Genetic prediction of causal association between serum bilirubin and hematologic malignancies: a two-sample Mendelian randomized and bioinformatics study

Introduction

An increasing number of cohort studies have shown a correlation between serum bilirubin and tumors, but no definitive causal relationship has been established between serum bilirubin and hematological malignancies.Therefore, the aim of the present study was to assess the causal relationship of serum bilirubin, including total bilirubin (TBIL) and direct bilirubin (DBIL), with hematological malignancies, including leukemia, lymphoma, and myeloma.

Methods

We used a genome-wide association study (GWAS) collection of TBIL, DBIL, and hematological malignancies data. Using two-sample Mendelian randomization(MR), we assessed the impact of TBIL and DBIL on hematological malignancies. For this study, the inverse variance weighting method (IVW) was the primary method of MR analysis. In the sensitivity analysis, the weighted median method, MR Egger regression, and MR-PRESSO test were used. To understand the mechanisms behind TBIL and DBIL, we used three different approaches based on screening single nucleotide polymorphisms (SNPs) and their associated genes, followed by bioinformatics analysis.

Results

The IVW test results showed evidence of effects of TBIL (odds ratio [OR]: 4.47, 95% confidence interval [CI]: 1.58-12.62) and DBIL (OR: 3.31, 95% CI: 1.08-10.18) on the risk of acute myeloid leukemia (AML).The findings from bioinformatics indicated that TBIL could potentially undergo xenobiotic metabolism through cytochrome P450 and contribute to chemical carcinogenesis.

Discussion

In this study, two-sample MR analysis revealed a causal relationship between TBIL, DBIL, and AML.

Acute Helicobacter pylori infection prevalence and association with metabolic abnormality in general Chinese population: A retrospective study

Helicobacter pylori (H pylori) infection was common worldwide and previous researches on the correlation between H pylori infection and metabolic abnormality provided inconsistent conclusions. We assessed acute H pylori infection prevalence and the relationship with metabolic abnormality in general Chinese population. Participants attending for the physical examination underwent a carbon-13 urea breath test. For individual, the following data were collected: age, gender, body mass index (BMI), systolic blood pressure, diastolic blood pressure, total protein, albumin, globulin (GLB), total bilirubin, direct bilirubin (DBIL), indirect bilirubin, alanine transaminase, glutamyl transpeptidase, alkaline phosphatase, cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, urea nitrogen, creatinine, uric acid, fasting plasma glucose (FPG), and homocysteine. A total of 29,154 participants were enrolled. The prevalence of acute H pylori infection was 29.79% (8684/29,154). Spearson correlation analysis showed that gender, BMI, ALB, GLB, total bilirubin, DBIL, indirect bilirubin, and FPG were closely related to H pylori infection. Multinomial logistic regressions analysis with stepwise subset selection further identified gender, BMI, ALB, GLB, DBIL, and FPG as independent risk factors for acute H pylori infection. Our results indicated that acute H pylori infection might has a significant impact on metabolic abnormalities, which should be further confirmed.

Direct Bilirubin, but not Indirect Bilirubin, is Associated with Short-term Adverse Events in HFpEF

OBJECTIVE

Abnormal live function tests have been identified as independent risk factors for ominous prognosis in patients with heart failure. However, most of the previous studies have failed to determine the contribution of direct bilirubin (DBIL) and indirect bilirubin (IBIL) separately. Hence, we aimed to explore whether DBIL or IBIL is correlated with the prognosis of heart failure with preserved ejection fraction (HFpEF).

Methods: A total of 19837 patients were hospitalized for HFpEF between January 2012 and January 2022 in Fuqing City Hospital affiliated with Fujian Medical University. The primary endpoint was in-hospital all-cause mortality. Secondary endpoints included in-hospital cardiovascular mortality and 30-day re-admission for heart failure.

Results: Univariable analysis indicated that patients with elevated DBIL or IBIL were exposed to a higher risk of mortality and re-admission. However, in multivariable models, both ln-transformed DBIL and TBIL, but not IBIL, were independent risk factors for in-hospital all-cause mortality [hazard ratio (HR)=1.796, 95% confidential interval (CI)=1.477-2.183, P＜0.001; HR=1.854, 95% CI=1.461-2.352, P＜0.001; HR=1.161, 95% CI=0.959-1.407, P=0.126] and in-hospital cardiovascular mortality (HR=1.831, 95% CI=1.345-2.492, P＜0.001; HR=1.899, 95% CI=1.300-2.773, P=0.001; HR=1.145, 95% CI=0.841-1.561, P=0.389). Only DBIL remained independently associated with 30-day readmission for heart failure (HR=1.361, 95% CI=1.036-1.787, P=0.027). Adding ln-transformed DBIL to model 1 increased its discriminatory capacity (C-statistic: 0.851 to 0.869, respectively), whereas adding ln-transformed IBIL yielded little increment (C-statistic: 0.851 to 0.852, respectively).

Conclusion: DBIL, but not IBIL, was associated with short-term ominous prognosis in patients with HFpEF. Hence, DBIL may be the superior predictor for prognosis in HFpEF.

Association between bilirubin and chronic kidney disease in hypertensive patients: The China hypertension registry study

Limited data exists on the association between Direct bilirubin (DBIL) and Indirect bilirubin (IBIL) with the risk of chronic kidney disease (CKD) among patients with hypertension. This study aimed to assess the relationship between DBIL and IBIL with the risk of CKD in a cohort of Chinese adults diagnosed with hypertension. This study included 14 182 Chinese patients with hypertension between the ages of 27 and 96. CKD, the outcome variable, was defined by an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 . The study employed multivariate linear and multivariate logistic regression analysis to evaluate the correlation between DBIL and IBIL with the risk of CKD. The prevalence of CKD in the study population was 9.77%. Multivariate logistic regression analysis showed that the increase in DBIL (OR: 0.66; 95% CI: 0.61, 0.71) and IBIL (OR: 0.75; 95% CI: 0.71, 0.81) were independently and negatively correlated with CKD. Further analyses using a restricted cubic spline (smooth-fitting curve) confirmed the linearly negative association between DBIL and IBIL with the risk of CKD. The subgroup analysis showed that the correlation between IBIL and CKD was stronger among men and populations <65 years of age (p for interaction <.05). DBIL and IBIL were independently and negatively associated with CKD. Furthermore, the correlation between DBIL and IBIL with CKD in the hypertensive population is more significant in those under 65 years of age. These findings may inform future strategies for the management of CKD.

