Steroids in biliary atresia: Single surgeon, single centre, prospective study

Background & Aims: The effect of adjuvant steroids in infants with biliary atresia (BA) is not clear and evidence of benefit is lacking. Methods: During the period Jan. 2000-Dec. 2011, 153 infants with isolated (CMV IgM - ve) BA underwent Kasai portoenterostomy (KPE) at < 70 days. They were divided into three groups: LOW-dose steroid (from a previous randomized trial; starting prednisolone 2 mg/kg/day, n = 18), HIGH-dose steroid (starting prednisolone 5 mg/kg/day, n = 44), and NO steroid [n = 72 + 19 placebo (from randomized trial) = 91]. Outcome was assessed by early liver biochemistry, clearance of jaundice (< 20 lmol/L), and actuarial native liver survival. Data are quoted as median (IQ range) and compared with non-parametric ANOVA, Chi or Logrank tests as appropriate. p <= 0.05 was regarded as significant. Results: All three groups were comparable for age (ANOVA, p = 0.31) and a surrogate marker of liver fibrosis [aspartate-aminotransferase index (APRi), ANOVA, p = 0.67]. At 1 month post KPE, there was a significant reduction in bilirubin [58 (25-91) vs. 91 (52-145) mu mol/L, p = 0.0015], AST [118 (91-159) vs. 155 (108-193) IU/L, p = 0.0015], and APRi [0.49 (0.28-0.89) vs. 0.82 (0.45-1.2), p = 0.005] for HIGH vs. NO steroid. There was a significant increase in % clearance of jaundice with the use of steroids [47/91 (52%) vs. 12/18 (67%) vs. 29/44 (66%); steroids vs. no steroids, p = 0.037]. There was no statistical difference in 4-year patient survival (96% vs. 94% vs. 95%) or native liver survival (4 year = 46% vs. 50 vs. 57%). Conclusions: The adjuvant use of prednisolone significantly improved early post-operative liver biochemistry (especially at the higher dose), and increased the proportion of infants who cleared their jaundice at 6 months post-KPE. Crown copyright (C) 2013 Published by Elsevier B.V. on behalf of the European Association for the Study of the Liver. All rights reserved.