Serum MMP-7 in the Diagnosis of Biliary Atresia Jingying Jiang, MD, Junfeng Wang, MD, PhD, Zhen Shen, MD, Xuexin Lu, MD, Gong Chen, MD, Yanlei Huang, MD, Rui Dong, MD, PhD, Shan Zheng, MD, PhD

BACKGROUND: The overlapping features of biliary atresia (BA) and other neonatal cholestasis with abstract alternative causes (non-BA) have posed challenges for diagnosis. Matrix metalloproteinase-7 (MMP-7) has been reported to be promising in diagnosing BA. We aimed to validate the diagnostic accuracy of MMP-7 for BA in a large population sample. METHODS: We enrolled 288 patients with neonatal obstructive jaundice from March 2017 to October 2018. Serum MMP-7 levels were measured by using an enzyme-linked immunosorbent assay. Receiver operating characteristic curves were constructed, and decision curve analysis was done. A Pearson correlation coefficient test was conducted to assess the correlation between MMP-7 levels and other characteristics. RESULTS: The median serum MMP-7 levels were 38.89 ng/mL (interquartile range: 22.96–56.46) for the BA group and 4.4 ng/mL (interquartile range: 2.73–6.56) for the non-BA group (P , .001). The area under the receiver operating characteristic curve value was 0.9829 for MMP-7, and the sensitivity, specificity, positive predictive value, and negative predictive value were 95.19%, 93.07%, 97.27%, and 91.43%, respectively, at a cutoff value of 10.37 ng/mL. When MMP-7 was combined with g glutamyl transferase, the diagnostic accuracy was slightly improved without significance when compared with MMP-7 alone and had an area under the curve of 0.9880 (P = .08). Decision curve analysis also showed potential for MMP-7 to be used for clinical applications. A significant correlation was found with fibrosis stage from liver biopsy (R = 0.47; P , .001). CONCLUSIONS: MMP-7 demonstrated good accuracy in diagnosing BA and holds promise for future clinical application. Furthermore, its correlation with liver fibrosis indicated its potential use as a therapeutic target or prognostic biomarker.

Department of Pediatric Surgery, Children’s Hospital of Fudan University, Shanghai Key Laboratory of Birth WHAT’S KNOWN ON THIS SUBJECT: Matrix Defects, and Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai, China metalloproteinase-7 was reported to have promising diagnostic accuracy for biliary atresia, but the related Drs Jiang and Wang conceptualized and designed the study, conducted the matrix studies are rare with a small sample size, and the metalloproteinase-7 measurement and the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Shen, Lu, Chen, and Huang collected the serum sample cutoff value has not yet been established. and data, designed the data collection instruments, and reviewed and revised the manuscript; Drs WHAT THIS STUDY ADDS: We validated matrix Dong and Zheng conceptualized and designed the study, coordinated and supervised data collection, metalloproteinase-7 efficacy in a larger population and and critically reviewed the manuscript for important intellectual content; and all authors approved found good performance in diagnosing biliary atresia. the final manuscript as submitted and agree to be accountable for all aspects of the work. Also, a significant correlation was found with fibrosis DOI: https://doi.org/10.1542/peds.2019-0902 stage, indicating its potential use as a therapeutic Accepted for publication Aug 19, 2019 target or prognostic biomarker. Address correspondence to Shan Zheng, MD, PhD, Department of Pediatric Surgery, Children’s Hospital of Fudan University, Shanghai Key Laboratory of Birth Defects, 399 Wan Yuan Rd, Shanghai To cite: Jiang J, Wang J, Shen Z, et al. Serum MMP-7 in 201102, China. E-mail: [email protected] the Diagnosis of Biliary Atresia. Pediatrics. 2019;144(5): e20190902

