and the lowest TGF-beta1 concentrations were found in children with biliary atresia before liver transplantation (P < 0.001). No statistically significant nephromegaly was observed in children with biliary atresia after liver transplantation or those with hepatoblastoma despite the presence of a mildly increased plasma HGF level and HGF/TGF-beta1 ratio. Plasma HGF/TGF-beta1 ratio correlated positively with degree of nephromegaly in all patients (r = 0.717; P < 0.001).

CONCLUSION

Our data suggest that liver transplantation reverses the nephromegaly present in children with biliary atresia and that plasma HGF/TGF-beta1 ratio may be associated with the development of nephromegaly in patients with biliary atresia.

Soluble adhesion molecule profiling in preoperative infants with biliary atresia

OBJECTIVE

Intercellular adhesion molecule (ICAM) expression in liver and bile duct remnant is a feature of the inflammatory component of biliary atresia (BA). Circulating levels of such soluble adhesion molecules (SAM) should reflect intrahepatic disease and would prove a useful adjunct in the evaluation of BA.

STUDY DESIGN

Serum ICAM-1 (sICAM-1), serum vascular cell adhesion molecule (sVCAM-1), and serum E selectin (sE-selectin) were measured by enzyme-linked immunosorbent assay in infants with BA at the time of portoenterostomy and stratified by outcome. Results are quoted as medians (range). Binary logistic regression analysis and actuarial survival curves were used to investigate the relationship of SAM profile to outcome. Significance was assumed at P values of < or = .05.

RESULTS

Sixty-one infants with BA were treated between 1996 and 2002 and at follow-up; 39 of these were alive and jaundice-free (good outcome, n = 39); 21 had been transplanted, and 1 died (poor outcome, n = 22). Preoperative values for sICAM-1 were 1233 (400-2000) ng/mL; sVCAM-1, 1204 (517-1921) ng/mL; and sE-selectin, 71 (26-192) ng/mL. sVCAM-1 (P < .0001) and sICAM-1 (P < .0001) significantly increased compared with normal control infants, although sE-selectin did not (P = .17). There was a significant correlation of age at surgery with sICAM-1 (r = 0.33, P = .01) but not with sVCAM-1 (r = 0.16, P = .23) or sE-selectin (r = 0.05, P = .70). Binary logistic regression analysis showed that the variables, sICAM-1, sE-selectin, or age at surgery, were not significant predictors of outcome, although sVCAM-1 approached significance (P = .069). A cutoff value for sVCAM-1 of 1380 ng/mL was defined by receiver operating characteristic curve analysis, and the cohort of patients with sVCAM-1 (> 1380 ng/mL) showed a significantly worse actuarial survival (P = .05).

CONCLUSION

Levels of sICAM-1 and sVCAM-1 are grossly elevated in BA, whereas sE-selectin levels are normal. Only sVCAM-1 levels have prognostic significance. SAM profiling has the potential to monitor the inflammatory process of BA and may guide more novel forms of pharmacological intervention or immunomodulation.

There is no association between K469E ICAM-1 gene polymorphism and biliary atresia

AIM: To determine whether there was an association between inter-cellular adhesion molecule-1 (ICAM-1) gene polymorphism and biliary atresia (BA), and to investigate the relationship between serum soluble ICAM-1 (sICAM-1) and clinical outcome in BA patients after surgical treatment.

METHODS: Eighty-three BA patients and 115 normal controls were genotyped. K469E ICAM-1 polymorphism was analyzed using PCR assay. Serum sICAM-1 was determined using ELISA method from 72 BA patients. In order to evaluate the association between these variables and their clinical outcome, the patients were categorized into two groups: patients without jaundice and those with persistent jaundice.

RESULTS: There were no significant differences between BA patients and controls in terms of gender, K469E ICAM-1 genotypes, and alleles. The proportion of patients having serum sICAM-1 ≥3 500 ng/mL in persistent jaundice group was significantly higher than that in the other group. In addition, there was no association between K469E ICAM-1 polymorphism and the status of jaundice in BA patients after Kasai operation.

CONCLUSION: ICAM-1 possibly plays an important and active role in the disease progression. However, the process is not associated with genetic variation of K469E ICAM-1 polymorphism.

Promoter polymorphism of the CD14 endotoxin receptor gene is associated with biliary atresia and idiopathic neonatal cholestasis

OBJECTIVE

To investigate whether single-nucleotide polymorphisms in the promoter regions of endotoxin-responsive genes CD14 and tumor necrosis factor-alpha (TNF-alpha) are associated with biliary atresia (BA) and idiopathic neonatal cholestasis (INC).

