Abstract
OBJECTIVES: To investigate the prognostic significance of aspartate aminotransferase to platelet ratio index (APRI) in relation to histopathological features across the clinical course of biliary atresia (BA). METHODS: In this observational cohort study, we enrolled 135 BA patients with available APRI values at Kasai portoenterostomy (KPE, n = 116) or at post-KPE follow-up (n = 70; serum samples, n = 139; liver biopsies, n = 139). APRI was matched to manual scorings of liver histology, ductular reaction (DR) analysed using neural network model and fibrosis quantified from Sirius Red-stained sections. RESULTS: APRI was elevated at both KPE and post-KPE follow-up (0.92 vs. 1.2, p = 0.5), and associated with biochemical markers of cholestasis, and decreased liver function. At KPE, APRI was higher in patients failing to resolve cholestasis postoperatively (0.80 vs. 0.96, p = 0.02) and both at KPE (0.77 vs. 0.94, p = 0.06) and post-KPE (0.7 vs. 2.1, p < 0.001) in those with subsequent need for liver transplant (LT). Across the disease course, APRI moderately predicted LT need (at KPE, HR = 1.4, p = 0.01; post-KPE, HR = 1.2, p < 0.001). APRI correlated with DR (at KPE, R = 0.37, p < 0.001; post-KPE, R = 0.35, p < 0.001), composed of biliary epithelium (R = 0.34, p < 0.001; R = 0.25, p < 0.01) and parenchymal intermediate hepatocytes (R = 0.33, p < 0.001; R = 0.43, p < 0.001) during the entire clinical course. APRI showed no correlation with quantified liver fibrosis at KPE (R = 0.16, p = 0.13), but correlated with quantified fibrosis (R = 0.22, p = 0.02) and Metavir staging (R = 0.46, p < 0.001) after KPE. No association was observed with portal inflammatory cell infiltration or histological cholestasis. CONCLUSIONS: APRI reflects biliary and portal injury rather than generalised liver fibrosis and associates with poor prognosis in BA.