Hepatic blood flow velocity before and 3 months after Kasai portoenterostomy is a prognostic indicator for native liver survival in biliary atresia

Biliary atresia (BA) is a progressive neonatal cholangiopathy causing fibrosis, cirrhosis, and portal hypertension. Kasai portoenterostomy (KPE) restores bile drainage and prolongs native liver survival (NLS), yet BA remains the leading cause of pediatric liver transplantation. Therefore, reliable predictors of KPE failure are needed. This study evaluated hepatic blood flow velocities (HBFV) via ultrasound as potential non-invasive predictors of NLS after KPE. We retrospectively analyzed 163 BA patients treated between 2008 and 2023 at two German tertiary centers. Standardized Doppler ultrasound measured HBFV before and 3 months after KPE. Hepatic artery velocities, resistive index (RI), and portal vein flow were correlated with liver function, cholestasis, and fibrosis grade (Ishak). Furthermore, we assessed their predictive value at 3-month follow-up for NLS at 6 and 24 months. NLS in the presented cohort was 63.58% at 6 months and 40% at 24 months follow-up. No significant associations were identified between HBFV and liver fibrosis grade or cholestasis parameters (p > 0.05). In BA infants with 24-month NLS, the systolic hepatic artery velocity decreased significantly from diagnosis to follow-up exam. (79.46 ± 32.14 [diagnosis] vs. 56.85 ± 18.39 [3-month follow-up]; p = 0.001). In BA infants who did not achieve 24-month NLS (KPE failure), the arterial resistive index was significantly increased during follow-up exam (0.76 ± 0.08 [diagnosis] vs. 0.87 ± 0.14 [3-month follow-up]; p < 0.001). CONCLUSION: Doppler-derived HBFV parameters may aid in early prognostication after KPE and warrant prospective validation in larger, multicenter cohorts. WHAT IS KNOWN: • Biliary atresia (BA) is the leading cause of pediatric liver transplantation. Despite Kasai portoenterostomy (KPE), many children develop fibrosis and liver failure. Reliable, non-invasive prognostic tools for KPE failure are still lacking. WHAT IS NEW: • Doppler-derived hepatic blood flow velocities (HBFV) before and after KPE can predict native liver survival (NLS). Increasing hepatic artery velocity and resistive index indicate poor outcomes, while an initial decrease in portal vein flow velocity suggests improved prognosis.