Title: Impact of graft size matching on graft survival in pediatric whole liver transplantations in recipients with biliary atresia weighing less than 10 kg  

Source: Transplantation Proceedings 2026, Feb 27. [E–publication]

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Date of publication: February 2026

Publication type: Retrospective study

Abstract: Background: The size mismatch between a liver graft and the recipient can result in complications and poor survival after pediatric whole liver transplantation (WLT).

Methods: A retrospective study was designed, which included 114 recipients. Multiple variable predictors of graft loss suggested the graft-to-native-liver weight ratio (GNLWR), and then the GNLWR was calculated and categorized into 2 groups. The demographic, operation, complications, and survival analysis data were collected and compared.

Results: Group 1 with a GNLWR < 0.41 had a higher incidence of hepatic artery thrombosis (HAT) and lower graft survival in the first 3 months (70.4% vs 96.6%, P < .001). Patient survival at 3 months was significantly different between groups (85.2% vs 97.7%, P = .010). As for the graft survival rate, it was 70.4% for group 1 at both 1 and 3 years, whereas it was 94.2% for group 2 at both 1 and 3 years. Additionally, the patient survival rate for group 1 was 85.2% at both 1 and 3 years, whereas for group 2, it was 95.4% at both 1 and 3 years. Further analysis showed the PELD score was the only independent risk factor for graft loss in the group with GNLWR < 0.41. It indicated a worse prognosis when the PELD score was more than 23.5.

Conclusions: A GNLWR of less than 0.41 suggested a poor prognosis for grafts in pediatric WLT recipients with biliary atresia weighing less than 10 kg. Reducing blood transfusions may help improve graft survival.

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Title: Global and regional prevalence, burden, and risk factors for MASLD in children and adolescents aged 5 to 24 years: a systematic review, meta-analysis, and modeling study  

Source: BMC Medicine 2026, Mar 18. [E–publication]

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Date of publication: March 2026

Publication type: Systematic review and meta analysis 

Abstract: Background: Obesity is associated with metabolic dysfunction-associated steatotic liver disease (MASLD). Despite the rising prevalence of obesity among children and adolescents, no studies have examined risk factors or developed models to estimate MASLD burden by sex, age group, or geographic location.

Objective: To estimate and predict the distribution and shifting patterns of the burden of MASLD in children and adolescents aged 5 to 24 years, globally, regionally, and in China.

Methods: We systematically searched PubMed, EMBASE, Web of Science, Cochrane, and CNKI for studies reporting the prevalence of MASLD and its closely related diagnostic constructs, including metabolic dysfunction-associated fatty liver disease (MAFLD) and non-alcoholic fatty liver disease (NAFLD), in 5-24-year-olds, and synthesized evidence across these definitions to estimate the burden of MASLD. Random-effects meta-regression synthesized age-, sex-, and year-specific prevalence and risk factors. Additionally, using data from the Global Burden of Disease, World Population Prospects, and Chinese National Survey on Students’ Constitution and Health, a risk factor-based model estimated global, regional, and provincial (China) MASLD burden. The protocol was registered in PROSPERO (CRD420251062351).

Results: Of 2747 records, 56 studies (54 English, 2 Chinese) were included; 37 informed prevalence and 38 informed risk factors. Our model indicated that the global MASLD prevalence among 5-24-year-olds was 7.0% (95% CI: 4.1, 11.7), increasing with age and year, and higher in boys. Asia had the largest number of cases in 2000 (63.8 million [51.5, 76.6]) and 2020 (160.9 million [134.5, 187.6]). Our model further indicated that Africa is projected to surpass Asia in total case numbers from 2040 onward. In China, MASLD prevalence among 6-18-year-olds was highest in Hebei, Shandong, and Beijing (2000) and in Tianjin, Shandong, and Heilongjiang (from 2020 onwards).

Conclusions: The prevalence of MASLD among children and adolescents continues to rise alongside the epidemic of obesity. Model-based estimates suggest that the burden of MASLD may shift over time towards currently less developed regions of the world, such as Africa, and less well-developed regions in China. Targeted investment in obesity prevention is urgently needed, as are health services to reduce the health impacts of MASLD during and beyond childhood and adolescence. 