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 144, number 5, November 2019:e20190902 ARTICLE Biliary atresia (BA) is a serious liver improvement.17 Although radiologic the diagnosis of BA. We evaluated the disease affecting newborns, with investigations (such as ultrasound, diagnostic accuracy of using MMP-7 higher incidence seen in the Asia- MRI, and hepatobiliary scintigraphy) alone and GGT alone or in Pacific region (∼1.06 in 10 000 live were reported to be helpful in combination as well as assessing the births) than within the United States differentiating BA from other correlation of MMP-7 with patient – (4.47 in 100 000).1 3 It is obstructive cholestasis, they are time age, liver function testing, and liver – characterized by inflammation and consuming and costly.18 23 Therefore, biopsy. atresia of extra and intrahepatic bile an effective biomarker would be This study was reviewed and ducts, resulting in obstructive extremely valuable for the approved by the ethics committee of jaundice and subsequent liver preoperative diagnosis of BA. the Children’s Hospital of Fudan fibrosis. The Kasai portoenterostomy Matrix metalloproteinase-7 (MMP-7), University (Shanghai, China) with procedure has been the first-line a protease responsible for tissue a waiver of requirement for informed treatment of BA since 1959, although remodeling, was discovered to be consent because of the use of left the pathogenesis is largely – associated with liver fibrosis in blood samples from routine unknown.3 8 Several studies have patients with BA.24,25 Lately, the investigations along with patient proposed that early diagnosis and Bezerra group26 identified that MMP- anonymity. The study was performed treatment is key to the restoration of – 7 was superior to all other potential in compliance with the Declaration of bile flow and favorable prognosis.9 13 biomarkers and had a significantly Helsinki and other relevant However, many other non-BA higher concentration in patients with regulations. cholestatic diseases, such as BA when compared with non-BA idiopathic cholestasis, Alagille using a high-throughput proteomic syndrome, and progressive familial Study Subjects assay (SOMAscan). This revealed its intrahepatic cholestasis, are similar to This study was conducted at potential role in the pathogenesis of BA in symptoms and noninvasive Children’s Hospital of Fudan BA and thereby its use as a potential laboratory and radiologic test results, University, an urban, tertiary-care biomarker and therapeutic target.26 leading to difficulties in the accurate academic children’s hospital in Recently, Yang et al27 compared diagnosis of BA. Our previous Shanghai, China. Infants between 30 serum MMP-7 concentration among retrospective study showed that 14% and 150 days of age with obstructive patients with BA and without BA and of 602 patients with BA-like neonatal jaundice (defined as a DB serum level healthy control infants and confirmed jaundice were found to be non-BA by .17 mmol/L and .20% of total its diagnostic accuracy with a cutoff using invasive diagnostic procedures bilirubin [TB]) were recruited from value of 52.85 ng/mL. The area under such as intraoperative March 2017 to October 2018. Blood the curve (AUC) was 0.99 with cholangiography and liver biopsy.14 samples were obtained from routine a sensitivity, specificity, and PPV of Therefore, it is critical to develop laboratory tests at admission, and the 98.67%, 95%, and 98.28%, a noninvasive diagnostic method with sera were stored at 280°C respectively.27 However, most good reliability and validity to avoid immediately after extraction. recently, Wu et al28 found that unnecessary invasive procedures. Intraoperative cholangiography and a serum MMP-7 level of .1.43 ng/mL subsequent histologic examination of was predictive of BA in infants with g glutamyl transferase (GGT), is 1 of liver biopsies were used to confirm cholestasis with a sensitivity of the factors measured in biochemical the diagnosis of BA. The gallbladders 97.30% and a specificity of 83.20%. liver function tests and is widely used of some patients were seen to be The cutoff value was different in the 2 to differentiate BA from non-BA, with completely atrophic, and the injection studies, although the patients were all an accuracy of 76% to 88% at a cutoff of contrast was hard to achieve, so BA from a Chinese cohort. Therefore, we value of ∼300 IU/L.15,16 However, in the infant would be diagnosed at conducted a single-center validation GGT alone is not enough to accurately once. Otherwise, a cholangiography diagnostic test for serum MMP-7 diagnose BA. We have developed and would be performed to further levels in a larger patient population validated a novel nomogram evaluate the anatomy of the to further evaluate diagnostic diagnostic model based on 5 intrahepatic bile ducts before a final accuracy and the cutoff value. variables, including sex, weight, direct diagnosis was made. Patients without bilirubin (DB), ln(GGT), and BA were confirmed by intraoperative ln(alkaline phosphatase [ALP]), which METHODS cholangiography demonstrating achieved better sensitivity (85.7%), a patent biliary tree. Percutaneous specificity (80.3%), and positive Study Design needle liver biopsy was also used to predictive value (PPV) (0.969). There This is a single-center diagnostic test exclude BA. These were also is, however, still room for to validate the use of serum MMP-7 in confirmed by genetic tests

Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 JIANG et al demonstrating specific gene biopsy were described by n (%). underwent diagnostic surgery. Fifty- mutations or the resolution of Continuous variables, including age, two of patients without BA jaundice without surgical GGT, TB, DB, total bile acid (TBA), underwent genotyping tests. The intervention during follow-up. The alanine aminotransferase (ALT), mean follow-up period for the follow-up information was collected aspartate aminotransferase (AST), patients was 482 6 180 days. The from outpatient clinical records and ALP, platelets, and the AST/platelet final diagnosis for patients without telephone communication. Patients ratio index (APRi), were expressed as BA included cytomegalovirus (CMV) with non-BA were further divided mean 6 SD and median and quartiles hepatitis (n = 26), Alagille syndrome into 2 groups: those with and without (quartile 1 [Q1], quartile 3 [Q3]). By (n = 8), citrin deficiency (n = 2), diagnostic surgery (Supplemental using univariate analysis, the x2 test progressive familial intrahepatic Fig 3). was conducted for sex, whereas the cholestasis (n = 6), parenteral Mann-Whitney U test was performed nutrition–associated cholestasis Parameters for all continuous variables because (n = 3), intrahepatic bile duct Baseline assessments, including of a failing Shapiro-Wilk W-test for dysplasia (n = 1), congenital absence demographic features, medical normal distribution. of a gallbladder (n = 1), gallbladder history, physical examination, and duplication (n = 1), neonatal Receiver operating characteristic laboratory and radiographic tests, sclerosing cholangitis (n = 1), and (ROC) curves were constructed to were performed on all patients. The idiopathic cholestasis (n = 52; calculate the best cutoff point and laboratory variables included Supplemental Tables 4 and 5). AUC for MMP-7 alone, GTT alone, and complete blood count and MMP-7 combined with GGT. The biochemical liver function tests. The The demographic and baseline sensitivity, specificity, PPV, and histologic features of all liver biopsy characteristics of the study subjects negative predictive value (NPV) were specimens were measured and in the BA and non-BA groups are used to show diagnostic accuracy. recorded by the same pathologist summarized in Table 1. The median Decision curve analysis (DCA) was (G.C.). The grades of inflammation age of the infant patients was 59 days performed to finalize the ranges of and stages of fibrosis were defined (interquartile range [IQR]: 48–69) in threshold probabilities within which according to the Metavir scale system, the BA group and 67 days (IQR: MMP-7, GGT, or MMP-7 combined ranging from A1–3toF0–4.29 51–84) in the non-BA group with GGT were clinically valuable for (P = .006). The majority of the the diagnosis of BA. The Pearson Serum MMP-7 Measurement patients without BA were boys correlation coefficient test was On the day of laboratory test, serum (75.25%), whereas the sex applied to assess the correlations samples from each patient were distribution in the BA group was between MMP-7 and other clinical obtained before the final diagnosis. the opposite, with the male characteristics, including grade of MMP-7 concentration was measured population representing 43.32% inflammation and stage of fibrosis, by by using an enzyme-linked and the female population using liver biopsy. Statistically immunosorbent assay (Cloud-Clone representing 56.68% (P , .001). significant differences were defined Corp, Wuhan, China). The serum The median level of GGT and as a P ,.05. All data analyses were samples from the patients with BA TB were found to be higher in performed by using Stata 14 software were diluted 16 times to the BA group (P , .001) when (Stata Corp, College Station, TX). accommodate the concentration compared with the non-BA group range of the kit (0–10 ng/mL), (P = .004). However, the 2 whereas samples from the patients RESULTS groups were comparable in DB, without BA were diluted 4 times. The TBA, ALT, AST, ALP, platelets, and person performing the measurements Study Population the APRi. All patients with and was blinded to the test result and A total of 288 eligible infants were without BA with diagnostic surgery final diagnosis. Each sample was enrolled, of whom 187 were underwent liver biopsy. However, provided with 2 technical replicates, diagnosed with BA, and of those, 34 the specimens of 15 patients with and the mean was recorded. had BA splenic malformation BA and 10 patients without BA were syndrome or other congenital too small and too close to the liver Statistical Analyses malformations, including congenital capsule for the pathologist to make Baseline characteristics of patients in heart disease, renal malformation, or a judgment on the inflammation the BA and non-BA groups were congenital intestinal malrotation. One grade or fibrosis stage, and another demonstrated by using frequency hundred one patients were confirmed 16 patients without BA underwent distributions and descriptive to have cholestasis with other causes needle liver biopsy. Inflammation statistics. Sex and stages of liver of non-BA, and of these, 38 and fibrosis stages of 172

