Ischemic-type Biliary Lesions Research Articles

Risk Factors for Infectious Complications following Endoscopic Retrograde Cholangiopancreatography in Liver Transplant Patients: A Single-Center Study.

Background: Liver transplant recipients often require endoscopic retrograde cholangiopancreatography (ERCP) for biliary complications, which can lead to infections. This retrospective single-center study aimed to identify risk factors for infectious complications following ERCP in liver transplant patients. Methods: A retrospective analysis was conducted on 285 elective ERCP interventions performed in 88 liver transplant patients at a tertiary care center. The primary endpoint was the occurrence of an infection following ERCP. Univariable and multivariable regression analyses, Cox regression, and log-rank tests were employed to assess the influence of various factors on the incidence of infectious complications. Results: Among the 285 ERCP interventions, isolated anastomotic stenosis was found in 175 cases, ischemic type biliary lesion (ITBL) in 103 cases, and choledocholithiasis in seven cases. Bile duct interventions were performed in 96.9% of all ERCPs. Infections after ERCP occurred in 46 cases (16.1%). Independent risk factors for infection included male sex (OR 24.19), prednisolone therapy (OR 4.5), ITBL (OR 4.51), sphincterotomy (OR 2.44), cholangioscopy (OR 3.22), dilatation therapy of the bile ducts (OR 9.48), and delayed prophylactic antibiotic therapy (>1 h after ERCP) (OR 2.93). Additionally, infections following previous ERCP interventions were associated with an increased incidence of infections following future ERCP interventions (p < 0.0001). Conclusion: In liver transplant patients undergoing ERCP, male sex, prednisolone therapy, and complex bile duct interventions independently raised infection risks. Delayed antibiotic treatment further increased this risk. Patients with ITBL were notably susceptible due to incomplete drainage. Additionally, a history of post-ERCP infections signaled higher future risks, necessitating close monitoring and timely antibiotic prophylaxis.

Impact on survival and ischaemic type biliary lesions: a meta-analysis comparing DCD and DBD grafts

Impact on survival and ischaemic type biliary lesions: a meta-analysis comparing DCD and DBD grafts

Retracted: Artificial Intelligence Algorithm-Based CTA Imaging for Diagnosing Ischemic Type Biliary Lesions after Orthotopic Liver Transplantation

Retracted: Artificial Intelligence Algorithm-Based CTA Imaging for Diagnosing Ischemic Type Biliary Lesions after Orthotopic Liver Transplantation

Outcomes of liver transplantation with thoracoabdominal normothermic regional perfusion: a matched-controlled initial experience in Spain

Thoracoabdominal (TA) normothermic regional perfusion (NRP) should allow the safe recovery of heart and liver grafts simultaneously in the context of controlled donation after circulatory death (cDCD). We present the initial results of cDCD liver transplantation with simultaneous liver and heart procurement in Spain until October 2021. Outcomes were compared with a matched cohort of cDCD with abdominal NRP (A-NRP) from participating institutions. Primary endpoints comprised early allograft dysfunction (EAD) or primary non-function (PNF), and the development of ischemic-type biliary lesions (ITBL). Six transplants were performed using cDCD with TA-NRP during the study period. Donors were significantly younger in the TA-NRP group than in the A-NRP group (median 45.6 years and 62.9 years respectively, p = 0.011), with a median functional warm ischemia time of 12.5 min in the study group and 13 min in the control group. Patient characteristics, procurement times, and surgical baseline characteristics did not differ significantly between groups. No patient in the study group developed EAD or PNF, and over a median follow-up of 9.8 months, none developed ITBL or graft loss. Extending A-NRP to TA-NRP for cardiac procurement may be technically challenging, but it is both feasible and safe, showing comparable postoperative outcomes to A-NRP.

Machine perfusion and the prevention of ischemic type biliary lesions following liver transplant: What is the evidence?