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Title: Transient elastography for accurate staging of liver fibrosis and predicting complications in children with autoimmune hepatitis  

Source: Journal of Pediatric Gastroenterology and Nutrition 2026, Mar 16. [E–publication] 

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Date of publication: March 2026 

Publication type: Cohort study

Abstract: Objectives: Autoimmune hepatitis (AIH) presents as hepatitis, chronic or acute liver failure. Liver fibrosis may progress to liver cirrhosis. Pharmacological treatment aims to preserve liver function and induce remission. Transient elastography (FibroScan®, TE) has already been applied in many chronic liver diseases for non-invasive liver stiffness/fibrosis assessment. We aimed to evaluate the usefulness of liver stiffness measurement (LSM) in relation to liver fibrosis on biopsy, selected clinical features and laboratory markers of liver function in the largest paediatric AIH cohort studied.

Methods: We included 86 children with AIH (41 females) with a mean age of 14 years with AIH. Thirty-seven patients were naïve, and 49 had been previously pharmacologically treated. All patients underwent diagnostic or monitoring liver biopsy and LSM on TE. In selected cases, upper gastrointestinal (UGI) endoscopy was performed to search for oesophageal varices (EV). The relationship between LSM and fibrosis stage was analysed statistically. The optimal cut-off values of LSM were calculated to predict individual fibrosis stages and the presence of EV using the area under the receiver operating characteristic curve (AUROC).

Results: In our study, LSM was highly accurate in assessing fibrosis staging. LSM strongly correlated with liver fibrosis r = 0.81, p < 0.0001. TE discriminated patients with severe fibrosis (F ≥ 3) from others with excellent sensitivity and specificity-AUROC of LSM was 0.95 with an optimal cut-off point of 8.3 kPa. Similar results were produced when analysing naïve and treated patients. In addition, LSM showed prognostic value in predicting EV with AUROC of 0.77.

Conclusions: TE can be accurately and reliably used in children with AIH to diagnose and monitor liver fibrosis and its complications as portal hypertension. TE may help to identify patients with severe fibrosis who may require UGI surveillance, therapy modifications and possibly liver transplantation.

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Title: Fructose-induced hepatic steatosis in non-obese children: a comprehensive review

Source: Nutrition and Health 2026, Mar 18. [E–publication]

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Date of publication: March 2026

Publication type: Review article

Abstract: Background/Objectives: Dietary fructose intake has increased markedly in Western countries, leading to an increase of children with a normal weight suffering from non-alcoholic fatty liver disease. The aim of this study is to examine current knowledge of the association between fructose consumption and hepatic steatosis in non-obese, non-diabetic children and adolescents and raise awareness of a well-known disease in a new cohort of paediatric patients.

Methods: This was a narrative literature review with systematic search elements. A literature search of PubMed, MEDLINE, EMBASE, Cochrane Library and Scopus was conducted with the final search completed on 21 September 2024. Eligible studies were peer-reviewed clinical or translational studies (including relevant animal models) reporting hepatic outcomes in paediatric populations without obesity or diabetes.

Results: Thirteen studies met inclusion criteria including experimental (n = 2) and observational (n = 4) studies and reviews (n = 4). Those studies demonstrated that high fructose intake promotes hepatic lipid accumulation via unregulated hepatic fructose metabolism, increased de novo lipogenesis, impaired VLDL secretion, oxidative stress and gut-derived inflammation.

Conclusion: Fructose-associated hepatic steatosis is a clinically relevant phenomenon in children without obesity or metabolic syndrome without symptoms, so paediatricians need to screen their patients for it. This review highlights mechanistic distinctions between fructose and glucose metabolism, discusses the complexity of clinical trials, which explains the current gap in literature, and it underscores the role of misleading health marketing and opaque food labelling in exacerbating this risk. It emphasises the need for targeted preventive strategies and clearer food labelling to reduce hidden fructose exposure in youth.