The association between serum ferritin and bilirubin with glycemic control among patients with type 2 diabetes mellitus

Previous evidence has shown an association between serum ferritin and bilirubin levels in the development of type 2 diabetes mellitus (T2DM) and glycemic control. However, the evidence is scarce in Saudi Arabia. In this study, we aimed to evaluate the association between serum ferritin and bilirubin levels with glycemic control in patients with T2DM. This was a cross-sectional study that involved 153 patients with T2DM recruited from outpatient diabetes clinics. Participants were categorized into two groups: well-controlled and uncontrolled T2DM, based on their glycemic status. We focused on comparing the iron profile and bilirubin levels between these two groups and examining the influence of antidiabetic medications on these parameters. A total of 153 patients with T2DM were included (58.2% women and 41.8% men). In both univariate and multivariate analyses, ferritin levels did not have a statistically significant association with glycemic control. However, patients with well-controlled T2DM had a significantly higher median level of total bilirubin and direct bilirubin than those with uncontrolled T2DM. Only direct bilirubin showed a statistically significant association with FBG less than 130 mg/dl and HbA1c level less than 7.0%. Ferritin level was not associated with glycemic control in patients with T2DM. On the other hand, direct bilirubin level was an independent predictor of better glycemic control. Monitoring direct bilirubin levels could aid in predicting glycemic control in T2DM and could be a potential target for developing antidiabetic medications.

Association between bilirubin levels with incidence and prognosis of stroke: A meta-analysis

Objective

Bilirubin has anti-inflammatory, antioxidant, and neuroprotective properties, but the association between bilirubin and stroke remains contentious. A meta-analysis of extensive observational studies on the relationship was conducted.

Methods

Studies published before August 2022 were searched in PubMed, EMBASE, and Cochrane Library. Cohort, cross-sectional and case-control studies that examined the association between circulating bilirubin and stroke were included. The primary outcome included the incidence of stroke and bilirubin quantitative expression level between stroke and control, and the secondary outcome was stroke severity. All pooled outcome measures were determined using random-effects models. The meta-analysis, subgroup analysis, and sensitivity analysis were performed using Stata 17.

Results

A total of 17 studies were included. Patients with stroke had a lower total bilirubin level (mean difference = -1.33 μmol/L, 95% CI: -2.12 to -0.53, P < 0.001). Compared with the lowest bilirubin level, total odds ratio (OR) of the highest bilirubin for the occurrence of stroke was 0.71 (95% CI: 0.61-0.82) and ischemic stroke was 0.72 (95% CI: 0.57-0.91), especially in cohort studies with accepted heterogeneity (I 2 = 0). Serum total and direct bilirubin levels were significantly and positively associated with stroke severity. A stratified analysis based on gender showed that the total bilirubin level in males correlated with ischemic stroke or stroke, which was not noted in females.

Conclusion

While our findings suggest associations between bilirubin levels and stroke risk, existing evidence is insufficient to establish a definitive association. Better-designed prospective cohort studies should further clarify pertinent questions (PROSPERO registration number: CRD42022374893).

Quantitative effects of bilirubin structural photoisomers on the measurement of direct bilirubin via the vanadate oxidation method

BACKGROUND

Exposing blood serum samples to ambient white light-emitting diode (WLED) light may accelerate bilirubin photoisomer production. We previously demonstrated the quantitative effect of bilirubin configurational isomers (BCI) on direct bilirubin (DB) value using the vanadate oxidation method. However, the effects of bilirubin structural photoisomers (BSI) remain unclear.

METHODS

In Study 1, the relationship between WLED irradiation time and BSI production was examined. Serum samples from five neonates were irradiated with WLED light for 0, 10, 30, 60 and 180 min. Bilirubin isomer concentration and BSI production rates were calculated. In Study 2, we performed quantitative investigation of BSI effect on DB values: Differences in DB, BCI and BSI values before and after irradiation were calculated as ⊿DB, ⊿BCI and ⊿BSI, respectively. Assuming the coefficient of BCI affecting DB values was 'a', relational expression was ⊿DB = a*⊿BSI + 0.19*⊿BCI. Serum samples from 15 neonates were irradiated with green LED light for 10 and 30 s. The respective bilirubin isomer levels were measured, and the coefficient was derived.

RESULTS

In Study 1, the median BSI production rate was 0.022 mg/dL per min in specimens with an unconjugated bilirubin concentration of 10.88 mg/dL. In Study 2, assuming that ⊿DB-0.19*⊿BCI was Y and ⊿BSI was X, the relational expression was Y = 0.34X-0.03 (R² = 0.87; p < .01) and a = 0.34.

CONCLUSIONS

Under ambient WLED light, serum sample generated 1.3 mg/dL BSIs in 1 h. Approximately 34% (0.44 mg/dL) of BSI concentrations was measured as DB when using the vanadate oxidation method according to the above equation.

Fractionated Bilirubin Among 252,892 Utah Newborns With and Without Biliary Atresia: A 15-year Historical Birth Cohort Study

OBJECTIVES

To determine whether neonatal conjugated or direct bilirubin levels were elevated in infants with biliary atresia, and to estimate the number of newborns that would have positive screens in the nursery necessitating repeat testing following discharge.

STUDY DESIGN

We used administrative data from a large integrated healthcare network in Utah to identify newborns who had a fractionated bilirubin recorded during birth admission from 2005 through 2019. Elevated conjugated bilirubin was defined as greater than 0.2 mg/dL and direct bilirubin was defined as greater than 0.5 mg/dL (>97.5^th percentile for the assays). We performed simulations to estimate the anticipated number of false positive screens.

RESULTS

There were 32 cases of biliary atresia and 468,161 live births during the study period (1/14,700). 252,892 newborns had fractionated bilirubin assessed including 26 of those subsequently confirmed to have biliary atresia. Conjugated or direct bilirubin was elevated in all 26 infants with biliary atresia and an additional 3,246 (1.3%) newborns without biliary atresia. Simulated data suggest nine to 21 per 1,000 screened newborns will have an elevated conjugated or direct bilirubin using laboratory-based thresholds for a positive screen. Screening characteristics improved with higher thresholds without increasing false negative tests.

CONCLUSIONS

This study validates the previous findings that conjugated or direct bilirubin are elevated in the newborn period in patients with biliary atresia. A higher threshold for conjugated bilirubin improved screening performance. Future studies are warranted to determine the optimal screening test for biliary atresia and to assess the effectiveness and cost-effectiveness of implementing such a program.

Serum Bilirubin Associated with Stroke Severity and Prognosis: Preliminary Findings on Liver Function after Acute Ischemic Stroke

OBJECTIVE

This study investigates relationships between serum bilirubin, stroke severity, and prognosis of patients with acute ischemic stroke (AIS) to elucidate the roles of the liver in AIS.