The widespread uptake of different machine perfusion (MP) strategies for liver transplant has been driven by an effort to minimize graft injury. Damage to the cholangiocytes during the liver donation, preservation, or early posttransplant period may result in stricturing of the biliary tree and inadequate biliary drainage. This problem continues to trouble clinicians, and may have catastrophic consequences for the graft and patient. Ischemic injury, as a result of compromised hepatic artery flow, is a well-known cause of biliary strictures, sepsis, and graft failure. However, very similar lesions can appear with a patent hepatic artery and these are known as ischemic type biliary lesions (ITBL) that are attributed to microcirculatory dysfunction rather than main hepatic arterial compromise. Both the warm and cold ischemic period duration appear to influence the onset of ITBL. All of the commonly used MP techniques deliver oxygen to the graft cells, and therefore may minimize the cholangiocyte injury and subsequently reduce the incidence of ITBL. As clinical experience and published evidence grows for these modalities, the impact they have on ITBL rates is important to consider. In this review, the evidence for the three commonly used MP strategies (abdominal normothermic regional perfusion [A-NRP], hypothermic oxygenated perfusion [HOPE], and normothermic machine perfusion [NMP] for ITBL prevention has been critically reviewed. Inconsistencies with ITBL definitions used in trials, coupled with variations in techniques of MP, make interpretation challenging. Overall, the evidence suggests that both HOPE and A-NRP prevent ITBL in donated after circulatory death grafts compared to cold storage. The evidence for ITBL prevention in donor after brain death grafts with any MP technique is weak.

Liver Transplantation in Recipients With a Positive Crossmatch: A Retrospective Single-Center Match-Pair Analysis.

A positive crossmatch (XM+) is considered a contraindication to solid abdominal organ transplantation except liver transplantation (LT). Conflicting reports exist regarding the effects of XM+ on post-transplant outcomes. The goal of this retrospective single-center analysis is to evaluate the influence of XM+ on relevant outcome parameters such as survival, graft rejection, biliary and arterial complications. Forty-nine adult patients undergoing LT with a XM+ between 2002 and 2017 were included. XM+ LT recipients were matched 1:2 with crossmatch negative (XM-) LT recipients based on the balance of risk (BAR) score. Patient and graft survival were compared using Kaplan-Meier survival analysis and the log-rank test. Comparative analysis of clinical outcomes in XM+ and XM- groups were conducted. Patient and graft survival were similar in XM+ and XM- patients. Rejection episodes did not differ either. Recipients with a strong XM+ were more likely to develop a PCR+ CMV infection. A XM+ was not associated with a higher incidence of biliary or arterial complications. Donor age, cold ischemia time, PCR+ CMV infection and a rejection episode were associated with the occurrence of ischemic type biliary lesions. A XM+ has no effects on patient and graft survival or other relevant outcome parameters following LT.

Incidence of Ischemia Reperfusion Injury Related Biliary Complications in Liver Transplantation: Effect of Different Types of Donors

Liver transplantation from donors after circulatory death (DCD) is associated with considerable rates of primary nonfunction and ischemic-type biliary lesions. Compared with donation was after brain death (DBD), the biggest disadvantage of DCD is warm ischemia injury in the procurement stage. Donation after brain death followed by circulatory death (DBCD) is a unique practice in China. Such donors should donate according to the DCD procedure, that is, remove life support and donate after cardiac arrest. We retrospectively analyzed donor and recipient characteristics with preoperative and postoperative parameters according to 3 donation types to comprehensively describe incidence of ischemia reperfusion injury (IRI) related biliary complications among different donor type adult liver transplantation recipients. A total of 50 patients were included in this study (DBD group n=17, DCD group n=26, DBCD group n=7). Only 1 patient, whose donor type was DBCD was diagnosed with ischemic-type biliary lesions demonstrated cast and retrograde ascending cholangitis. Rates of primary graft non-function (DBD n=1, 5.9%; DCD n=2, 7.7%; DBCD, 0%; P=.546) were similar and total biliary complications (DBD n=1, 5.9%; DCD n=1, 3.8%; DBCD N=2, 28.6%; P=.042) were different. No differences were found regarding development of postreperfusion syndrome or coagulopathy in 3 groups. Compared with standard DBD donor, the clinical outcome of DCD donor liver transplantation was satisfactory, with no increase in the incidence of IRI, and, no difference in the incidence of ischemic bile duct complications. This work was carried out in compliance with the Helsinki Congress and the Declaration of Istanbul.

