Risk factors for cholangitis after Kasai procedure in biliary atresia patients: a systematic review and meta-analysis

Cholangitis is a clinically significant complication following Kasai portoenterostomy in patients with biliary atresia (BA). This meta-analysis aimed to review the available literature on the risk factors for post-Kasai cholangitis.

The PubMed, Web of Science, Embase, Cochrane Library, Google Scholar, and Chinese databases (CNKI, Wanfang, VIP, and SinoMed) were searched to identify relevant studies published until April 2025. Three researchers independently evaluated the literature quality and extracted data individually. Statistical synthesis was performed using RevMan 5.4 (The Cochrane Collaboration), with supplementary analyses including sensitivity testing and bias assessment conducted in Stata version 18.0 (StataCorp).

Fifty-seven studies with 3007 cholangitis from 7024 BA patients met the inclusion criteria. Operative age >60 days [ I2  = 15%, relative risk (RR) = 0.85, 95% confidence interval (CI): 0.74-0.99, P = 0.03], high risk of malnutrition ( I2  = 49%, RR = 3.11, 95% CI: 1.76-5.48, P < 0.0001), low vitamin D receptor (VDR) expression ( I2  = 0%, RR = 2.73, 95% CI: 1.44-5.17, P = 0.002), bile lake ( I2  = 15%, RR = 2.30, 95% CI: 1.63-3.23, P < 0.00001), and persistent jaundice ( I2  = 88%, RR = 1.32, 95% CI: 1.01-1.71, P = 0.04) were significant risk factors of post-Kasai cholangitis. Anti-reflux valve ( I2  = 47%, RR = 0.81, 95% CI: 0.72-0.91, P = 0.0002), steroids ( I2  = 0%, RR = 1.24, 95% CI: 1.06-1.45, P = 0.006), high-dose steroid ( I2  = 1%, RR = 0.60, 95% CI: 0.48-0.75, P < 0.00001), and probiotics ( I2  = 0%, RR = 2.97, 95% CI: 1.29-6.85, P = 0.01) were significant protective factors of post-Kasai cholangitis.

The present meta-analysis identified four risk factors and four protective factors for post-Kasai cholangitis, emphasizing the necessity of rigorous monitoring throughout the therapeutic process.