Predictors of demand for liver transplantation in children undergoing Kasai portoenterostomy for biliary atresia

Context Biliary atresia (BA) remains the most common indication for pediatric liver transplantation worldwide. Ultimately, 50-80% of BA patients will require a liver transplant Thus, much of the research in the field has focused on identifying predictors for transplant and optimizing the efficacy of Kasai portoenterostomy (KPE), in order to decrease the need for transplantation and avoid the risks of lifelong immunosuppression. Aim The aim of this study was to identify perioperative risk factors for the need of liver transplantation following KPE operation for BA. Patients and methods A retrospective analysis of 150 patients undergoing KPE for BA at Hepatobiliary and Pancreatic Surgery Department, National Liver Institute, Menoufia University, from May 2013 to May 2018, was carried out. Patients were divided into two groups: group one included 73 (48.7%) patients who survived without the need for liver transplantation and group two included 77 (51.3%) patients with mortality, listed for liver transplantation or transplanted; thereafter, logistic regression analysis was used to identify the independent predictors of cases needing liver transplantation. Statistical analysis used Continuous variables were expressed as mean +/- SD and categorical variables as proportions. Univariate analysis for the two groups were carried out using the independent samples t test for continuous variables and chi(2) test for categorical variables. Logistic regression analysis was used to identify the independent predictors of cases needing liver transplantation. Receiver operating characteristic analysis was used for the cut-off determination of predictive parameters using MedCalc application, version 18.2.1. Results The mean age at the time of operation was 74.9 +/- 14.6 days after birth (range, 31-111 days); there were 70 (46.7%) male babies and 80 (53.3%) female babies. The mean preoperative weight was 4.6 +/- 0.6 kg, while the mean preoperative height was 57.3 +/- 3.58 cm. Total bilirubin and albumin levels at 1 and 3 months following KPE were associated with death or the need for liver transplantation; however, only a total bilirubin level of more than 6 mg/dl at 3 months is an independent predictor of the need for liver transplantation. Age at the time of KPE and postoperative steroid use were not associated with improved transplant-free survival. Conclusion Total bilirubin level of more than 7.3 mg/dl at 1 month and a level of more than 6 mg/dl at 3 months after KPE are predictive of the need for liver transplantation (P<0.001). Albumin level of less than or equal to 2.5 g/dl at 1 month and a level of less than or equal to 3 g/dl at 3 months after KPE are predictive of the need for liver transplantation (P<0.001); however, only total bilirubin level of more than 6 mg/dl at 3 months is an independent predictor of the need for transplantation (P<0.001). Age at the time of KPE and postoperative steroid use were not associated with improved transplant-free survival.