Abdominal normothermic regional perfusion in controlled donation after circulatory determination of death liver transplantation: Outcomes and risk factors for graft loss

Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012-2019, with outcomes evaluated through December 31, 2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A-NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A-NRP and 258 with SRR. Median donor age was 59years (interquartile range 49-67years). Adjusted risk estimates were improved with A-NRP for overall biliary complications (OR 0.300, 95% CI 0.197-0.459, p<.001), ischemic type biliary lesions (OR 0.112, 95% CI 0.042-0.299, p<.001), graft loss (HR 0.371, 95% CI 0.267-0.516, p<.001), and patient death (HR 0.540, 95% CI 0.373-0.781, p=.001). Cold ischemia time (HR 1.004, 95% CI 1.001-1.007, p=.021) and re-transplantation indication (HR 9.552, 95% CI 3.519-25.930, p<.001) were significant independent predictors for graft loss among cDCD livers with A-NRP. While use of A-NRP helps overcome traditional limitations in cDCD liver transplantation, opportunity for improvement remains for cases with prolonged cold ischemia and/or technically complex recipients, indicating a potential role for complimentary ex situ perfusion preservation techniques.

The biliary microbiome in ischaemic-type biliary lesions can be shaped by stenting but is resilient to antibiotic treatment.

This study aims to characterize the biliary microbiome as neglected factor in patients with ischaemic-type biliary lesions (ITBL) after liver transplantation. Therefore, the V1-V2 region of the 16S rRNA gene was sequenced in 175 bile samples. Samples from patients with anastomotic strictures (AS) served as controls. Multivariate analysis and in silico metagenomics were applied cross-sectionally and longitudinally. The microbial community differed significantly between ITBL and AS in terms of alpha and beta diversity. Both, antibiotic treatment and stenting were associated independently with differences in the microbial community structure. In contrast to AS, in ITBL stenting was associated with pronounced differences in the biliary microbiome, whereas no differences associated with antibiotic treatment could be observed in ITBL contrasting the pronounced differences found in AS. Bacterial pathways involved in the production of antibacterial metabolites were increased in ITBL with antibiotic treatment. After liver transplantation, the biliary tract harbours a complex microbial community with significant differences between ITBL and AS. Fundamental changes in the microbial community in ITBL can be achieved with biliary stenting. However, the effect of antibiotic treatment in ITBL was minimal. Therefore, antibiotics should be administered wisely in order to reduce emerging resistance of the biliary microbiome towards external antibiotics.

Artificial Intelligence Algorithm-Based CTA Imaging for Diagnosing Ischemic Type Biliary Lesions after Orthotopic Liver Transplantation.

The study focused on the clinical application value of artificial intelligence-based computed tomography angiography (CTA) in the diagnosis of orthotopic liver transplantation (OLT) after ischemic type biliary lesions (ITBL). A total of 66 patients receiving OLT in hospital were selected. Convolutional neural network (CNN) algorithm was used to denoise and detect the edges of CTA images of patients. At the same time, the quality of the processed image was subjectively evaluated and quantified by Hmax, Ur, Cr, and other indicators. Then, the digital subtraction angiography (DSA) diagnosis and CTA diagnosis based on CNN were compared for the sensitivity, specificity, positive predictive value, negative predictive value, and patient classification results. It was found that CTA can clearly reflect the information of hepatic aorta lesions and thrombosis in patients with ischemic single-duct injury after liver transplantation. After neural network algorithm processing, the image quality is obviously improved, the lesions are more prominent, and the details of lesion parts are also well displayed. ITBL occurred in 40 (71%) of 56 patients with abnormal CTA at early stage. ITBL occurred in only 8 (12.3%) of 65 patients with normal CTA at early stage. Early CTA manifestations had high sensitivity (72.22%), specificity (87.44%), positive predictive value (60.94%), and negative predictive value (92.06%) for the diagnosis of ITBL. It was concluded that artificial intelligence-based CTA had high clinical application value in the diagnosis of ITBL after OLT.

