{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T07:30:43Z","timestamp":1786692643667,"version":"build-2736575974"},"reference-count":42,"publisher":"AOSIS","issue":"1","license":[{"start":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T00:00:00Z","timestamp":1786924800000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:p>Background:\u00a0The aspartate aminotransferase-to-platelet ratio index (APRi) has been proposed as a non-invasive biomarker of liver injury in biliary atresia (BA). However, conflicting evidence and varying cutoff values have left its association with histologically confirmed liver damage uncertain. This study assessed the relationship between APRi and liver injury severity (Meta-Analysis of Histological Data in Viral Hepatitis [METAVIR] F0\u2013F4) in BA and evaluated its predictive value.\nMethods:\u00a0A retrospective analytical review of electronic records was conducted for all BA patients treated at a South African academic hospital between 01 January 2009 and 31 December 2019.\nResults:\u00a0Sixty-seven patients were included, 74.6% of whom were female. The most common subtypes were cytomegalovirus (CMV) immunoglobulin M-positive (IgM+) BA (34.3%) and isolated BA (31.3%); about one-third could not be classified because CMV serology was unavailable. Liver biopsy METAVIR scores were F1 (8.3%), F2 (50.0%), F3 (18.3%) and F4 (23.3%). In a sub-analysis (n\u00a0= 39), APRi modestly differentiated \u2264 F2 from \u2265 F3 fibrosis at a cutoff of 2.69 (area under the receiver operating characteristic curve 0.61). Decision curve analysis suggested modest clinical utility despite a non-significant logistic regression model (odds ratio 1.25; 95% confidence interval 0.94\u20131.92;\u00a0p\u00a0= 0.2). Of the 55 patients with known outcomes, 94.5% (n\u00a0= 52) had confirmed mortality or were referred for palliative care.\nConclusion:\u00a0Aminotransferase-to-platelet ratio index should not replace established clinical decision-making but may provide useful adjunctive information alongside clinical, biochemical and histological assessment. These findings provide contextual evidence from a South African resource-limited setting and support prospective multicentre validation before routine clinical implementation.\nContribution:\u00a0The study contributes evidence supporting continued evaluation of APRi as an adjunctive non-invasive biomarker in BA in the South African setting.<\/jats:p>","DOI":"10.4102\/jcmsa.v4i1.447","type":"journal-article","created":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T07:00:46Z","timestamp":1786690846000},"update-policy":"https:\/\/doi.org\/10.4102\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Analysis of aspartate aminotransferase-to-platelet ratio index and liver fibrosis in biliary atresia"],"prefix":"10.4102","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6422-9272","authenticated-orcid":false,"given":"Elizabeth","family":"Brits","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/009xwd568","id-type":"ROR","asserted-by":"publisher"}],"name":"University of the Free State"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8508-8667","authenticated-orcid":false,"given":"Stephen","family":"Brown","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/009xwd568","id-type":"ROR","asserted-by":"publisher"}],"name":"University of the Free State"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7614-900X","authenticated-orcid":false,"given":"Lezelle","family":"Botes","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/033z08192","id-type":"ROR","asserted-by":"publisher"}],"name":"Central University of Technology"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6427-0278","authenticated-orcid":false,"given":"Michael","family":"Pienaar","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/009xwd568","id-type":"ROR","asserted-by":"publisher"}],"name":"University of the Free State"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2580","published-online":{"date-parts":[[2026,8,17]]},"reference":[{"key":"ref0","doi-asserted-by":"crossref","unstructured":"Hartley JL, Davenport M, Kelly DA. Biliary atresia. Lancet. 