METHODS

This retrospective study collected data from 527 patients diagnosed with AIS within 24 hours after their symptom onset. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS). Mild stroke was defined as NIHSS≤5. Prognosis was assessed with modified Rankin Scale (mRS) on 90 days after AIS and good prognosis was defined as mRS≤2. The patients were divided based on their total bilirubin (Tbil) and direct bilirubin (Dbil) levels to study these serum markers' association with the severity of stroke. Tbil levels were measured and compared with mRS on 90 days to analyze prognosis of mild stroke patients.

RESULTS

Both Tbil abnormal (NIHSS = 6.8 ± 5.3) and Dbil abnormal groups (NIHSS = 7.3 ± 5.7) had higher NIHSS scores on admission than the normal groups (p< 0.05 or p< 0.01, respectively). Severity of stroke at discharge was similar between these groups (p = 0.025 and 0.019, respectively). Serum bilirubin levels were independently associated with stroke severity on admission and discharge after risk factors were adjusted (p< 0.001 and p< 0.05, respectively; β (95%CI) were 0.116 (0.064-0.167) and 0.058 (0.012-0.103), respectively). The average Tbil levels of mild stroke with good prognosis was 15.1 ± 6.4umol/l versus 11.8 ± 3.1umol/l with poor prognosis; this difference was statistically significant (p = 0.003). The same difference was observed with Dtil levels but it did not reach a significant level.

CONCLUSION

High Tbil and Dbil level within 48 hours of symptom onset could be an independent marker of severity of stroke on admission and discharge for all AIS patients. For patient with mild stroke, elevation of bilirubin after AIS suggests a good prognosis. These findings imply that the liver play the key roles in the mechanism of AIS.

Causal relationships of neonatal jaundice, direct bilirubin and indirect bilirubin with autism spectrum disorder: A two-sample Mendelian randomization analysis

Background

Multiple systematic reviews and meta-analyses have examined the association between neonatal jaundice and autism spectrum disorder (ASD) risk, but their results have been inconsistent. This may be because the included observational studies could not adjust for all potential confounders. Mendelian randomization study can overcome this drawback and explore the causal relationship between the both.

Methods

We used the data of neonatal jaundice, direct bilirubin (DBIL), indirect bilirubin (IBIL), and ASD collected by genome-wide association study (GWAS) to evaluate the effects of neonatal jaundice, DBIL and IBIL on ASD by using a two-sample Mendelian randomized (MR). The inverse variance-weighted method (IVW) was the main method of MR analysis in this study. Weighted median method, MR-Egger regression and mendelian randomization pleiotropy residual sum and outlier (MR-PRESSO) test were used for sensitivity analysis.

Results

There was no evidence of an effect of neonatal jaundice (OR, 1.002, 95% CI, 0.977-1.027), DBIL (OR, 0.970, 95% CI, 0.884-1.064) and IBIL (OR, 1.074, 95% CI, 0.882-1.308) on ASD risk by IVW test. In the weighted median method, MR-Egger regression and leave-one-out analysis, the results were robust and no heterogeneity or pleiotropy was observed.

Conclusions

We found that neonatal jaundice, DBIL and IBIL were not associated with ASD in this study. However, this paper did not explore the effect of severity and duration of jaundice on ASD in different ethnic populations, which may require further research.

Effect of Direct Bilirubin Level on Clinical Outcome and Prognoses in Severely/Critically Ill Patients With COVID-19

Objectives

We aimed to investigate how changes in direct bilirubin (DBiL) levels in severely/critically ill the coronavirus disease (COVID-19) patients during their first week of hospital admission affect their subsequent prognoses and mortality.

Methods

We retrospectively enrolled 337 severely/critically ill COVID-19 patients with two consecutive blood tests at hospital admission and about 7 days after. Based on the trend of the two consecutive tests, we categorized patients into the normal direct bilirubin (DBiL) group (224), declined DBiL group (44) and elevated DBiL group (79).

Results

The elevated DBiL group had a significantly larger proportion of critically ill patients (χ²-test, p < 0.001), a higher risk of ICU admission, respiratory failure, and shock at hospital admission (χ²-test, all p < 0.001). During hospitalization, the elevated DBiL group had significantly higher risks of shock, acute respiratory distress syndrome (ARDS), and respiratory failure (χ²-test, all p < 0.001). The same findings were observed for heart damage (χ²-test, p = 0.002) and acute renal injury (χ²-test, p = 0.009). Cox regression analysis showed the risk of mortality in the elevated DBiL group was 2.27 (95% CI: 1.50–3.43, p < 0.001) times higher than that in the normal DBiL group after adjusted age, initial symptom, and laboratory markers. The Receiver Operating Characteristic curve (ROC) analysis demonstrated that the second test of DBiL was consistently a better indicator of the occurrence of complications (except shock) and mortality than the first test in severely/critically ill COVID-19 patients. The area under the ROC curve (AUC) combined with two consecutive DBiL levels for respiratory failure and death was the largest.

Conclusion

Elevated DBiL levels are an independent indicator for complication and mortality in COVID-19 patients. Compared with the DBiL levels at admission, DBiL levels on days 7 days of hospitalization are more advantageous in predicting the prognoses of COVID-19 in severely/critically ill patients.

Comparative analysis of cystic biliary atresia and choledochal cysts

OBJECTIVE

Cystic biliary atresia (CBA) is a rare and peculiar type of biliary atresia (BA) that is easily confused with infantile choledochal cysts (CCs). This study explored information for early CBA diagnosis and treatment.

METHOD

The authors retrospectively analyzed the clinical data of 32 children with hilar cysts from January 2013 to May 2021. According to the diagnosis, they were divided into the CBA (n = 12) and CC (n = 20) groups. Patient features, biochemical indexes, preoperative ultrasound characteristics, cholangiography features, and intraoperative findings were analyzed and compared between the two groups.

RESULTS

The alanine aminotransferase, aspartate aminotransferase, total bilirubin, and direct bilirubin levels in the CBA group were higher than in the CCs group (P < 0.05). Additionally, B-mode ultrasound showed a cystic mass in front of the hepatic hilum, and the cyst size was much smaller in the CBA group compared with the CC group (2.2 ± 1.3 cm vs. 6.0 ± 2.2 cm, P < 0.001). Among all of the parameters, cyst width was the most accurate for identifying CBA and CCs. A cutoff value of 2.5 cm (area under the curve, 0.98, P < 0.001) showed 90.9% sensitivity and 95% specificity for cyst size.

CONCLUSION

For children with early-onset severe jaundice, and if the width of the cystic mass was ≤2.5 cm, a diagnosis of CBA was highly likely. Early cholangiography and surgical treatment are necessary for the effective treatment of these infants.