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 144, number 5, November 2019 3 TABLE 1 Demographics and Clinical Characteristics of Each Group BA (N = 187) Non-BA (N = 101) Pa Sex, n (%) Male 81 (43.32) 76 (75.25) ,.001 Female 106 (56.68) 25 (24.75) Age, d Mean 6 SD 61.5 6 19.0 68.1 6 22.6 .006 Median 59 67 — Q1, Q3 48, 69 51, 84 — GGT, IU/L Mean 6 SD 532.2 6 389.01 164.2 6 164.9 ,.001 Median 407.5 117 — Q1, Q3 235, 756 76, 203 — TB, mmol/L Mean 6 SD 170.6 6 51.5 158.0 6 79.5 .004 Median 162.8 140.1 — Q1, Q3 136.5, 193.7 100, 188.8 — DB, mmol/L Mean 6 SD 103.3 6 31.3 100.7 6 47.5 .21 Median 97.3 93.5 — Q1, Q3 82.5, 116.5 68.2, 128.8 — TBA, mmol/L Mean 6 SD 120.7 6 55.9 137.2 6 81.3 .32 Median 108.9 112.9 — Q1, Q3 86.6, 138.4 92.1, 141.2 — ALT, IU/L Mean 6 SD 168.8 6 161.2 198.5 6 170.5 .06 Median 118 161 — Q1, Q3 72, 188 72, 269 — AST, IU/L Mean 6 SD 254.5 6 205.6 287.1 6 238.8 .19 Median 195 230 — Q1, Q3 131, 289 137, 378 — ALP, IU/L Mean 6 SD 613.7 6 217.9 637.3 6 253.1 .61 Median 594 604.5 — Q1, Q3 458, 713 438, 758 — Platelet, 3 109 per L Mean 6 SD 381.7 6 139.5 362.6 6 140.9 .26 Median 375.5 346.5 — Q1, Q3 284, 471 272.5, 444.5 — APRi Mean 6 SD 1.98 6 2.25 2.64 6 2.83 .08 Median 1.34 1.76 — Q1, Q3 0.90, 2.01 0.94, 3.17 — Inflammation stage, n (%) A1 0 3 (6.82) ,.001 A2 43 (25) 18 (40.91) A3 129 (75) 23 (52.27) Fibrosis stage, n (%) S0 0 1 (2.27) ,.001 S1 0 21 (47.73) S2 77 (44.77) 14 (31.82) S3 75 (43.60) 7 (15.91) S4 20 (11.63) 1 (2.27) —, not applicable. a P between the BA and non-BA groups. x2 test were applied to sex and inflammation and fibrosis stages of liver biopsy, and the rest were tested by using a Mann-Whitney U test. patients with BA and 44 Serum MMP-7 Concentration From 4.40 ng/mL (IQR: 2.73–6.56) for the patients without BA were obtained, Each Group non-BA group (P , .001). The non-BA both showing significant The median serum MMP-7 levels group was further divided into 2 differences between these 2 were 38.89 ng/mL (IQR: groups, 1 with diagnostic surgery and groups (P , .001). 22.96–56.46) for the BA group and the other without surgery. The

Downloaded from www.aappublications.org/news by guest on September 24, 2021 4 JIANG et al median serum MMP-7 levels were MMP-7 was 10.37 ng/mL, with MMP-7 combined with GGT (Table 2, 4.94 ng/mL (IQR: 2.52–7.58) for the a sensitivity, specificity, PPV, and NPV Fig 1). group with diagnostic surgery and of 95.19%, 93.07%, 97.27%, and Furthermore, we also analyzed the 4.25 ng/mL (IQR: 3.07–6.07) for the 91.43%, respectively. When MMP-7 diagnostic value of MMP-7 in nonsurgery group, which showed no was combined with GGT, the AUC subgroups of patients with relatively statistical significance (P = .57; Fig 1). value was 0.9880, with sensitivity, low GGT (,300 IU/L) and at ages Furthermore, the serum MMP-7 specificity, PPV, and NPV values of between 30 and 60 days. Both concentrations were also calculated 95.70%, 98.02%, 98.90%, and showed good performance in for each different diagnosis diagnosing BA (Supplemental Fig 5). (Supplemental Fig 4, Supplemental 95.52%, respectively. However, there fi Tables 4 and 5). were no signi cant differences when compared with MMP-7 alone (P = Correlation of MMP-7 With Multiple Clinical Characteristics fi Diagnostic Value of MMP-7 for BA .08). The results of DCA con rmed and supported the use of MMP-7 in Correlation analysis was The AUC was found to have a value of performed on MMP-7 with the prediction of BA because the 0.9829 (95% confidence interval [CI]: multiple clinical characteristics, 0.9702–0.9957) for MMP-7 alone, ranges of the threshold probabilities including age and laboratory which was greater than the AUC value were wide and practical with a net parameters in the entire cohort of 0.8723 (95% CI: 0.8296–0.9149) benefitof.50%, which is stable and as well as in the BA and non-BA for GGT alone. The cutoff value for better than GGT alone but close to groups separately. A moderate