2009;374(9702):1704\u20131713. https:\/\/doi.org\/10.1016\/S0140-6736(09)60946-6","DOI":"10.1016\/S0140-6736(09)60946-6"},{"key":"ref1","doi-asserted-by":"crossref","unstructured":"Jimenez-Rivera C, Jolin-Dahel KS, Fortinsky KJ, Gozdyra P, Benchimol EI. International incidence and outcomes of biliary atresia. J Pediatr Gastroenterol Nutr. 2013;56(4):344\u2013354. https:\/\/doi.org\/10.1097\/MPG.0b013e318282a913","DOI":"10.1097\/MPG.0b013e318282a913"},{"key":"ref2","doi-asserted-by":"crossref","unstructured":"Davenport M. Biliary atresia: Outcome and management. Indian J Pediatr. 2006;73(9):825\u2013828. https:\/\/doi.org\/10.1007\/BF02790394","DOI":"10.1007\/BF02790394"},{"key":"ref3","doi-asserted-by":"crossref","unstructured":"Haafiz AB. Liver fibrosis in biliary atresia. Expert Rev Gastroenterol Hepatol. 2010;4(3):335\u2013343. https:\/\/doi.org\/10.1586\/egh.10.29","DOI":"10.1586\/egh.10.29"},{"key":"ref4","doi-asserted-by":"crossref","unstructured":"Wildhaber BE. Biliary atresia: 50 years after the first Kasai. Int Sch Res Notices. 2012;2012:132089. https:\/\/doi.org\/10.5402\/2012\/132089","DOI":"10.5402\/2012\/132089"},{"key":"ref5","doi-asserted-by":"crossref","unstructured":"Sinha CK, Davenport M. Biliary atresia. J Indian Assoc Pediatr Surg. 2008;13(2):49\u201356. https:\/\/doi.org\/10.4103\/0971-9261.43015","DOI":"10.4103\/0971-9261.43015"},{"key":"ref6","doi-asserted-by":"crossref","unstructured":"Hukkinen M, Kerola A, Lohi J, et al. Treatment policy and liver histopathology predict biliary atresia outcomes: Results after national centralization and protocol biopsies. J Am Coll Surg. 2018;226(1):46\u201357.e1. https:\/\/doi.org\/10.1016\/j.jamcollsurg.2017.09.009","DOI":"10.1016\/j.jamcollsurg.2017.09.009"},{"key":"ref7","doi-asserted-by":"crossref","unstructured":"Shteyer E, Ramm GA, Xu C, White FV, Shepherd RW. Outcome after portoenterostomy in biliary atresia: Pivotal role of degree of liver fibrosis and intensity of stellate cell activation. J Pediatr Gastroenterol Nutr. 2006;42(1):93\u201399. https:\/\/doi.org\/10.1097\/01.mpg.0000189324.80323.a6","DOI":"10.1097\/01.mpg.0000189324.80323.a6"},{"key":"ref8","doi-asserted-by":"crossref","unstructured":"Shneider BL, Mazariegos GV. Biliary atresia: A transplant perspective. Liver Transpl. 2007;13(11):1482\u20131495. https:\/\/doi.org\/10.1002\/lt.21303","DOI":"10.1002\/lt.21303"},{"key":"ref9","doi-asserted-by":"crossref","unstructured":"Serinet M-O, Wildhaber BE, Brou\u00e9 P, et al. Impact of age at Kasai operation on its results in late childhood and adolescence: A rational basis for biliary atresia screening. Pediatrics. 2009;123(5):1280\u20131286. https:\/\/doi.org\/10.1542\/peds.2008-1949","DOI":"10.1542\/peds.2008-1949"},{"key":"ref10","doi-asserted-by":"crossref","unstructured":"Davenport M, Puricelli V, Farrant P, et al. The outcome of the older (\u2265 100 days) infant with biliary atresia. J Pediatr Surg. 2004;39(4):575\u2013581. https:\/\/doi.org\/10.1016\/j.jpedsurg.2003.12.014","DOI":"10.1016\/j.jpedsurg.2003.12.014"},{"key":"ref11","doi-asserted-by":"crossref","unstructured":"Brits E, Le Grange SM. Biliary atresia: The profile, management and outcome of patients treated at a tertiary hospital in central South