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Title: Menstrual dysfunction is associated with elevated liver enzymes in adolescent females: a United States population-based study 

Source: Journal of Adolescent Health 2026, 78 (4): 633-638

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Date of publication: March 2026 

Publication type: Population-Based Study

Abstract: Purpose: Polycystic ovary syndrome and metabolic dysfunction-associated steatotic liver disease (MASLD) both emerge during adolescence; however, it remains unknown whether menstrual abnormalities and hyperandrogenism signals increased hepatic risk.

Methods: We analyzed 2011-2020 National Health and Nutrition Examination Survey data for 1,651 females aged 12-19 years in the United States who were at least 2 years postmenarche. Amenorrhea was defined as self-reported absence of menses in the past 12 months. Biochemical hyperandrogenism was defined as free androgen index ≥5. Elevated alanine aminotransferase (ALT; >22 U/L) was the primary hepatic outcome; suspected MASLD was defined as elevated ALT plus ≥1 cardiometabolic risk factor. Survey-weighted logistic regression models adjusted for age, race and ethnicity, and body mass index (BMI) percentile.

Results: Amenorrhea was reported by 2.8% of participants and was associated with higher odds of elevated ALT (adjusted odds ratio 2.5, 95% confidence interval 1.1-5.7). Biochemical hyperandrogenism was also associated with elevated ALT (adjusted odds ratio 2.6, 95% confidence interval 1.4-4.8). The positive association between insulin resistance and ALT was stronger among adolescents with amenorrhea (β = 2.7 vs. 1.1). Although ALT levels rose with increasing BMI, adolescents with amenorrhea had consistently higher ALT prevalence, including those with a normal BMI.

Discussion: Amenorrhea and hyperandrogenism, hallmark features of polycystic ovary syndrome, are independently associated with elevated ALT and suspected MASLD in adolescent females. These findings support ALT screening for youth with menstrual dysfunction, even in the absence of obesity, to enable earlier detection and more integrated endocrine-hepatic care. 

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Title: Go with the flow: Hepatic hemodynamics impact outcomes in pediatric liver transplant  

Source: Pediatric Transplantation 2026, 30 (3): e70262 

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Date of publication: March 2026 

Publication type: Review article

Abstract: Background: Vascular complications persist as a challenging barrier to pediatric liver transplantation. With an incidence of 5%-10%, portal venous and hepatic arterial thromboses remain a major cause for early graft loss in this population. Real-time evaluation of flow parameters at various time points in the transplant course offers an ability to diagnose and even prevent such complications, and may consequently enhance long-term graft and recipient outcomes.

Methods: This review summarizes clinical studies describing liver hemodynamics in pediatric recipients and the utilization of flow parameters for the hepatic artery, portal vein, and hepatic vein.

Results: Preoperative parameters by doppler ultrasonography (DUS) predict the need for portal vein reconstruction which can assist with perioperative planning. Intraoperatively, real-time assessment of flow parameters predicts vascular complications and assists in evaluating the adequacy of graft inflow modulation (GIM). Postoperative surveillance remains critical to detection of both venous and arterial thrombosis and stenosis, but normal measurement ranges often vary based on patient age, underlying liver disease diagnosis, type of graft, and time from transplantation.

Conclusions: Future studies are needed to evaluate the most effective screening protocols and define intra-operative and post-operative measurements that should prompt surgeons to consider intervention in this vulnerable population.

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Title: Liver function indicators as risk factors of pediatric metabolic (dysfunction)-associated fatty liver disease: a systematic review and meta-analysis  

Source: Translational Pediatrics 2026, 15 (2): 49 

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Date of publication: February 2026 

Publication type: Systematic review and meta-analysis

Abstract: Background: Metabolic (dysfunction)-associated fatty liver disease (MAFLD) is the most common chronic liver disorder in children and adolescents, with its prevalence rising alongside the global childhood obesity epidemic. Liver function indicators offer a potential non-invasive screening alternative, but existing evidence on their association with pediatric MAFLD is inconsistent due to heterogeneous study designs and populations. Therefore, this systematic review and meta-analysis aimed to synthesize global evidence to definitively evaluate liver function indicators as risk factors for MAFLD in children and adolescents.