Association between indocyanine green clearance test and ischemic type biliary lesions within one year after orthotopic liver transplantation

Ischemic type biliary lesions (ITBLs), a particular subset of non-anastomotic biliary strictures (NAS), are characterized by intra and extrahepatic strictures that occur in the absence of either hepatic artery thrombosis or stenosis. When they occur within the first year after liver transplantation their development is mostly related to ischemia–reperfusion injury (IRI). The indocyanine green plasma disappearance rate (ICG-PDR) might be able to predict the probability of IRI-induced graft damage after liver transplantation. Our aim was to evaluate the association between ICG-PDR and the occurrence of ITBLs. Secondly, we searched for evidence of IRI in patients presenting ITBLs. This retrospective single-center observational study assessed a cohort of 60 liver transplant patient s . Each patient underwent ICG-PDR on the 1st postoperative day. ITBLs were identified by means of either cholangiography or magnetic resonance imaging evidence of a deformity and narrowing of the biliary tree in the absence of hepatic artery thrombosis/stenosis. ITBLs were discovered in 10 patients out of 60 liver recipients (16.67%) within one year after transplantation. A low ICG-PDR value was found to be a significant predictive factor for ITBL development, with an OR of 0.87 and a 95% CI of 0.77–0.97. Liver biopsies were performed in 56 patients presenting unexplained abnormal liver function test results. A statistically significant association was found between the development of ITBLs and anatomopathological evidence of IRI. Retrospective, single-center study. The findings from this study show a relationship between low ICG-PDR values on first post-operative-day and the occurrence of ITBLs within 1 year after transplantation. Las lesiones biliares de tipo isquémico (ITBL) representan un subconjunto de estenosis biliares no anastomóticas, caracterizadas por estenosis intra y extrahepáticas, que ocurren en ausencia de trombosis o estenosis de la arteria hepática. Cuando ocurren dentro del primer año después del trasplante de hígado, están relacionadas principalmente con la lesión por isquemia-reperfusión (IRI). La tasa de desaparición del plasma con verde de indocianina (ICG-PDR) podría estimar el daño del injerto inducido por IRI después de un trasplante. Nuestro objetivo es evaluar la asociación entre ICG-PDR y la aparición de ITBL. También investigamos la evidencia de IRI entre los pacientes que presentaron ITBL. Estudio observacional, retrospectivo, unicéntrico, realizado en una cohorte de 60 receptores trasplantados con determinacion del ICG-PDR el primer día posoperatorio. Las ITBL se definieron mediante colangiografía o evidencia por resonancia magnética de deformidad del árbol biliar en ausencia de trombosis/estenosis de la arteria hepática. De 60 receptores, se descubrieron ITBL en 10 pacientes (16,67%) en el primer año. El valor bajo de ICG-PDR es un factor predictivo significativo para ITBL, con OR = 0,87 y un IC (95%) = 0,77-0,97. Se analizaron 56 biopsias hepáticas para la presencia de IRI, si los receptores presentaban una prueba de función hepática anormal inexplicable, encontrando asociación significativa entre ITBL y evidencia anatomopatológica de IRI. Estudio retrospectivo, unicéntrico. Este estudio encontró una relación entre los valores bajos de ICG-PDR en el primer día posoperatorio y la aparición de ITBL dentro de un año posterior al trasplante.

Author response to: Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity-score matched study.

Author response to: Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity-score matched study.

Comment on: Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity-score matched study.

Comment on: Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity-score matched study.

Similar Results in Liver Transplantation From Controlled Donation After Circulatory Death Donors With Normothermic Regional Perfusion and Donation After Brain Death Donors: A Case-Matched Single-Center Study.

Although good results have been reported with the use of normothermic regional perfusion (NRP) in controlled donation after circulatory death (cDCD) liver transplantation (LT), there is a lack of evidence to demonstrate similar results to donation after brain death (DBD). We present a single-center retrospective case-matched (1:2) study including 100 NRP cDCD LTs and 200 DBD LTs and a median follow-up of 36months. Matching was done according to donor age, recipient Model for End-Stage Liver Disease score, and cold ischemia time. The following perioperative results were similar in both groups: alanine transaminase peaks of 909 U/L in the DBD group and 836 U/L in the cDCD group and early allograft disfunction percentages of 21% and 19.2%, respectively. The 1-year and 3-year overall graft survival for cDCD was 99% and 93%, respectively, versus 92% and 87%, respectively, for DBD (P = 0.04). Of note, no cases of primary nonfunction or ischemic-type biliary lesion were observed among the cDCD grafts. Our results confirm that NRP cDCD LT meets the same outcomes as those obtained with DBD LT and provides evidence to support the idea that cDCD donors per se should no longer be considered as "marginal donors" when recovered with NRP.