FIGURE 1 Serum MMP-7 concentration in the BA and non-BA groups and diagnostic accuracy for MMP-7 alone, GGT alone, and MMP-7 combined with GGT. A, Boxes and whiskers represent the median and IQR. A Mann-Whitney U test was applied. B, ROC plots. The AUC value is 0.9829, 0.8723, 0.9880 for each. C, DCA showing wide and practical ranges of threshold probabilities for MMP-7 with a stable net benefit of 50% or more, which is much better than for GGT alone. NS, no significance. a P , .0001.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 144, number 5, November 2019 5 TABLE 2 Diagnostic Accuracy of MMP-7, GGT, and MMP-7 with GGT Cutoff AUC 95% CI Sensitivity, Specificity, PPV, % NPV, % Value % % MMP-7, ng/mL 10.32 0.9829 0.9700–0.9957 95.19 93.07 97.27 91.43 GGT, IU/L 185 0.8723 0.8296–0.9149 86.02 73.27 85.63 76.36 MMP-7 and — 0.9880 0.9779–0.9981 95.70 98.02 98.90 95.52 GGT —, not applicable.

correlation with GGT level was between BA and other causes of non- the following. First, Serum MMP-7 observed in all 3 groups, whereas BA cholestasis. Furthermore, current concentration was significantly age was found to correlate in the BA diagnostic methods can be costly, higher in the BA group, when group alone (Supplemental time consuming, and highly invasive. compared with the non-BA group, Fig 6). Matrix metalloproteinases (MMP) and either with or without diagnostic their endogenous inhibitors have surgery. Second, the AUC of MMP- Correlation of MMP-7 With been found to be involved in the 7 was greater than that of GGT Inflammation Grade and Fibrosis activation of hepatic stellate cells and alone, and the DCA further validated Stage in Liver Biopsies increase extracellular matrix, both of its clinical benefit; when MMP-7 A total of 216 liver biopsy results which are associated with the and GGT were combined, there was were obtained, including from 172 fibrogenic mechanism of BA. This has no significant improvement in patients with BA and 44 patients been found based on reports looking their discriminatory ability. without BA. Serum MMP-7 at MMP expression in liver specimens The performance remained concentration was also analyzed with at different time points in patients good in a subgroup of patients with the inflammation grades and fibrosis with BA, 1 during the Kasai procedure low GGT (,300 IU/L) and between stages from liver biopsy (summarized and the other from liver ages 30 and 60 days. Third, Serum in Table 3). A significant correlation transplant.24,25 Among all MMPs, MMP-7 levels were correlated with was found with the fibrosis stage by MMP-7 is the most consistent marker, GGT in both groups, whereas it was using the Pearson correlation as observed in several studies using only correlated with age in the BA coefficient test (R = 0.47; P , .001), animal models of BA.30–32 Moreover, group. Fourth, the serum MMP-7 level whereas no significant differences recent diagnostic tests have further was also correlated to the fibrosis were seen with different confirmed its diagnostic accuracy as stage using liver biopsy, whereas no inflammation grades (R = 0.12; a biomarker for BA.27,28 However, significance was found within P = .07; Fig 2). a cutoff value has not been agreed on different grades of inflammation. at present. The above findings have confirmed DISCUSSION In our study, conducted at a promising diagnostic accuracy for It is currently challenging to the largest liver center for pediatric serum MMP-7 as a biomarker for BA accurately diagnose BA on the basis patients in China, we aimed to and suggest it is superior to GGT, of existing diagnostic approaches validate the diagnostic accuracy which is currently widely used in because of overlapping similarities of serum MMP-7 levels. We found clinical diagnosis. However, compared