Africa. S Afr Med J. 2023;113(11):57\u201362. https:\/\/doi.org\/10.7196\/SAMJ.2023.v113i11.845","DOI":"10.7196\/SAMJ.2023.v113i11.845"},{"key":"ref12","doi-asserted-by":"crossref","unstructured":"Davenport M, Superina R. Primary liver transplant in biliary atresia: The case for and against. J Pediatr Surg. 2024;59(8):1418\u20131426. https:\/\/doi.org\/10.1016\/j.jpedsurg.2024.03.005","DOI":"10.1016\/j.jpedsurg.2024.03.005"},{"key":"ref13","doi-asserted-by":"crossref","unstructured":"Muntean A, Kronfli R, Makin E, Davenport M. The AST-to-platelet ratio index (APRi) at Kasai portoenterostomy: Standing the test of time. J Pediatr Surg. 2023;58(12):2347\u20132351. https:\/\/doi.org\/10.1016\/j.jpedsurg.2023.06.012","DOI":"10.1016\/j.jpedsurg.2023.06.012"},{"key":"ref14","doi-asserted-by":"crossref","unstructured":"The French METAVIR Cooperative Study Group, Bedossa P. Intraobserver and interobserver variations in liver biopsy interpretation in patients with chronic hepatitis C. Hepatology [serial online]. 1994 [cited 2026 May 08];20(1 Pt 1):15\u201320. Available from: https:\/\/doi.org\/10.1002\/hep.1840200104","DOI":"10.1002\/hep.1840200104"},{"key":"ref15","doi-asserted-by":"crossref","unstructured":"Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med. 2001;344(7):495\u2013500. https:\/\/doi.org\/10.1056\/NEJM200102153440706","DOI":"10.1056\/NEJM200102153440706"},{"key":"ref16","doi-asserted-by":"crossref","unstructured":"Kaur N, Goyal G, Garg R, Tapasvi C, Chawla S, Kaur R. Potential role of noninvasive biomarkers during liver fibrosis. World J Hepatol. 2021;13(12):1919\u20131935. https:\/\/doi.org\/10.4254\/wjh.v13.i12.1919","DOI":"10.4254\/wjh.v13.i12.1919"},{"key":"ref17","doi-asserted-by":"crossref","unstructured":"Ovchinsky N, Moreira RK, Lefkowitch JH, Lavine JE. Liver biopsy in modern clinical practice: A pediatric point-of-view. Adv Anat Pathol. 2012;19(4):250\u2013262. https:\/\/doi.org\/10.1097\/PAP.0b013e31825c6a20","DOI":"10.1097\/PAP.0b013e31825c6a20"},{"key":"ref18","doi-asserted-by":"crossref","unstructured":"Grieve A, Makin E, Davenport M. Aspartate aminotransferase-to-platelet ratio index (APRi) in infants with biliary atresia: Prognostic value at presentation. J Pediatr Surg. 2013;48(4):789\u2013795. https:\/\/doi.org\/10.1016\/j.jpedsurg.2012.10.010","DOI":"10.1016\/j.jpedsurg.2012.10.010"},{"key":"ref19","doi-asserted-by":"crossref","unstructured":"Suominen JS, Lampela H, Heikkil\u00e4 P, Lohi J, Jalanko H, Pakarinen MP. APRi predicts native liver survival by reflecting portal fibrogenesis and hepatic neovascularization at the time of portoenterostomy in biliary atresia. J Pediatr Surg. 2015;50(9):1528\u20131531. https:\/\/doi.org\/10.1016\/j.jpedsurg.2014.11.046","DOI":"10.1016\/j.jpedsurg.2014.11.046"},{"key":"ref20","doi-asserted-by":"crossref","unstructured":"Yang LY, Fu J, Peng X-F, et al. Validation of aspartate aminotransferase to platelet ratio for diagnosis of liver fibrosis and prediction of postoperative prognosis in infants with biliary atresia. World J Gastroenterol. 2015;21(19):5893\u20135900. https:\/\/doi.org\/10.3748\/wjg.v21.i19.5893","DOI":"10.3748\/wjg.v21.i19.5893"},{"key":"ref21","doi-asserted-by":"crossref","unstructured":"Hukkinen M, Lohi J, Heikkil\u00e4 P, et al. Noninvasive evaluation of liver fibrosis and portal hypertension after successful portoenterostomy for biliary atresia. Hepatol Commun. 2019;3(3):382\u2013391. https:\/\/doi.org\/10.1002\/hep4.1306","DOI":"10.1002\/hep4.1306"},{"key":"ref22","doi-asserted-by":"crossref","unstructured":"Lurie Y, Webb M, Cytter-Kuint R, Shteingart S, Lederkremer GZ. Non-invasive diagnosis of liver fibrosis and cirrhosis. World J Gastroenterol. 