| Impact of bacterial infection on native liver survival in children with cirrhosis due to biliary atresia |
Varissara Kaewchaivijit1 
, Pornthep Tanpowpong1,2
, Songpon Getsuwan1,2
, Sophida Boonsathorn3
, Chatmanee Lertudomphonwanit1,2
, Suporn Treepongkaruna1,25
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1Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
2Ramathibodi Excellence Center in Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
3Division of Infectious diseases, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand |
Correspondence:
Pornthep Tanpowpong, Email: pornthep.tan@mahidol.ac.th
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Received: 25 February 2026 • Revised: 14 June 2026 • Accepted: 15 June 2026 |
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| Abstract |
Background
Biliary atresia (BA) is a common cause of cirrhosis in children, and serious bacterial infections may worsen clinical outcomes.
Purpose
To study the characteristics, associated factors, and outcomes of infections in children with cirrhosis secondary to BA.
Methods
A retrospective cohort study was conducted in children aged <18 years with cirrhosis due to BA between 2014 and 2023. Patients were categorized as having proven/suspected bacterial infection, presumed viral infection, or no documented infection. The clinical characteristics, associated risk factors, predictive models, and native liver survival outcomes, including liver transplantation (LT) and death, were analyzed.
Results
Among 150 children, 94 (62.7%) had 222 infection episodes and 249 had infection-related diagnosis. Of the 222 episodes, 143 (64.4%) were classified as proven/suspected bacterial infections; cholangitis was the most common bacterial diagnosis (39.7%). Univariate analysis showed that proven/suspected bacterial infection was associated with higher pediatric end-stage liver disease scores at the first visit and during fever episodes and with higher total and direct bilirubin levels during fever episodes. C-reactive protein (CRP) cutoff of 31 mg/L yielded 75.4% sensitivity, 68.2% specificity, and an area under the receiver operating characteristic curve of 0.80 (95% confidence interval [CI], 0.69–0.90) for distinguishing proven/suspected bacterial from presumed viral infections. Overall, 54% of patients underwent LT, 24% survived with their native liver, 8% died, and 14% were lost to follow-up. After adjustment for disease severity and infection history before referral, proven/suspected bacterial infection was associated with lower native liver survival (adjusted hazard ratio, 1.88; 95% CI, 1.51–2.33).
Conclusion
Infections are common in children with cirrhosis due to BA. Serum CRP may help distinguish proven/suspected bacterial from other infections. Bacterial infections were associated with lower native liver survival; therefore, appropriate management and prevention may improve native liver survival. |
| Key Words:
Bacterial infection, Chronic liver disease, C-reactive protein, Native liver survival, Liver transplantation |
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