Methods: Four databases-The Cochrane Library, Embase, Web of Science, and PubMed-were searched from inception to July 5, 2025. The eligible studies were observational in design and focused on children and adolescents (<18 years), comparing MAFLD prevalence/risk between those with abnormal versus normal liver function indicators. Two independent researchers performed literature screening, information collection, and quality evaluation per the eligibility criteria. The ‘meta’ package in R was adopted to compute the odds ratio (OR) and corresponding 95% confidence interval (CI) for the association between liver function indicators and MAFLD. Heterogeneity and publication bias were also assessed.

Results: This meta-analysis incorporated 27 studies, involving 3,237 confirmed MAFLD cases. Levels of alanine aminotransferase (ALT) [OR (95% CI): 1.15 (1.01, 1.30)], gamma-glutamyl transferase (GGT) [1.30 (1.09, 1.56)], and high-density lipoprotein (HDL) [0.97 (0.96, 0.98)] were associated with MAFLD risk. Elevated ALT [OR (95% CI): 20.63 (2.39, 178.09)], total cholesterol (TC) [3.36 (1.15, 9.82)], triglycerides (TG) [4.86 (2.37, 9.98)], low-density lipoprotein (LDL) [3.74 (1.15, 12.19)], and decreased HDL [2.77 (1.97, 3.91)] were identified as potential risk factors for MAFLD in children and adolescents. Overall, subgroup analyses (by confounder adjustment status and study design), sensitivity analyses, and meta-regression did not identify potential sources of heterogeneity. No significant publication bias was observed.

Conclusions: Liver function indicators show promise as screening tools for the early detection of MAFLD susceptibility. This study has several limitations, including a small number of included studies, resulting in heterogeneity, as well as the inherent risk of bias (ROB) in observational designs and the imprecision of some results.

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Title: Contemporary outcomes of isolated liver and combined liver-lung transplantation for cystic fibrosis in children 

Source: Journal of Pediatric Gastroenterology and Nutrition 2026, Mar 9. [E–publication]

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Date of publication: March 2026

Publication type: Article

Abstract: Objective: To compare isolated liver transplantation (LT) for cystic fibrosis (CF) versus other indications and versus combined liver-lung transplantation (CLLT) for CF in children and identify factors associated with survival.

Methods: We compared clinical and survival data after first isolated LT for CF versus other indications and versus CLLT for CF in children (<18 years) using United Network for Organ Sharing data (02/2002-12/2024).

Results: A total of 157 pediatric CF transplant recipients were included (LT: 145; CLLT: 12). Isolated CF LT recipients had higher total bilirubin (TB) than CLLT (median 1.6 vs. 0.7 mg/dL, p = 0.02). A higher proportion of CF transplant recipients with high TB levels (≥1.5 mg/dL) had ascites, encephalopathy, and required life support compared to those with low TB levels (<1.5 mg/dL). CF LT demonstrated superior patient survival versus CF CLLT (log-rank test, p = 0.02; 5-year: 89.1% vs. 72.2%), but inferior versus non-CF LT (log-rank test, p < 0.001; 5-year: 91.5%). Multivariable Cox regression showed increased risk of patient mortality and liver graft loss in CF CLLT recipients compared to isolated CF LT recipients (hazard ratio [HR] = 2.92, 95% confidence interval [95% CI]: 1.20-7.07, p = 0.02 and HR = 2.56, 95% CI: 1.09-5.98, p = 0.03, respectively) and recipients with higher TB levels (HR = 1.05, 95% CI: 1.01-1.10, p = 0.008 and HR = 1.05, 95% CI: 1.01-1.09, p = 0.008, respectively), when adjusting for recipient age, albumin and international normalized ratio (INR) at time of LT, ICU status, and liver graft type. Multivariable Cox regression of isolated LT recipients showed increased risk of patient mortality (HR = 2.03, 95% CI: 1.41-2.93, p < 0.001) and liver graft loss (HR = 1.54, 95% CI: 1.13-2.11, p = 0.006) for CF compared to non-CF etiologies, when adjusting for recipient age, albumin, INR, and TB at time of LT, ICU status, and liver graft type.