2015;21(41):11567\u201311583. https:\/\/doi.org\/10.3748\/wjg.v21.i41.11567","DOI":"10.3748\/wjg.v21.i41.11567"},{"key":"ref23","doi-asserted-by":"crossref","unstructured":"Christensen E. Prognostic models including the Child\u2013Pugh, MELD and Mayo risk scores \u2013 Where are we and where should we go? J Hepatol. 2004;41(2):344\u2013350. https:\/\/doi.org\/10.1016\/j.jhep.2004.06.005","DOI":"10.1016\/j.jhep.2004.06.005"},{"key":"ref24","doi-asserted-by":"crossref","unstructured":"Bourdeaux C, Tri TT, Gras J, et al. PELD score and posttransplant outcome in pediatric liver transplantation: A retrospective study of 100 recipients. Transplantation. 2005;79(9):1273\u20131276. https:\/\/doi.org\/10.1097\/00007890-200505150-00060","DOI":"10.1097\/00007890-200505150-00060"},{"key":"ref25","doi-asserted-by":"crossref","unstructured":"Nakamura H, Tanaka E, Kaneko M, et al. The clinical importance of the trimethadione tolerance test as a method for quantitative assessment of hepatic functional reserve in patients with biliary atresia. J Clin Pharm Ther. 2001;26(6):417\u2013424. https:\/\/doi.org\/10.1046\/j.1365-2710.2001.00370.x","DOI":"10.1046\/j.1365-2710.2001.00370.x"},{"key":"ref26","doi-asserted-by":"crossref","unstructured":"Wai C-T, Greenson JK, Fontana RJ, et al. A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C. Hepatology. 2003;38(2):518\u2013526. https:\/\/doi.org\/10.1053\/jhep.2003.50346","DOI":"10.1053\/jhep.2003.50346"},{"key":"ref27","doi-asserted-by":"crossref","unstructured":"Lind RC, Verkade HJ, Porte RJ, Hulscher JBF. Aspartate transaminase-to-platelet ratio index is not correlated with severity of fibrosis or survival in children with biliary atresia. J Pediatr Gastroenterol Nutr. 2012;54(5):698. https:\/\/doi.org\/10.1097\/MPG.0b013e318244d19d","DOI":"10.1097\/MPG.0b013e318244d19d"},{"key":"ref28","doi-asserted-by":"crossref","unstructured":"Kong F, Dong R, Chen G, et al. Progress in biomarkers related to biliary atresia. J Clin Transl Hepatol. 2024;12(3):305\u2013315. https:\/\/doi.org\/10.14218\/JCTH.2023.00260","DOI":"10.14218\/JCTH.2023.00260"},{"key":"ref29","doi-asserted-by":"crossref","unstructured":"Vickers AJ, van Calster B, Steyerberg EW. A simple, step-by-step guide to interpreting decision curve analysis. Diagn Progn Res. 2019;3(1):18. https:\/\/doi.org\/10.1186\/s41512-019-0064-7","DOI":"10.1186\/s41512-019-0064-7"},{"key":"ref30","unstructured":"WeiTing C, ShuangJie L. Clinical value of transient elastography, aspartate aminotransferase-to-platelet ratio index, and fibrosis-4 in the diagnosis of liver fibrosis in children with biliary atresia. J Clin Hepatol. 2020;36(3):546\u2013550. https:\/\/lcgdbzz.org\/en\/article\/doi\/10.3969\/j.issn.1001-5256.2020.03.015"},{"key":"ref31","doi-asserted-by":"crossref","unstructured":"Shah I, Madgum N. Correlation of APRI Index with Metavir index in children with neonatal cholestasis without biliary atresia. Ann Hepatol [serial online]. 2018 [cited n.d.];17(4):592\u2013595. Available from: https:\/\/www.sciencedirect.com\/science\/article\/pii\/S166526811930482X","DOI":"10.5604\/01.3001.0012.0924"},{"key":"ref32","doi-asserted-by":"crossref","unstructured":"Chen S, Liao B, Zhong Z, et al. Supersonic shearwave elastography in the assessment of liver fibrosis for postoperative patients with biliary atresia. Sci Rep. 2016;6(1):31057. https:\/\/doi.org\/10.1038\/srep31057","DOI":"10.1038\/srep31057"},{"key":"ref33","doi-asserted-by":"crossref","unstructured":"Kim SY, Seok JY, Han SJ, Koh H. Assessment of liver fibrosis and cirrhosis by aspartate aminotransferase-to-platelet ratio index in children with biliary atresia. J Pediatr Gastroenterol Nutr. 2010;51(2):198\u2013202. https:\/\/doi.org\/10.1097\/MPG.0b013e3181da1d98","DOI":"10.1097\/MPG.0b013e3181da1d98"},{"key":"ref34","doi-asserted-by":"crossref","unstructured":"Lampela H, Kosola S, Heikkil\u00e4 P, Lohi J, Jalanko H, Pakarinen MP. Native liver histology after successful portoenterostomy in biliary atresia. J Clin Gastroenterol. 