Soybean-Oil Lipid Minimization for Prevention of Intestinal Failure-Associated Liver Disease in Late-Preterm and Term Infants With Gastrointestinal Surgical Disorders

BACKGROUND

Intestinal failure-associated liver disease (IFALD), a multifactorial disease, is common among infants with gastrointestinal surgical disorders (GISDs). Prolonged soy-based intravenous lipid emulsion (S-ILE) intake is associated with IFALD, but preventive studies of limiting S-ILE have been inconclusive. Furthermore, a double-blind, randomized preventive trial (DBRPT) of S-ILE intake has not been performed in infants with GISDs. Our objective was to compare the effect of 1 g/kg/d vs 2 g/kg/d S-ILE intake for 6 weeks on the incidence of IFALD and the rate of rise of direct bilirubin (DB) in infants with GISDs.

METHODS

A DBRPT was conducted in infants with GISDs at ≥34 weeks' gestational age (GA) admitted to the NICU within 72 hours after birth. Infants were randomized in a 1:1 ratio to receive either 1 or 2 g/kg/d S-ILE for 6 weeks. IFALD was defined as DB ≥2 mg/dL.

RESULTS

Forty infants were studied. The 2 groups had similar clinical characteristics except for GA and blood group incompatibility. Thirty percent of infants in each group developed IFALD (P = .94). However, infants in the group receiving 1 g/kg/d S-ILE (n = 20) had a lower rate of rise of DB compared with infants in the group receiving 2 g/kg/d S-ILE (n = 20).

CONCLUSIONS

Reducing S-ILE intake for 6 weeks in infants with GISD at ≥34 weeks' GA may not prevent IFALD. The extrapolated data on the rate of rise of DB suggest a possible risk of earlier development of IFALD with S-ILE intake of 2 g/kg/d, as compared with 1 g/kg/d, beyond the 6-week study period.

Contribution of the laboratory to a diagnosis process by sequential reflective testing: Paraprotein interference on a direct bilirubin assay

Errors in laboratory medicine occur in the preanalytical, analytical, and postanalytical phases. The errors are mostly detected in the preanalytical period. However, analytical errors are still an important source of error, despite their frequency is reduced significantly in years thanks to developments in laboratories. In this case, an analytical error was noticed during the verification of a patient’s results. The direct bilirubin of a 66-year-old male patient admitted to the emergency department was higher than the total bilirubin. The patient’s symptoms were fatigue and dyspnoea. Albumin and haemoglobin (Hb) concentrations of the patient were significantly low. After considering the patient’s demographics and laboratory results, the laboratory specialist suspected a paraproteinemia interference. Total protein was performed as a reflective test. The albumin/globulin ratio was reversed. Thereafter, serum protein electrophoresis (SPEP) and immunofixation electrophoresis (IFE) were performed as another reflective tests, respectively. SPEP and IFE results were in favour of monoclonal gammopathy. The patient was directed to a haematologist, underwent a bone marrow biopsy, and the result was reported as Waldenstrom’s macroglobulinemia with plasma cell differentiation expressing IgM-Kappa. The patient went on a chemotherapy protocol, and his condition has been improved in subsequent months. Detection of analytical errors is of great importance, like in our case, and may be used as a tool to identify patients who have not yet been diagnosed. The laboratory specialist must dominate the entire process of each test in the laboratory, be aware of the limitations of tests, and turn these disadvantages into advantages when necessary.

Radiographic Features and Clinical Factor for Preoperative Prediction in the Bulging Duodenal Papilla With Malignancy

Background

To investigate characteristic clinical and imaging features and establish a scoring system for preoperative prediction of malignancy in the bulging duodenal papilla.

Methods

A total of 147 patients with bulging duodenal papilla (Benign enlargement n = 67; malignant enlargement n = 80) from our hospital between 2010 and 2020 were retrospectively analyzed. We investigated meaningful clinical and CT imaging features and established the score model through logistic regression and weighted. The calibration test, the ROC, AUC, and cut-off points were performed in score model. The model was also divided into three score ranges for convenient clinical evaluation.

Results

Three clinical and CT imaging features were finally included in the score model including direct bilirubin (DBil) increase >7 umol/L (3 points), pancreatic duct (PD) dilation >5 mm (2 points), and irregular shape (2 points). The AUCs of the primary predictive model and score model were 0.896 (95% CI, 0.835-0.940) and 0.896 (95% CI, 0.835-0.940), respectively. This scoring system presented with a sensitivity of 78.8% and a specificity of 88.1% when using 2.5 points as cutoff value. Three score ranges were also proposed for convenient clinical use as follows: 0-2 points; 3-4 points; 5-7 points. The number of patients with malignant duodenal papillary enlargement increased with the increasing scores.

Conclusions

We proposed a convenient scoring system to preoperative predict malignancy in the bulging duodenal papilla.

Baseline Serum Bilirubin and Risk of First Stroke in Hypertensive Patients

Background

Data on the association between serum bilirubin and the risk of stroke are limited and inconclusive. We aimed to evaluate the association between serum bilirubin and the risk of first stroke and to examine any possible effect modifiers in hypertensive patients.

Methods and Results

Our study was a post hoc analysis of the CSPPT (China Stroke Primary Prevention Trial). A total of 19 906 hypertensive patients were included in the final analysis. Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% CIs for the risk of first stroke associated with serum bilirubin levels. The median follow‐up period was 4.5 years. When serum total bilirubin was assessed as tertiles, the adjusted HR of first ischemic stroke for participants in tertile 3 (12.9–34.1 μmol/L) was 0.75 (95% CI, 0.59–0.96), compared with participants in tertile 1 (<9.3 μmol/L). When direct bilirubin was assessed as tertiles, a significantly lower risk of first ischemic stroke was also found in participants in tertile 3 (2.5–24.8 μmol/L) (adjusted HR, 0.77; 95% CI, 0.60–0.98), compared with those in tertile 1 (<1.6 μmol/L). However, there was no significant association between serum total bilirubin (tertile 3 versus 1: adjusted HR, 1.45; 95% CI, 0.89–2.35) or direct bilirubin (tertile 3 versus 1: adjusted HR, 1.27; 95% CI, 0.76–2.11) and first hemorrhagic stroke.

Conclusions

In this sample of Chinese hypertensive patients, there was a significant inverse association between serum total bilirubin or direct bilirubin and the risk of first ischemic stroke.