METHODS

We obtained genomic DNA from 90 patients with established diagnosis of BA and 28 patients with INC. Forty-two adult patients with hepatitis B-related cirrhosis and 143 healthy children served as control populations. The genotypes of CD14/C(-159)T and TNF-alpha/G(-308)A (G allele, TNF*1; A allele, TNF*2) were determined by using a restriction enzyme-based assay. Plasma soluble CD14 levels were determined in different disease stages and genotypes of BA.

RESULTS

The frequencies of T allele and T/T homozygosity of the CD14/-159 promoter polymorphism were significantly higher in patients with BA (T allele: 61.7%; T/T genotype: 42.2%) and in patients with INC (T allele: 67.9%; T/T genotype: 53.6%) but not in control populations. Decrease of plasma soluble CD14 from the early stage of BA when the patients received a Kasai operation to the late stage of liver cirrhosis was observed in carriers of the T/T and T/C genotypes but not in carriers of the C/C genotype. The TNF-alpha/-308 promoter polymorphisms (TNF*1 and TNF*2) were not associated with BA.

CONCLUSION

These findings show that the single-nucleotide polymorphism at CD14/-159 is associated with the development of BA and INC. Endotoxin susceptibility may play a role in the pathogenesis of infantile cholestasis.

Is There Any Difference in Anesthetic Management of Biliary Atresia and Glycogen Storage Disease Patients Undergoing Liver Transplantation?

BACKGROUND

The purpose of the study was to compare the intraoperative blood glucose changes and the dosage of glucose infused between biliary atresia and glycogen storage disease (GSD) patients undergoing living donor liver transplantation (LDLT).

PATIENTS AND METHODS

The anesthesia records of biliary atresia and GSD patients undergoing LDLT were reviewed retrospectively. The levels of intraoperative blood glucose before operation, after induction of anesthesia, in the dissection, anhepatic, 10 min after reperfusion, and at the end of operation, as well as the dosage glucose infused, were compared between groups. The Mann-Whitney U test was used for statistical analysis; P < 0.05 was regarded as significant.

RESULTS

Seventy-two biliary atresia patients were grouped into group I (GI) and 8 GSD patients into group II (GII). The blood glucose levels of both groups increased after operation and remained hyperglycemic, around 100-300 mg/dl, until the end of the operation. The mean glucose amounts infused were 2.7 +/- 1.9 and 2.5 +/- 1.15 mg/kg/min for GI and GII, respectively.

CONCLUSION

No significant difference was found in the anesthetic management between groups. The only difference was that the GSD patients required continuous glucose supply the night before the operation, while biliary atresia patients did not.

Serum interleukin-8 in children with biliary atresia: relationship with disease stage and biochemical parameters

Biliary atresia (BA) is a neonatal obliterative cholangiopathy of unknown etiology. Despite the Kasai procedure, hepatic fibrosis and portal hypertension (PH) still occur. Interleukin-8 (IL-8) is an important mediator of inflammation and immune response in human disease. The objective of this study was to investigate the potential role of IL-8 in the pathogenesis of the progressive, sclerosing, inflammatory process and fibrosis in BA. A total of 60 pediatric patients with BA and 15 healthy children were evaluated. The mean ages of BA patients and controls were 6.3 +/- 0.6 and 6.7 +/- 1.1 years, respectively. The patients were classified into two groups according to their clinical outcomes: patients with jaundice (total bilirubin +/- 25.5 micromol/l) and patients without jaundice (total bilirubin < 25.5 micromol/l). The IL-8 levels in serum samples were determined by commercially available enzyme-linked immunosorbent assay. Serum IL-8 levels were higher in the BA patients than in healthy children (236.2 +/- 60.1 vs. 34.5 +/- 12.1 pg/ml, P < 0.001). Patients with jaundice had lower levels of albumin but had greater levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and gamma glutamyl transpeptidase compared with patients without jaundice. Serum IL-8 levels in the jaundice group were significantly higher than in those without jaundice (516.5 +/- 130.0 vs. 49.3 +/- 10.4 pg/ml, P < 0.0005). Furthermore, patients with PH had higher IL-8 levels than those without PH (378.1 +/- 102.2 vs. 106.6 +/- 48.4 pg/ml, P < 0.005). In the jaundice-free group, IL-8 levels were elevated in patients with PH compared with those without PH (79.0 +/- 17.4 vs. 19.7 +/- 5.8 pg/ml, P < 0.005). The present study demonstrated elevation of serum IL-8 levels in children with BA. Serum IL-8 levels were also higher in patients with jaundice compared with patients without jaundice. These findings suggest that IL-8 may play a significant role in the pathogenesis of BA.