2014;48(8):721\u2013728. https:\/\/doi.org\/10.1097\/MCG.0000000000000013","DOI":"10.1097\/MCG.0000000000000013"},{"key":"ref35","doi-asserted-by":"crossref","unstructured":"McKoy JM, Bennett CL, Scheetz MH, et al. Hepatotoxicity associated with long-versus short-course HIV-prophylactic nevirapine use: A systematic review and meta-analysis from the research on adverse drug events and reports (RADAR) project. Drug Saf. 2009;32(2):147\u2013158. https:\/\/doi.org\/10.2165\/00002018-200932020-00007","DOI":"10.2165\/00002018-200932020-00007"},{"key":"ref36","doi-asserted-by":"crossref","unstructured":"Delicio AM, Lajos GJ, Amaral E, Cavichiolli F, Polydoro M, Milanez H. Adverse effects in children exposed to maternal HIV and antiretroviral therapy during pregnancy in Brazil: A cohort study. Reprod Health. 2018;15(1):76. https:\/\/doi.org\/10.1186\/s12978-018-0513-8","DOI":"10.1186\/s12978-018-0513-8"},{"key":"ref37","doi-asserted-by":"crossref","unstructured":"Zani A, Quaglia A, Hadzi\u0107 N, Zuckerman M, Davenport M. Cytomegalovirus-associated biliary atresia: An aetiological and prognostic subgroup. J Pediatr Surg. 2015;50(10):1739\u20131745. https:\/\/doi.org\/10.1016\/j.jpedsurg.2015.03.001","DOI":"10.1016\/j.jpedsurg.2015.03.001"},{"key":"ref38","unstructured":"Lisowska-Miko\u0142ajk\u00f3w D, Miko\u0142ajk\u00f3w A, Reczuch J, Kr\u00f3lak-Olejnik B. [Congenital cytomegalovirus infection \u2013 still a relevant problem (based on own experience and literature)] [article in Polish]. Dev Period Med. 2018;22(1):49\u201357. https:\/\/doi.org\/10.34763\/devperiodmed.20182201.4957"},{"key":"ref39","doi-asserted-by":"crossref","unstructured":"Shen Q-L, Chen Y-J, Wang Z-M, et al. Assessment of liver fibrosis by Fibroscan as compared to liver biopsy in biliary atresia. World J Gastroenterol. 2015;21(22):6931\u20136936. https:\/\/doi.org\/10.3748\/wjg.v21.i22.6931","DOI":"10.3748\/wjg.v21.i22.6931"},{"key":"ref40","doi-asserted-by":"crossref","unstructured":"Kim S, Kang Y, Lee MJ, Kim MJ, Han SJ, Koh H. Points to be considered when applying FibroScan S probe in children with biliary atresia. J Pediatr Gastroenterol Nutr. 2014;59(5):624\u2013628. https:\/\/doi.org\/10.1097\/mpg.0000000000000489","DOI":"10.1097\/MPG.0000000000000489"},{"key":"ref41","doi-asserted-by":"crossref","unstructured":"Hwang J, Yoon HM, Kim KM, et al. Assessment of native liver fibrosis using ultrasound elastography and serological fibrosis indices in children with biliary atresia after the Kasai procedure. Acta Radiol. 2021;62(8):1088\u20131096. https:\/\/doi.org\/10.1177\/0284185120948489","DOI":"10.1177\/0284185120948489"}],"container-title":["Journal of the Colleges of Medicine of South Africa"],"original-title":[],"link":[{"URL":"https:\/\/jcmsa.org.za\/index.php\/jcmsa\/article\/view\/447\/1202","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T07:00:59Z","timestamp":1786690859000},"score":1,"resource":{"primary":{"URL":"https:\/\/jcmsa.org.za\/index.php\/jcmsa\/article\/view\/447"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,17]]},"references-count":42,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1,1]]}},"URL":"https:\/\/doi.org\/10.4102\/jcmsa.v4i1.447","relation":{},"ISSN":["3105-4331","2960-110X"],"issn-type":[{"value":"3105-4331","type":"print"},{"value":"2960-110X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,17]]},"article-number":"a447"}}