Conclusion: Isolated LT for CF was associated with superior survival compared to CLLT for CF, but inferior survival compared to LT for non-CF indications. Higher TB in CF may be a marker of inferior outcomes post-LT.

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Title: Adenovirus disease following pediatric liver transplantation: 10-year experience from a large pediatric transplant program 

Source: Pediatric Transplantation 2026, 30 (3): e70298

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Date of publication: March 2026  

Publication type: Retrospective cohort study 

Abstract: Background: Human adenovirus in immunocompromised patients can be life-threatening. We describe the prevalence, clinical presentation, and treatment of adenovirus after pediatric liver transplantation at a large transplant center.

Methods: We performed a retrospective cohort study of adenovirus infection in children from 2013 to 2022. We compared incidence, clinical characteristics, and outcomes of post-transplant children by adenovirus treatment status.

Results: Adenovirus disease developed in 26% (84/320) children after liver transplant. Median age at liver transplant was 17.5 months, 48% were female; 50% had biliary atresia. Fever (53%), gastrointestinal symptoms (48%), and hepatitis (41%) were the most common clinical presentations at diagnosis. Median time to adenovirus diagnosis was 80 days (IQR 19-260) with 40% (n = 31/84) identified within 30 days post-transplant. Disseminated adenovirus (≥ 2 organ involvement) occurred in 24% (20/84). Fourteen patients (17%) received cidofovir, and most (13/14, 93%) had DNAemia, compared to 57% untreated patients with DNAemia (p = 0.013). Median peak adenovirus load was 491 805 copies/mL (IQR 24 800-1 900 000) in treated vs. 1000 copies/mL (IQR 595-794 794) in untreated patients (p < 0.001). Overall mortality was 8% (7/84).

Conclusion: The incidence of symptomatic and disseminated adenovirus disease was high in our pediatric liver transplant patients, particularly within 30 days post-transplant. Patients who received cidofovir treatment presented with high viral load and had the highest mortality. There is a critical need for evidence-based guidance for early antiviral management of adenovirus disease after pediatric liver transplant.

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Title: Unveiling hepatic protein alterations in neonatal and infant biliary atresia

Source: Clinical Pharmacology and Therapeutics 2026, Mar 4. [E–publication]

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Date of publication: March 2026

Publication type: Article

Abstract: Pediatric populations differ from adults in drug elimination capacity. While current scaling methods account for enzyme and transporter maturation, they overlook comorbidities, such as biliary atresia (BA), a liver disease appearing within the first 2-8 weeks of life that can progress to cirrhosis. Such conditions may impair hepatic drug clearance, requiring dose adjustments. Physiologically based pharmacokinetic (PBPK) tools aim to address such cases and have been advocated to fill gaps in clinical data instead of less formalized and evidence-based guesswork. However, the paucity of systems data in rare disease populations has hindered the development of robust PBPK models. This study used global liquid chromatography and tandem mass spectrometry (LC-MS/MS) proteomics to quantify drug-metabolizing enzymes and transporters in diseased neonatal (n = 13) and infant (n = 12) liver samples, revealing significant expression changes in biliary atresia (BA) livers vs. controls (n = 19). Based on cohort means, CYP2A6, CYP2B6, and CYP2E1 levels were 6-17-fold higher in BA livers compared to controls, while CYP4F11 and CYP20A1 were reduced. UGT1A1, UGT2B4, and UGT2B7 showed up to 16-fold higher abundance in neonates with BA. Among transporters, ABCF1 abundance increased dramatically (46-fold), whereas B3AT/SLC4A1, ADT1/SLC25A4, and S27A5/SLC27A5 were decreased. The observed alterations suggest that assuming similar liver function in BA and non-BA patients has implications, with impact varying by drug clearance pathway. While in silico models can explore this, clinical pharmacokinetic studies in BA are essential for verification. To our knowledge, such studies are absent. Our observations underscore the urgent need for dedicated pharmacokinetic studies in BA patients to improve precision dosing.

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