TABLE 3 Correlation of MMP-7 Concentration and Liver Biopsy Mean 6 SD Median Q1, Q3 P Inflammation stages (n) A1 (3) 3.18 6 1.71 2.38 2.01, 5.14 .07 A2 (61) 33.01 6 32.37 25.71 7.04, 50.66 A3 (152) 38.20 6 29.52 35.28 16.63, 52.74 Fibrosis stages (n) S0 (1) — 2.38 — ,.001 S1 (21) 3.98 6 2.19 3.80 2.44, 5.59 S2 (91) 31.21 6 27.08 23.44 10.47, 45.86 S3 (82) 43.52 6 27.35 39.66 24.18, 53.91 S4 (21) 63.59 6 36.67 48.42 37.29, 82.21 For P, a Pearson correlation coefficient test was applied. —, not applicable.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 6 JIANG et al FIGURE 2 Correlation of MMP-7 and inflammation grade and fibrosis stage of liver biopsy. Boxes and whiskers represent the median and IQR. A, No significance in MMP-7 and inflammation grade (R = 0.12; P = 0.07). B, MMP-7 was well correlated to fibrosis stage (R = 0.47; P , .001). A1–3 and F0–4 refer to the grades of inflammation and stages of fibrosis according to the Metavir scale system.

with a previous study from the a project measuring fresh and frozen between MMP-7 and liver fibrosis Bezerra group,26 the median serum serum samples, and also different after the Kasai procedure.24,25,33 MMP-7 level and cutoff values were dilution algorithms, in the hope This study confirmed a correlation lower in our patients, although the of further standardizing MMP-7 between MMP-7 levels and liver same kit and protocol were used.26,27 measurement. fibrosis in the early stages of However, in opposition to this is Moreover, as in the previous BA, indicating its potential use 28 a study from the Wu group using study, we have also found that as a noninvasive biomarker for fi a different kit (enzyme-linked serum MMP-7 levels were evaluating liver brosis before immunosorbent assay; DuoSet, R&D positively correlated to GGT in the Kasai procedure or liver Systems, Inc, Minneapolis, MN). These all patients, with a slightly biopsy, therefore aiding the direction discrepancies may be due to improved diagnostic accuracy but of treatment of individuals in the differences in the sample collection or no significant difference seen future. Furthermore, it may dilution algorithm. The serum when using MMP-7 combined with also be used as a noninvasive fi samples were separated in our GGT. MMP-7 correlated with age measurement of liver brosis biochemistry department, as only in the BA group, just as during follow-up after the described in our protocol, reported previously. The Kasai procedure, and stored at 280°C before reason for this may be that serving as a prognostic measurement. The period the process of liver fibrosis is biomarker for BA. between sample collection and much quicker with age in patients However, our study has measurement ranged from with BA. In addition to the some limitations remaining. several days to several months, previous study, most patients Firstly, this study was conducted which may interfere with enrolled in the current study in a single center, although the concentration levels because underwent liver biopsy, and the sample size was large. The of degradation. The serum specimens were scored by the same application of a new biomarker samples from the Wu study28 were pathologist for both inflammation requires samples from those stored for up to 10 years, which and fibrosis stage. The Pearson of different races and regions to may explain the low concentration correlation coefficient test confirm efficacy for the majority of values seen. The sera from patients showed that serum MMP-7 levels the population. A prospective with and without BA were diluted were well correlated to the study will provide stronger evidence by either 16 times or 4 times, as fibrosis stage. This was paralleled for determining the diagnostic recommended by the protocol, with the correlation between accuracy of a new biomarker. and none were found to exceed the MMP-7 and age in the BA group. So However, the blood samples for measurement range. Furthermore, far, most of the previous studies the enrolled patients were we are currently working on have focused on the correlation collected and measured together

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 144, number 5, November 2019 7 in batches to maximize the use 30 and 60 days of age further ABBREVIATIONS of the kits. However, the person confirmed its value for the conducting the measurement of early diagnosis of BA. ALP: alkaline phosphatase MMP-7 concentration was ALT: alanine aminotransferase blinded to diagnosis to avoid APRi: aspartate aminotransferase/ investigator bias and simulate CONCLUSIONS platelet ratioindex a prospective study design. Secondly, AST: aspartate aminotransferase The use of MMP-7 as the BA and non-BA groups in our AUC: area under thecurve a marker to differentiate study were not age matched BA: biliary atresia BA from non-BA holds great because many of the patients CI: confidence interval promise. However, the protocol without BA showed low possibility CMV: cytomegalovirus used to obtain and measure the of BA and were always referred DB: direct bilirubin blood samples requires further to their local hospitals first and DCA: decision curve analysis standardization before clinical had been followed up as neonatal GGT: g glutamyl transferase application. The mechanism by physiologic jaundice for some IQR: interquartilerange which MMP-7 is expressed in BA time before referral to us, thereby MMP: matrix metalloproteinase pathogenesis and liver fibrosis delaying the time of the first visit MMP-7: matrix deserves further study to to our hospital. However, because metalloproteinase-7 determine its value as age has no significant correlation NPV: negative predictivevalue a therapeutic target and/ with serum MMP-7 levels in PPV: positive predictivevalue or prognostic biomarker. non-BA group, according to our Q1: quartile 1 results and also those of previous Q3: quartile 3 studies, the discriminatory ROC: receiver operating ability of MMP-7 between BA ACKNOWLEDGMENT characteristic and non-BA was still valid in this We sincerely thank Dr Lian Chen for TB: total bilirubin study. Furthermore, our subgroup her guidance in histology TBA: total bileacid analysis in patients between examinations.