Clinical biochemistry test eliminator providing cost-effectiveness with five algorithms

Objectives: The purpose of this study is to investigate the elimination ratios of requested unnecessary tests and the cost-effectiveness to be achieved by means of 5 different algorithms with clinical validity defined in an artificial intelligence program.Methods: The clinician orders received from the hospital information management system were adapted to eliminate AST, direct bilirubin, chlorine, fPSA and fT3 tests using five different algorithms defined in the ALIN IQ software.Results: In this study, 18387 AST, 9500 direct bilirubin, 61 free PSA, 1127 FT3 and 11172 chlorine tests that were ordered within 45 days were eliminated using 5 different algorithms defined in the ALIN IQ software in the Laboratory of Harran University Faculty of Medicine. USD 5592.76 was saved in 45 days. The annual saving is expected to be 363710 tests and USD 45363.49.Conclusion: Five different tests were successfully eliminated with this study. Open-code smart softwares, which can create indefinite algorithms may be utilized as test eliminators in diagnostic clinical laboratories. Millions of dollars may be saved by means of such artificial intelligence softwares that can be adapted to any analyzer across the world.

The Relationship Between Serum Bilirubin Levels and Peripheral Arterial Disease and Gender Difference in Patients With Hypertension: BEST Study

We evaluated the relationship between serum bilirubin levels and ankle-brachial index (ABI) to determine whether gender affected the relationship between bilirubin levels and peripheral arterial disease (PAD) in patients with hypertension. A total of 543 patients were included in our studies (78 patients with PAD and 465 without PAD). Peripheral arterial disease was defined as ABI <0.90 for either and/or both sides. Serum bilirubin levels were measured with a vanadate oxidation method by using fasting venous blood samples. Serum total bilirubin (TBiL) and direct bilirubin (DBiL) levels were higher in males compared with females (both P < .05). Total bilirubin and DBiL were significantly lower in the PAD group. After adjustment for cardiovascular risk factors, PAD was independently negatively related to TBiL and DBiL, with odds ratios (OR) 0.914 (95% confidence interval [CI]: 0.845-0.990) and 0.748 (95% CI: 0.572-0.977). In addition, there was a relationship between PAD and bilirubin levels (TBiL-OR = 0.884, 95% CI: 0.792-0.985; DBiL-OR = 0.621; 95% CI: 0.424-0.909) only in males but not in females. Future studies should further evaluate whether interventions that increase serum bilirubin levels will have a particular role in PAD prevention in males.

Associations between different bilirubin subtypes and diabetic microvascular complications in middle-aged and elderly individuals

AIMS

Some studies have reported associations between bilirubin and diabetic microvascular complications. However, these studies focused only on total bilirubin (TBIL) without distinguishing different bilirubin subtypes. In this study, we aimed to investigate the associations of TBIL, direct bilirubin (DBIL) and indirect bilirubin (IBIL) levels with albuminuria/creatinine ratio (ACR) and the prevalence of diabetic retinopathy (DR) among diabetic adults.

METHODS

We analyzed 4368 individuals out of 4813 diabetic participants enrolled from seven communities in 2018 in a cross-sectional study. Participants underwent several checkups, including the measurement of anthropometric parameters, blood pressure, glucose, lipid profile, TBIL, DBIL, IBIL and ACR. DR was detected by high-quality fundus photographs and was remotely read by ophthalmologists.

RESULTS

Compared with the first quartile of DBIL, participants in the fourth quartile had a lower prevalence of high ACR (odds ratio (OR) 0.76; 95% confidence interval (CI) 0.59, 0.99) (p for trend < 0.05). Neither TBIL nor IBIL was associated with the prevalence of high ACR. In DR, higher DBIL and TBIL by one standard deviation was associated with a 19% (OR 0.81; 95% CI 0.69, 0.94) and a 12% (OR 0.88; 95% CI 0.78, 0.99) lower frequency of DR, respectively (both p for trend < 0.05). However, IBIL was not associated with the prevalence of DR. These associations were adjusted for potential confounding factors.

CONCLUSION

DBIL had a stronger association with high ACR and DR than TBIL or IBIL did in diabetic adults. The effect of DBIL on diabetic complications should be noted and investigated in further studies.

[Value of serum gamma-glutamyl transpeptidase combined with direct bilirubin in the diagnosis of biliary atresia in infants]

OBJECTIVE

To study the value of serum gamma-glutamyl transpeptidase (GGT) combined with direct bilirubin (DB) in the diagnosis of biliary atresia.

METHODS

A total of 667 infants with cholestasis who were hospitalized and treated from July 2010 to December 2018 were enrolled as subjects. According to the results of intraoperative cholangiography and follow-up, they were divided into biliary atresia group with 234 infants and cholestasis group with 433 infants. The two groups were compared in terms of age of onset, sex, and serum levels of total bilirubin (TB), DB, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bile acid (TBA), and GGT. A receiver operating characteristic (ROC) curve analysis was performed for indices with statistical significance, and the area under the ROC curve (AUC) and the optimal cut-off value for diagnosis were calculated.

RESULTS

The biliary atresia group had a significantly younger age of onset than the cholestasis group (P<0.001). There were no significant differences in sex, ALT, and AST between the two groups (P>0.05), while the biliary atresia group had significantly higher serum levels of TB, DB, TBA, and GGT than the cholestasis group (P<0.05). GGT combined with DB had the highest AUC of 0.892 (95% confidence interval: 0.868-0.916) in the diagnosis of biliary atresia. At the optimal cut-off values of 324.0 U/L for GGT and 115.1 μmmol/L for DB, GGT combined with DB had a sensitivity of 79.8% and a specificity of 83.2% in the diagnosis of biliary atresia.

CONCLUSIONS

GGT combined with DB has high sensitivity and specificity in the diagnosis of biliary atresia and can be used as an effective indicator for diagnosis of biliary atresia in infants.

The Relationship of Perforated Appendicitis with Total and Direct Bilirubin

Introduction Very different results have been reported regarding the relationship between bilirubin and perforated appendicitis. We observed this relationship with our own studies. Methods The patients, who underwent appendectomy, were retrospectively categorized as perforated and non-perforated based on their files. Those with a total bilirubin (TB) 1.20 mg/dL or less were considered normal whereas those with a 1.21 mg/dL or higher were considered having a high. Those with a direct bilirubin (DB) 0.50 mg/dL or less were considered normal whereas those with a 0.51 mg/dL or higher were considered having a high. The patients were assessed under two groups. Perforated appendicitis (PA) and non-perforated appendicitis (NPA) were analyzed according to the TB in Group 1 and the DB in Group 2. Results Group 1 included 269 patients whose TB were measured. Of those, 218 had NPA and 51 had PA. The rate of patients with high TB among the patients with PA was 1.37 times higher than those with NPA (p ˂ 0.01). Group 2 included 258 patients whose DB values were measured. Of those, 208 had NPA and 50 had PA. The rate of patients with high TB among the patients with PA was 1.71 times higher than those with NPA (p ˂ 0.001). Conclusion In the diagnosis of PA, both TB and DB show low diagnostic values. In the diagnosis, they can only be considered as a supportive factor to other parameters. However, in the case of a differential diagnosis, we recommend using DB since it has a higher sensitivity and specificity.