Author response to: Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity score-matched study.

Author response to: Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity score-matched study.

Comment on: Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity score-matched study.

Comment on: Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity score-matched study.

Different Timing of Cholangiocyte and Hepatocyte Damage in Liver Preservation: Time to Implement Donor Interventions and New Preservation Techniques to Prevent Ischemic-type Biliary Lesions.

We read with interest the article by Gilbo et al1 assessing the impact of donor hepatectomy and implantation time on the incidence of early allograft dysfunction (EAD) and nonanastomotic strictures (NASs) in liver transplantation (LT). Donor hepatectomy and implantation time seem to have a linear negative impact on the incidence of NAS and EAD, respectively. A 10-min increase in either of these times is roughly as detrimental as a 1-h increase of cold ischemia time. This article expands our understanding of the importance of warm ischemia in LT, confirming findings from previous studies.2 We would like to provide further data and share our comments on this inspiring article. In 2016–1017, we collected data about times and graft temperatures in 160 first adult LTs with grafts from brain-dead donors. Liver temperature was measured at different time points using an infrared thermometer. In our experience, we were unable to show a significant impact of donor hepatectomy and implantation time on LT outcome, likely because of limited sample size and different practices that led to very little variability of these parameters. Median (interquartile range) time of donor hepatectomy and portal vein anastomosis was 47 (40–55) and 24 (21–28) min, respectively, and correlated poorly with graft temperature at the end of donor hepatectomy (R = 0.03, P = 0.61) and before graft reperfusion into recipient (R = 0.11, P = 0.16). However, our data (Figure 1) clearly show that liver grafts do suffer from a period of warm ischemia during retrieval and implantation.FIGURE 1.: Boxplot showing liver graft temperature at different time points during retrieval, back table preparation, and implantation. IQR, interquartile range.Analysis of EAD predictors in the study by Gilbo et al was somewhat hampered by the lack of inclusion of potentially important confounders, like macrosteatosis and severity of liver disease. Moreover, blood transfusions and early thrombotic events are also main determinants of EAD, as demonstrated by their incorporation in the recently developed early allograft failure simplified estimation score.3 Nonetheless, this study interestingly suggests that donor and recipient warm ischemia may impact differently on cholangiocytes and hepatocytes. Indeed, donor hepatectomy time had no effect on EAD (which is mainly determined by hepatocytes function), whereas implantation time was irrelevant with regard to NAS, which reflects cholangiocytes damage. Thus, cholangiocyte injury seems to happen at an earlier timing during graft retrieval and preservation, a finding in keeping with observations that histological damage to biliary epithelium and peribiliary glands is already apparent before graft reperfusion. As a logical implication, interventions focused on the earlier phase of organ preservation are likely needed to tackle NAS, especially in donors after circulatory death, a setting in which normothermic regional perfusion and hypothermic oxygenated machine perfusion have been associated with a significant NAS reduction.4,5 Besides underscoring once more the importance of proper training and technique in LT, this study confirms the role of ischemia-reperfusion injury in determining NAS and highlights the need to implement donor and preservation strategies to reduce their incidence. Future studies will have to assess whether the detrimental role of donor hepatectomy and implantation time persists also when alternative retrieval or preservation modalities are used.

Association between indocyanine green clearance test and ischemic type biliary lesions within one year after orthotopic liver transplantation