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2019 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Received financial support from Shanghai Key Disciplines (2017ZZ02022), National Natural Science Foundation of China (81770519, 81771633, and 81873545), Shanghai Hospital Development Center (SHDC12018X22), the Science Foundation of Shanghai Excellent Youth Scholars (2017YQ042), The Science Foundation of Shanghai (17411960600, 14411969800, 16411952200, and 18411969100), and Children’s National Medical Center (EK1125180104, EKYY20180204, EK112520180301, and EK112520180301). POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES 1. Hopkins PC, Yazigi N, Nylund CM. 5. Asai A, Miethke A, Bezerra JA. pathogenesis of biliary atresia. Pediatr Incidence of biliary atresia and timing Pathogenesis of biliary atresia: defining Surg Int. 2017;33(12):1233–1241 of hepatoportoenterostomy in the biology to understand clinical 9. Feldman AG, Mack CL. Biliary atresia: United States. J Pediatr. 2017;187: phenotypes. Nat Rev Gastroenterol clinical lessons learned. J Pediatr 253–257 Hepatol. 2015;12(6):342–352 Gastroenterol Nutr. 2015;61(2):167–175 2. Lee KJ, Kim JW, Moon JS, Ko JS. 6. Davenport M. Biliary atresia: from 10. Lopez RN, Ooi CY, Krishnan U. Early and Epidemiology of biliary atresia in Korea. Australia to the zebrafish. J Pediatr peri-operative prognostic indicators in J Korean Med Sci. 2017;32(4):656–660 Surg. 2016;51(2):200–205 infants undergoing hepatic 3. Davenport M. Biliary atresia: clinical 7. Hartley JL, Davenport M, Kelly DA. portoenterostomy for biliary atresia: aspects. Semin Pediatr Surg. 2012; Biliary atresia. Lancet. 2009;374(9702): a review. Curr Gastroenterol Rep. 2017; 21(3):175–184 1704–1713 19(4):16 4. Alagille D. Extrahepatic biliary atresia. 8. Kilgore A, Mack CL. Update on 11. Obayashi J, Kawaguchi K, Manabe S, Hepatology. 1984;4(suppl 1):7S–10S investigations pertaining to the et al. Prognostic factors indicating