Detecting paraprotein interference on a direct bilirubin assay by reviewing the photometric reaction data

BACKGROUND

The direct bilirubin (D-Bil) assay on the AU Beckman Coulter instrumentation can be interfered by paraproteins, which may result in spurious D-Bil results. In a previous work, we took advantage of this fact to detect this interference, thus helping with the identification of patients with unsuspected monoclonal gammopathies. In this work, we investigate the possibility to detect interference based on the review of the photometric reactions, regardless of the D-Bil result.

METHODS

The D-Bil assay was carried out in a set of 2164 samples. It included a group of 164 samples with paraproteins (67 of which caused interference on the assay), as well as different groups of samples for which high absorbance background readings could also be expected (i.e. hemolyzed, lipemic, or icteric samples). Photometric reaction data were reviewed and receiver operating characteristics (ROC) curves were used to establish a cut-off for absorbance that best discriminates interference.

RESULTS

The best cut-off was 0.0100 for the absorbance at the first photometric point of the complementary wavelength in the blank cuvette. Once the optimal cut-off for probable interference was selected, all samples analyzed in our laboratory that provided absorbance values above this cut-off were further investigated to try to discover paraproteins. During a period of 6 months, we detected 44 samples containing paraproteins, five of which belonged to patients with non-diagnosed monoclonal gammopathies.

CONCLUSIONS

Review of the photometric reaction data permits the systematic detection of paraprotein interference on the D-Bil AU assay, even for samples for which reasonable results are obtained.

Correlation of HLA-DP/DQ polymorphisms with transplant etiologies and prognosis in liver transplant recipients

Previous study has identified that the genetic variants in the human leukocyte antigen (HLA)-DP/DQ region were strongly associated with hepatitis B virus (HBV) infection. But their roles in liver function recovery after hepatic transplantation were still obscure. This study aimed to investigate whether HLA-DP/DQ polymorphisms were associated with post-transplant etiologies and prognosis in Chinese liver transplant recipients.A total of 144 liver transplant recipients were enrolled, which were divided into 2 groups according to the transplant etiology: HBV-related disease and non-HBV-related disease. HBV-related disease includes 3 subgroups: liver cirrhosis, hepatocellular carcinoma, and progressive HBV hepatitis. Three single-nucleotide polymorphisms HLA-DP (rs3077 and rs9277535) and HLA-DQ (rs7453920) were studied in all recipients by high-resolution melting curve analysis. Liver function indices (albumin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma-glutamyltranspeptidase, direct bilirubin, total bilirubin) and coagulation indices (prothrombin time, platelet, international normalized ratio, fibrinogen) were routinely tested. After transplant, 10 recipients who were positive for HBsAg or with elevation in HBV virus load were regarded as HBV recurrence.No significant association of HLA-DP/DQ polymorphisms with HBV recurrence or transplant etiology was observed (P < .05). Recipients with HLA-DQ (rs7453920) AG and AA genotype had lower direct bilirubin levels than GG genotype individuals, especially on the 14th day after surgery (17.80 vs. 5.35, P  =  .038). Patients with A alleles displayed earlier liver function recovery than patients with G alleles (7 vs. 6 months). No significant correlation was shown in HLA-DP rs3077 and rs9277535 with HBV infection or liver function recovery (P < .05).Our study concluded that HLA-DP (rs3077 and rs9277535) and HLA-DQ (rs7453920) were not significantly associated with HBV recurrence or HBV susceptibility, but HLA-DQ rs7453920 was related to prognosis of liver transplant recipients. HLA-DQ rs7453920 A might be used as an indicator of earlier recovery and better prognosis after transplantation.

Resolution of liver disease in transient abnormal myelopoiesis with fish oil emulsion

Neonates with Down syndrome are at risk of developing transient abnormal myelopoiesis (TAM), which is characterized by transient clonal myeloproliferation of the blast cells. TAM can resolve spontaneously, but some patients die at an early age due to organ failure. Liver fibrosis in TAM is a life-threatening condition, but treatment options have not yet been established. Here, we report on the case of an infant with TAM complicated by liver disease, whose hyperbilirubinemia was successfully ameliorated with omega-3 fatty acid (ω3FA) lipid emulsion. Timely ω3FA lipid emulsion may be a feasible treatment for liver disease in TAM before serious liver damage develops.

Nomograms incorporated serum direct bilirubin level for predicting prognosis in stages II and III colorectal cancer after radical resection

An elevated serum bilirubin has been reported to be associated with a reduced risk of some cancer; however, the prognostic significance of serum bilirubin in colorectal cancer wasn’t fully understood. The purpose of this study was to evaluate whether serum bilirubin could predict the prognosis of patients in stages II and III colorectal cancer. A retrospective cohort of 986 patients with colorectal cancer who received surgical resection between January 2005 and December 2010 was included in the study. Levels for serum bilirubin were obtained from medical records. Survival analysis was used to evaluate the predictive value of bilirubin. Serum direct bilirubin (DBIL) was validated as a significant prognostic factor by univariate cox regression test for both overall survival (OS) and disease free survival (DFS) (P < 0.05). X-tile program identified 3.6 as optimal cutoff values for DBIL in terms of OS and DFS. Patients were then divided into DBIL high (DBIL ≥ 3.60 μmol/l) and low group (DBIL < 3.60 μmol/l) according to the optimal cutoff. High DBIL had higher percentage of lymph node metastasis and lymphovascular invasion as compared with low DBIL levels (P < 0.05). Multivariate cox regression analyses confirmed that high DBIL level was an independently prognostic factor for both OS (HR: 1.337, 95% CI: 1.022–1.748, P = 0.034) and DFS (HR: 1.312, 95% CI: 1.049–1.643, P = 0.018). In addition, nomograms on OS and DFS were established according to all significant factors, and c-indexes were 0.715 (95% CI: 0.683–0.748) and 0.704 (95% CI: 0.678–0.730), respectively. Nomograms based on OS and DFS can be recommended as practical models to evaluate prognosis for CRC patients.