Prevalence of hepatitis A virus infection in children with biliary atresia

This study aimed at identifying the prevalence of hepatitis A virus (HAV) infection in children with biliary atresia (BA). Blood samples were collected from children with BA whom had undergone portoenterostomy and attended the pediatric liver clinic, King Chulalongkorn Memorial Hospital between May 2002 and May 2003. Seventy-seven patients, 45 females and 32 males, ages ranging from 0.2-19 years (mean +/- SD = 5.9 +/- 4.6 years) were enrolled in the study. The HAV seropositivity rate of patients aged <10 years and > or =10 years were 13.1% and 25%, respectively. The seropositivity rate of patients with favorable outcomes (total bilirubin level < or =2 mg/dl) and unfavorable outcome (total bilirubin level >2 mg/dl) were 17.5% and 13.5%, respectively, which were not statistically different (p = 0.6). Children suffering from BA with failed portoenterostomy are at risk of developing severe liver damage at an early age. In these patients a superimposed acute liver infection due to a hepatitis virus, including HAV, may affect liver function and lead to particularly severe disease. The effectiveness of HAV immunization in this particular group of children merits further study.

Association of serum interleukin-8 levels with the degree of fibrosis in infants with chronic liver disease

OBJECTIVE

Biliary atresia is a neonatal obstructive cholangiopathy characterized by a destructive, obliterative process affecting both the intrahepatic and extrahepatic ducts of the biliary tree that uniquely presents in the first months of life. The consequence of progressive inflammatory and sclerotic reaction is the development of obstructive jaundice. To determine the proinflammatory cytokine profile in children with biliary atresia, we measured circulating levels of interleukin (IL)-1beta, IL-6, tumor necrosis factor-alpha and IL-8.

METHODS

Twelve children, five males and seven females, with biliary atresia were studied. In addition, four patients with progressive familial intrahepatic cholestasis and three with Alagille syndrome were also included. Five patients with neonatal hepatitis were studied as controls of a liver disease without portal fibrosis. Serum concentration of total and conjugated bilirubin, gamma-glutamyl transferase and glutamic-pyruvic transaminase were measured by routine methods in all patients at time of sampling for the study. The degree of fibrosis in liver biopsies was scored using the histologic activity index.

RESULTS

In our study IL-8 was detectable in 11 of 12 patients with biliary atresia with a median level of 262 pg/ml and a highly statistically significant difference (P < 0.0001) from controls. In patients with progressive familial intrahepatic cholestasis or with Alagille syndrome serum IL-8 levels were similarly elevated. In patients with neonatal hepatitis, IL-8 levels were marginally increased. Serum IL-8 levels were significantly correlated (Rs = 0.725, P < 0.0001) with the histologic activity index.

CONCLUSIONS

Although further studies are needed to determine the role of IL-8 in portal inflammation, our results suggest that increased production of IL-8 may be a mechanism leading to the progressive portal inflammation and fibrosis in patients with chronic liver disease.

Serum hepatocyte growth factor and clinical outcome in biliary atresia

PURPOSE

Biliary atresia (BA) remains one of the most intractable liver diseases leading to liver fibrosis. Serum hepatocyte growth factor (HGF) has been shown to increase in cirrhotic patients. The aim of this study was to investigate the possible role of HGF in BA.

METHODS

Serum levels of HGF were determined using an enzyme-linked immunosorbent assay from 28 BA patients and 25 healthy children. The patients were categorized into 3 groups according to their clinical outcomes (good, fair, and poor): group A (good), jaundice-free patients (total bilirubin [TB] < 2.0 mg%); group B (fair), patients with mild to moderate jaundice (TB, 2 to 10 mg%); and group C (poor), patients with marked jaundice (TB > 10 mg%). Unpaired t test and analysis of variance (ANOVA) with post-hoc tests were used. Data were expressed as mean and SEM.

RESULTS

Serum HGF levels in BA patients were higher than the controls (P =.02). Subgroup analysis found that there were 12 patients in group A, 8 patients in group B, and 8 patients in group C. The mean age of patients in groups A, B, and C were 5.34 +/- 0.52, 7.45 +/- 1.98, and 5.49 +/- 1.57 years (P >.05). Serum HGF in controls and groups A, B, and C were 0.24 +/- 0.03, 0.28 +/- 0.04, 0.36 +/- 0.09, and 0.56 +/- 0.07 ng/mL, respectively. Serum HGF levels in BA patients with poor outcome were higher than patients with good outcome (P =.02). There was no difference in serum HGF of BA patients with fair outcome compared with other groups.

CONCLUSIONS

Serum HGF is elevated in BA. Furthermore, BA patients with poor outcome have significantly elevated HGF compared with patients with good outcome. Serum HGF levels may be predictive of prognosis with respect to the progression of liver dysfunction. However, the results of HGF in patients with fair outcome are inconclusive, probably because of the small sample size. Further studies are needed to elucidate the detailed mechanisms.