BackgroundIschemic type biliary lesions (ITBLs), a particular subset of non-anastomotic biliary strictures (NAS), are characterized by intra and extrahepatic strictures that occur in the absence of either hepatic artery thrombosis or stenosis. When they occur within the first year after liver transplantation their development is mostly related to ischemia–reperfusion injury (IRI). The indocyanine green plasma disappearance rate (ICG-PDR) might be able to predict the probability of IRI-induced graft damage after liver transplantation. ObjectiveOur aim was to evaluate the association between ICG-PDR and the occurrence of ITBLs. Secondly, we searched for evidence of IRI in patients presenting ITBLs. MethodsThis retrospective single-center observational study assessed a cohort of 60 liver transplant patients. Each patient underwent ICG-PDR on the 1st postoperative day. ITBLs were identified by means of either cholangiography or magnetic resonance imaging evidence of a deformity and narrowing of the biliary tree in the absence of hepatic artery thrombosis/stenosis. ResultsITBLs were discovered in 10 patients out of 60 liver recipients (16.67%) within one year after transplantation. A low ICG-PDR value was found to be a significant predictive factor for ITBL development, with an OR of 0.87 and a 95% CI of 0.77–0.97. Liver biopsies were performed in 56 patients presenting unexplained abnormal liver function test results. A statistically significant association was found between the development of ITBLs and anatomopathological evidence of IRI. LimitationsRetrospective, single-center study. ConclusionsThe findings from this study show a relationship between low ICG-PDR values on first post-operative-day and the occurrence of ITBLs within 1 year after transplantation.

Donation after circulatory death liver transplantation: An in-depth analysis and propensity score-matched comparison.

Careful donor-recipient matching and reduced ischemia times have improved outcomes following donation after circulatory death (DCD) liver transplantation (LT). This study examines a single-center experience with DCD LT including high-acuity and hospitalized recipients. DCD LT outcomes were compared to a propensity score-matched (PSM) donation after brain death (DBD) LT cohort (1:4); 32 DCD LT patients and 128 PSM DBD LT patients transplanted from 2008 to 2018 were included. Analyses included Kaplan-Meier estimates and Cox proportional hazards models examining patient and graft survival. Median MELD score in the DCD LT cohort was 22, with median MELD of 27 for DCD LT recipients with decompensated cirrhosis. No difference in mortality or graft loss was found (p<.05) between DCD LT and PSM DBD LT at 3years post-transplant, nor was DCD an independent risk factor for patient or graft survival. Post-LT severe acute kidney injury was similar in both groups. Ischemic-type biliary lesions (ITBL) occurred in 6.3% (n=2) of DCD LT recipients, resulting in 1 graft loss and 1 death. This study supports that DCD LT outcomes can be similar to DBD LT, with a low rate of ITBL, in a cohort including high-acuity recipients. Strict donor selection criteria, ischemia time minimization, and avoiding futile donor/recipient combinations are essential considerations.

Ultrasound-Based Multimodal Imaging Predicting Ischemic-Type Biliary Lesions After Living-Donor Liver Transplantation.

BackgroundIschemic-type biliary lesions (ITBL) are accepted as the most incomprehensible biliary complications after living-donor liver transplantation (LDLT). Early predicting the development of ITBL in pediatric patients permits more preventive strategies. However, few studies have focused on the early prediction of ITBL.ObjectiveThis study aimed to establish a nomogram including ultrasound-based multimodal imaging to predict ITBL in children with biliary atresia (BA) within 2 years after receiving LDLT.MethodsThe records of 94 BA children with at least one year of follow-up after LDLT were reviewed retrospectively. They were randomly divided into a training cohort for constructing a nomogram (n=64) and a validation cohort (n=30). In the training cohort, patients diagnosed as ITBL were included in the ITBL group and those without any vascular and biliary complication were included in the non-ITBL group. Multivariate Cox regression was used for the establishment of the nomogram in predicting the risk of ITBL within 2 years post-LDLT. The discrimination and calibration of the nomogram were internally and externally validated. The performances of the nomogram and the individual components were compared by the area under the curve (AUC) of receiver operating characteristic (ROC) curve.ResultsIn the training cohort, 18 BA children were included in the ITBL group and 46 were in the non-ITBL group. Last pediatric end-stage liver disease (PELD) score, gamma-glutamyl transpeptidase (GGT), resistive index (RI), and liver stiffness measurement (LSM) were the independent predictors for the development of ITBL within 2 years post-LDLT. The nomogram incorporating these independent predictors showed good discrimination and calibration by the internal and external validation. Its performance was better than any individual component in predicting the prognosis (P < 0.05).ConclusionThe established nomogram may be used to predict the risk of ITBL within 2 years post-LDLT in BA children.