Serum Bilirubin Levels and the Presence and Progression of Abdominal Aortic Aneurysms

The relationship between bilirubin levels and peripheral artery disease has been documented. Our aim was to demonstrate the possible relationship between serum bilirubin levels and abdominal aortic aneurysms (AAAs). The study included 219 patients, 110 had a previous diagnosis of AAA and 109 patients were normal controls. Only patients with AAAs which had a size of 40 to 54 mm were included in the study. Baseline laboratory values and 2 computerized tomographic measurements 12 months apart were recorded. Patients with AAA had significantly higher white blood cell (WBC) counts and neutrophil-lymphocyte ratio (NLR) but lower total and direct bilirubin levels compared with the control patients ( P < .05). Multivariate logistic regression analysis showed that WBC, NLR, and total and direct bilirubin levels were independent predictors of the presence of an AAA ( P = .03, P = .001, P = .001, and P = .001, respectively). White blood cells and total bilirubin level were independent predictors of a rapidly enlarging AAA (>10 mm/y, P = .002 and P < .001, respectively). This study demonstrated that increased WBC and decreased total bilirubin levels were independent predictors of an AAA, especially the subgroup in which the AAA was rapidly expanding.

Liver injury is associated with mortality in sickle cell disease

BACKGROUND

Increased life expectancy in sickle cell disease (SCD) has resulted in greater recognition of the consequences of repeated intravascular vaso-occlusion and chronic haemolysis to multiple organ systems.

AIM

To report the long-term consequences of liver dysfunction in SCD.

METHODS

A cohort of SCD patients was prospectively evaluated at the National Institutes of Health (NIH) Clinical Center. The association of mortality with liver enzymes, parameters of liver synthetic function and iron overload was evaluated using Cox regression.

RESULTS

Exactly, 247 SCD patients were followed up for 30 months of whom 22 (9%) died. After controlling for predictors, increased direct bilirubin (DB), ferritin, alkaline phosphatase and decreased albumin were independently associated with mortality. In a multivariable model, only high DB and ferritin remained significant. Ferritin correlated with hepatic iron content and total blood transfusions but not haemolysis markers. Forty patients underwent liver biopsies and 11 (28%) had fibrosis. Twelve of 26 patients (48%) had portal hypertension by hepatic venous pressure gradient (HVPG) measurements. All patients with advanced liver fibrosis had iron overload; however, most patients (69%) with iron overload were without significant hepatic fibrosis. Ferritin did not correlate with left ventricular dysfunction by echocardiography. DB correlated with bile acid levels suggesting liver pathology. Platelet count and soluble CD14 correlated with HVPG indicating portal hypertension.

CONCLUSIONS

Ferritin and direct bilirubin are independently associated with mortality in sickle cell disease. Ferritin likely relates to transfusional iron overload, while direct bilirubin suggests impairment of hepatic function, possibly impairing patients' ability to tolerate systemic insults.

Direct bilirubin as a prognostic biomarker in enteric fistula patients complicated with sepsis: a case-control study

OBJECTIVE

The objective of this study was to evaluate the predictive value of serial bilirubin determinations for mortality in enteric fistula (EF) patients complicated with sepsis.

METHODS

From January 1st, 2012 to January 13rd, 2013, a prospective study enrolling 162 patients was performed. Patients were divided into the survivors group (n = 119) and non-survivors group (n = 43) according to 28-day outcomes. Laboratory variables on day 0, day 3 and day 7 after admission were recorded. DB0 was defined as serum direct bilirubin (DB) value in admission, while ΔDB3 as the changes from DB3 to DB0. The definition applied to other parameters. The results were validated in an independent cohort of 116 patients.

RESULTS

Compared with survivors, non-survivors had significantly higher DB7 (23.1 ± 10.6 vs. 11.2 ± 1.1, P < 0.001) and procalcitonin (PCT7) (5.2 ± 2.8 vs. 1.7 ± 0.3 P = 0.006). ROC analysis showed that DB7 > 12.8 μmol/L and ΔDB7 > 7.3 μmol/L were reliable predictors (DB7: 86.4% sensitivity, 88.6% specificity (area under the curve (AUC): 0.881, P < 0.001; ΔDB7: 84.4% sensitivity, 85.1% specificity, AUC: 0.865, P < 0.001) for mortality.The combination form (DB7 > 12.8 μmol/L + ΔPCT7 < 5.3 ng/ml) had greatest predictive value (AUC: 0.894, P < 0.001). Their predictive values were confirmed in the validation cohort.

CONCLUSIONS

Serum direct bilirubin was a reliable predictor for mortality in enteric fistula patients, which should be paid close attention in the critical care.

A novel homozygous no-stop mutation in G6PC gene from a Chinese patient with glycogen storage disease type Ia

Glycogen storage disease type Ia (GSD-Ia) is an autosomal recessive genetic disorder resulting in hypoglycemia, hepatomegaly and growth retardation. It is caused by mutations in the G6PC gene encoding Glucose-6-phosphatase. To date, over 80 mutations have been identified in the G6PC gene. Here we reported a novel mutation found in a Chinese patient with abnormal transaminases, hypoglycemia, hepatomegaly and short stature. Direct sequencing of the coding region and splicing-sites in the G6PC gene revealed a novel no-stop mutation, p.*358Yext*43, leading to a 43 amino-acid extension of G6Pase. The expression level of mutant G6Pase transcripts was only 7.8% relative to wild-type transcripts. This mutation was not found in 120 chromosomes from 60 unrelated healthy control subjects using direct sequencing, and was further confirmed by digestion with Rsa I restriction endonuclease. In conclusion, we revealed a novel no-stop mutation in this study which expands the spectrum of mutations in the G6PC gene. The molecular genetic analysis was indispensable to the diagnosis of GSD-Ia for the patient.

Short-term administration of an aqueous extract of kalanchoe integra var. crenata (Andr.) Cuf leaves produces no major organ damage in Sprague-Dawley rats

ETHNOPHARMACOLOGICAL RELEVANCE

Kalanchoe intergra (Ki) leaf extract is an orally administered multipurpose plant medicine in Ghana and other parts of the world for the treatment of ulcers, pain and adenoma of the prostate gland. There is paucity of information concerning its short-term usage. The present study is aimed at conducting histopathological and biochemical studies in a 14-day sub-acute toxicity studies using female Sprague-Dawley rats.

MATERIALS AND METHODS

Crude extract of Ki leaves was prepared and freeze-dried. A 14-day sub-acute toxicity studies was conducted using 2 week old nulliparous and non-pregnant female Sprague-Dawley rats (120-150g). Reconstituted Ki was administered at a dosage of 900mgkg(-1) (high dose), 300mgkg(-1) with a control group receiving an equivalent volume of distilled water (as vehicle) by gastric lavage. Histopathological studies of major organs and blood chemistry analysis were performed on blood obtained via cardiac puncture into EDTA tubes after euthanisation.

RESULTS

There was a significant decrease in urea (p<0.016) and creatinine levels (p<0.001) in both the high and low dose groups. There was an increase in ALP levels (P=0.01) in both the high and low dose groups. ALT and AST rather decreased significantly in both the high and low dose groups (p<0.0001). Histopathological results did not show any abnormalities in all the H&E stained paraffin sections. Thus the photomicrographs of the liver, kidney and heart were within histopathological limits.

