The extent of intestinal failure-associated liver disease in patients referred for intestinal rehabilitation is associated with increased mortality: an analysis of the Pediatric Intestinal Failure Consortium database

Background

The advent of regional multidisciplinary intestinal rehabilitation programs has been associated with improved survival in pediatric intestinal failure. Yet, the optimal timing of referral for intestinal rehabilitation remains unknown. We hypothesized that the degree of intestinal failure-associated liver disease (IFALD) at initiation of intestinal rehabilitation would be associated with overall outcome.

Methods

The multicenter, retrospective Pediatric Intestinal Failure Consortium (PIFCon) database was used to identify all subjects with baseline bilirubin data. Conjugated bilirubin (CBili) was used as a marker for IFALD, and we stratified baseline bilirubin values as CBili < 2 mg/dL, CBili 2–4 mg/dL, and CBili > 4 mg/dL. The association between baseline CBili and mortality was examined using Cox proportional hazards regression.

Results

Of 272 subjects in the database, 191 (70%) children had baseline bilirubin data collected. 38% and 28% of patients had CBili > 4 mg/dL and CBili < 2 mg/dL, respectively, at baseline. All-cause mortality was 23%. On univariate analysis, mortality was associated with CBili 2–4 mg/dL, CBili > 4 mg/dL, prematurity, race, and small bowel atresia. On regression analysis controlling for age, prematurity, and diagnosis, the risk of mortality was increased by 3-fold for baseline CBili 2–4 mg/dL (HR 3.25 [1.07–9.92], p = 0.04) and 4-fold for baseline CBili > 4 mg/dL (HR 4.24 [1.51–11.92], p = 0.006). On secondary analysis, CBili > 4 mg/dL at baseline was associated with a lower chance of attaining enteral autonomy.

Conclusion

In children with intestinal failure treated at intestinal rehabilitation programs, more advanced IFALD at referral is associated with increased mortality and decreased prospect of attaining enteral autonomy. Early referral of children with intestinal failure to intestinal rehabilitation programs should be strongly encouraged.

Level of evidence

Treatment Study, Level III.