Downloaded from www.aappublications.org/news by guest on September 24, 2021 8 JIANG et al survival with native liver after Kasai 19. Kim YH, Kim MJ, Shin HJ, et al. MRI- MMP-7 as a sentinel of epithelial injury procedure for biliary atresia. Pediatr based decision tree model for and of biliary atresia. Sci Transl Med. Surg Int. 2017;33(10):1047–1052 diagnosis of biliary atresia. Eur Radiol. 2017;9(417):eaan8462 – 12. Song Z, Dong R, Shen Z, et al. Surgical 2018;28(8):3422 3431 27. Yang L, Zhou Y, Xu PP, et al. Diagnostic outcome and etiologic heterogeneity of 20. Mandelia A, Lal R, Mutt N. Role of accuracy of serum matrix infants with biliary atresia who hepatobiliary scintigraphy and metalloproteinase-7 for biliary atresia. received Kasai operation less than preoperative liver biopsy for exclusion Hepatology. 2018;68(6):2069–2077 60 days after birth: a retrospective of biliary atresia in neonatal 28. Wu JF, Jeng YM, Chen HL, et al. study. Medicine (Baltimore). 2017; cholestasis syndrome. Indian J Pediatr. Quantification of serum matrix – 96(26):e7267 2017;84(9):685 690 metallopeptide 7 levels may assist in 13. Tyraskis A, Davenport M. Steroids after 21. Yoon HM, Suh CH, Kim JR, et al. the diagnosis and predict the outcome the Kasai procedure for biliary atresia: Diagnostic performance of sonographic for patients with biliary atresia. the effect of age at Kasai features in patients with biliary atresia: J Pediatr. 2019;208:30–37.e1 portoenterostomy. Pediatr Surg Int. a systematic review and meta-analysis. 29. Goodman ZD. Grading and staging – 2016;32(3):193 200 J Ultrasound Med. 2017;36(10): systems for inflammation and fibrosis – 14. Sun S, Chen G, Zheng S, et al. Analysis of 2027 2038 in chronic liver diseases. J Hepatol. clinical parameters that contribute to 22. Zhou L, Shan Q, Tian W, et al. Ultrasound 2007;47(4):598–607 the misdiagnosis of biliary atresia. for the diagnosis of biliary atresia: 30. Iordanskaia T, Malesevic M, Fischer G, – J Pediatr Surg. 2013;48(7):1490 1494 a meta-analysis. AJR Am J Roentgenol. et al. Targeting extracellular – 15. Chen X, Dong R, Shen Z, Yan W, Zheng S. 2016;206(5):W73 W82 cyclophilins ameliorates disease Value of gamma-glutamyl 23. Zhou LY, Jiang H, Shan QY, et al. Liver progression in experimental biliary transpeptidase for diagnosis of biliary stiffness measurements with atresia. Mol Med. 2015;21(1):657–664 atresia by correlation with age. supersonic shear wave elastography in 31. Nadler EP, Li X, Onyedika E, Greco MA. J Pediatr Gastroenterol Nutr. 2016; the diagnosis of biliary atresia: Differential expression of hepatic – 63(3):370 373 a comparative study with grey-scale US. fibrosis mediators in sick and – 16. Tang KS, Huang LT, Huang YH, et al. Eur Radiol. 2017;27(8):3474 3484 spontaneously recovered mice with Gamma-glutamyl transferase in the 24. Hsieh CS, Chuang JH, Huang CC, et al. experimental biliary atresia. J Surg diagnosis of biliary atresia. Acta Evaluation of matrix metalloproteinases Res. 2010;159(2):611–617 – Paediatr Taiwan. 2007;48(4):196 200 and their endogenous tissue inhibitors 32. Nadler EP, Patterson D, Violette S, et al. 17. Dong R, Jiang J, Zhang S, et al. in biliary atresia-associated liver Integrin alphavbeta6 and mediators of fi Development and validation of novel brosis. J Pediatr Surg. 2005;40(10): extracellular matrix deposition are up- – diagnostic models for biliary atresia in 1568 1573 regulated in experimental biliary a large cohort of Chinese patients. 25. Huang CC, Chuang JH, Chou MH, et al. atresia. J Surg Res. 2009;154(1):21–29 – EBioMedicine. 2018;34:223 230 Matrilysin (MMP-7) is a major matrix 33. Kerola A, Lampela H, Lohi J, et al. 18. He JP, Hao Y, Wang XL, et al. Comparison metalloproteinase upregulated in Increased MMP-7 expression in biliary fi of different noninvasive diagnostic biliary atresia-associated liver brosis. epithelium and serum underpins native – methods for biliary atresia: a meta- Mod Pathol. 2005;18(7):941 950 liver fibrosis after successful analysis. World J Pediatr. 2016;12(1): 26. Lertudomphonwanit C, Mourya R, Fei L, portoenterostomy in biliary atresia. 35–43 et al. Large-scale proteomics identifies J Pathol Clin Res. 2016;2(3):187–198

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 144, number 5, November 2019 9 Serum MMP-7 in the Diagnosis of Biliary Atresia Jingying Jiang, Junfeng Wang, Zhen Shen, Xuexin Lu, Gong Chen, Yanlei Huang, Rui Dong and Shan Zheng Pediatrics originally published online October 11, 2019;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2019/10/09/peds.2 019-0902 References This article cites 33 articles, 1 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2019/10/09/peds.2 019-0902#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Gastroenterology http://www.aappublications.org/cgi/collection/gastroenterology_sub Hepatology http://www.aappublications.org/cgi/collection/hepatology_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 24, 2021 Serum MMP-7 in the Diagnosis of Biliary Atresia Jingying Jiang, Junfeng Wang, Zhen Shen, Xuexin Lu, Gong Chen, Yanlei Huang, Rui Dong and Shan Zheng Pediatrics originally published online October 11, 2019;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2019/10/09/peds.2019-0902

Data Supplement at: http://pediatrics.aappublications.org/content/suppl/2019/10/09/peds.2019-0902.DCSupplemental

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on September 24, 2021