CONCLUSION

Ki leaf extract is non-toxic when administered by the oral route over a time period of 14 days at the above doses.

The role of NAD(+)-dependent isocitrate dehydrogenase 3 subunit α in AFB1 induced liver lesion

Aflatoxin B1 (AFB1) is a potent hepatocarcinogen that causes carcinogenesis in many animal species. In previous study, we found that isocitrate dehydrogenase 3α subunit (IDH3α) was upregulated in AFB1-induced carcinogenesis process. In this study, the sequences of IDH3α from various species were compared and the protein expression levels in different organs were examined, and the results showed that IDH3α was a widely distributed protein and shared highly conserved sequence in various species. In the same time, IDH3α was demonstrated to accumulate in a dose-dependent manner induced by AFB1 in cells, and was also up-regulated in the process of AFB1-induced liver lesion. Similar results were observed when H2O2 was used to replace AFB1. Over-expression of IDH3α increased the phosphorylation level of Akt (Protein kinase B) and neutralized the cellular toxicity induced by AFB1 or H2O2 and apoptosis induced by AFB1, while the reduced expression of IDH3α by siRNA decreased the phosphorylation, indicating that IDH3α played important roles in oxidative stress-induced PI3K/Akt pathway. Overall, the results suggested that AFB1 treatment could increase the expression of IDH3α, and the activated PI3K/Akt pathway by IDH3α eventually neutralized the apoptosis induced by AFB1.

The presence of hepatitis B core antibody is associated with more advanced liver disease in alcoholic patients with cirrhosis

BACKGROUND

Liver disease is more severe in patients with chronic hepatitis B virus (HBV) infections and alcohol-induced liver injury. Whether the same is true for alcoholic patients with cirrhosis who have recovered from previous HBV infections remains to be determined.

OBJECTIVES

To document the extent of liver disease in alcoholic patients with cirrhosis who test negative for hepatitis B surface antigen (HBsAg) and test positive for antibody to hepatitis B core antigen (anti-HBc).

METHODS

Two hundred fifty-four alcoholic patients with cirrhosis were divided into anti-HBc-positive (N = 171) and anti-HBc-negative (N = 83) cohorts. Demographic, clinical, and biochemical features were retrospectively analyzed. Prognostic scores and the prevalence of patients at high risk for short-term mortality were calculated. Logistic regression was used to identify factors associated with an increased risk for short-term mortality.

RESULTS

Jaundice was more common in the anti-HBc-positive cohort (32.2% vs. 18.1%, p = 0.02). This cohort also had higher serum bilirubin (70.9 vs. 50.4 μM/L, p = 0.03), prothrombin times (15.6 vs. 14.4 s, p = 0.01), MELD scores (8.5 vs. 4.6, p = 0.01), i-MELD scores (28.6 vs. 24.7, p = 0.03), MDF scores (14.2 vs. 6.8, p = 0.02) and ABIC scores (7.2 vs. 6.6, p = 0.01). In addition, anti-HBC-positive patients were more often at high risk for short-term mortality (40.4% vs. 26.5%, p = 0.03). Multivariate analysis identified anti-HBc-positive status (OR: 1.84; 95% CI: 1.10-3.36) and alcohol intake ≥150 g/day (OR: 2.01; 95% CI: 1.10-3.66) as independent risk factors for high risk of mortality.

CONCLUSION

The anti-HBc-positive state is associated with more advanced liver disease in alcoholic patients with cirrhosis. A prospective study including HBV-DNA testing and liver biopsies should be considered to validate and further elucidate these findings.

Patients with biliary atresia have elevated direct/conjugated bilirubin levels shortly after birth

OBJECTIVES

Healthy infants are thought to acquire biliary atresia (BA) in the first weeks of life. Because those diagnosed earlier have better outcomes, we were interested in determining the earliest time BA could be detected. We started by examining the immediate postnatal period, hypothesizing that newborns would not yet have acquired disease and still have normal direct/conjugated bilirubin (DB/CB) levels.

PATIENTS AND METHODS

Newborn DB/CB levels were obtained retrospectively from birth hospitals. Subjects with BA were born between 2007 and 2010 and cared for at Texas Children's Hospital. Those with BA splenic malformation syndrome or born prematurely were excluded. Control subjects were term newborns who later never developed neonatal liver disease.

RESULTS

Of the 61 subjects with BA, 56% had newborn DB/CB levels measured. All DB/CB levels exceeded laboratory norms and rose over time. At 24 to 48 hours of life, subjects with BA had mean DB levels significantly higher than those of controls (1.4 ± 0.43 vs. 0.19 ± 0.075 mg/dL, P < .0001), even while their mean total bilirubin (TB) levels remained below phototherapy limits. Finally, despite the elevated DB/CB levels, the majority of patients (79%) had normal DB:TB ratios ≤ 0.2.

CONCLUSIONS

Patients with BA have elevated DB/CB levels shortly after birth. To detect affected infants earlier and improve outcomes, the results suggest two possibilities: (1) screen all newborns for elevated DB/CB levels, rather than just those who appear jaundiced; and then (2) follow all newborns with elevated DB/CB levels, rather than just those with DB:TB ratios >0.2.

Persistent alanine aminotransferase elevations in children with parenteral nutrition-associated liver disease

BACKGROUND

Parenteral nutrition-associated liver disease (PNALD) is a serious condition affecting many children with short bowel syndrome. The aim of this study was to longitudinally assess serum alanine aminotransferase (ALT), a marker for hepatocyte injury, in enterally fed children with PNALD.

METHODS

Retrospective chart review of 31 patients treated from 1999 to 2006 by the Center for Advanced Intestinal Rehabilitation at Children's Hospital Boston (Mass). Inclusion criteria included PN duration of greater than 3 months with subsequent tolerance of full enteral nutrition and evidence of PN-associated liver injury. Time to normalize ALT and direct bilirubin were estimated using Kaplan-Meier and Cox proportional hazards methods.

RESULTS

Mean age PN cessation was 6 months (range, 2-14 months). Median PN duration was 18 weeks (interquartile range [IQR], 13-33 weeks), and median follow-up was 24 weeks (IQR, 14-48 weeks). After transition to full enteral nutrition, 74% of children normalized direct bilirubin, whereas only 50% normalized ALT. Kaplan-Meier median time to direct bilirubin and ALT normalization were 13 weeks and 35 weeks, respectively (P = .001).

CONCLUSION

Children with PNALD who have achieved PN independence have persistent ALT elevation despite normal direct bilirubin levels. This implies that hepatic injury may be ongoing beyond the time of bilirubin normalization in this cohort of patients.