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The AST-to-Platelet Ratio Index (APRi) at Kasai Portoenterostomy: Standing the Test of Time
Ancuta Muntean1, Rania Kronfli1, Erica Makin1
1Department of Pediatric Surgery, Kings College Hospital, London, SE5 9RS, UK.
Insights
The AST-to-platelet ratio index (APRi) can predict outcomes in infants with biliary atresia (BA) after Kasai portoenterostomy (KPE). Higher APRi scores correlate with poorer jaundice clearance and reduced native liver survival, offering a valuable prognostic tool.
Area of Science:
- Pediatric Surgery
- Hepatology
- Biomarkers
Background:
- Outcomes for infants with biliary atresia (BA) after Kasai portoenterostomy (KPE) vary significantly.
- The AST-to-platelet ratio index (APRi) is a potential surrogate marker for liver fibrosis.
Purpose of the Study:
- To investigate the long-term relationship between APRi and outcomes in infants undergoing KPE for BA.
- To assess APRi's prognostic value in stratifying BA patients.
Main Methods:
- Prospective data collection from January 1998 to December 2021.
- Analysis of 473 infants with calculated APRi at the time of KPE.
- Statistical analysis including Chi-squared and log-rank tests.
Main Results:
- A significant correlation was observed between APRi and age at KPE.
- Higher APRi quartiles showed a stepwise decrease in jaundice clearance and native liver survival.
- Cytomegalovirus (CMV) positive BA infants had significantly higher APRi scores.
Conclusions:
- APRi is a valuable prognostic marker for stratifying biliary atresia patients.
- APRi provides an objective method to assess the biological status of BA at presentation.
- CMV status is associated with higher APRi scores in BA patients.
Aims:
The outcomes following surgical treatment of infants with biliary atresia (BA) varies across the world with many possible confounding factors. APRi (AST-to-platelet ratio index) is a simple surrogate marker of liver fibrosis and we sought to determine its long-term relationship (if any) with outcome post-Kasai portoenterostomy (KPE).
Methods:
Prospectively acquired database (Jan 1998-Dec 2021). Clearance of jaundice was defined as achieving <20 umol/L post-KPE. Categorical and survival data were tested using Chi2 tests and a log rank test respectively. P ≤ 0.05 was regarded as significant. Data are quoted as median (interquartile range) unless otherwise stated.
Results:
There were 473 infants with a calculated APRi at time of KPE [0.70 (IQR 0.45-1.2)] and known outcomes. There was significant but moderate correlation with age at KPE (rS = 0.43; P < 0.0001). APRi was divided into quartiles (1st 0.11-0.44, n = 120; 2nd 0.45-0.69, n = 120; 3rd 0.70-1.18, n = 115 and 4th 1.2-15.1; n = 118). There was a clear distinction in APRi levels between CMV + ve BA and the other groups (Syndromic BA, Cystic BA, Isolated BA), with an overrepresentation of CMV IgM + ve BA in the higher APRi quartiles (Χ2 = 26.6; P = 0.0002). Clearance of jaundice showed a stepwise decrease across the quartiles (67%; 58%; 55%; 49%; overall Χ2 = 7.8, P = 0.049 and P = 0.005 for trend). Decreasing native liver survival also showed a significant trend (P = 0.01).
Conclusion:
APRi appears to be of fundamental prognostic value in stratifying the BA population. In our series, CMV status was associated with higher APRi score and appears to be different. This simple variable offers an objective method of assessing the biological status of BA at presentation and variability between different series.
Level Of Evidence:
II (prospective comparison).
