Introduction and objectives:The rising prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) in Chinese children necessitates non-invasive fibrosis assessment. However, there is a paucity of pediatric-specific diagnostic tools. The objective of this study was to evaluate the performance of seven established non-invasive indices for staging liver fibrosis in Chinese children with biopsy-proven MASLD. Materials and methods:A cross-sectional analysis was conducted in children with MASLD. Liver fibrosis staging (F0-F4) was determined via histological assessment. The diagnostic performance of seven non-invasive indices (APRI, FIB-4, PNFI, TyG, AAR, API, NFS) was evaluated using Spearman correlation analysis and area under the receiver operating characteristic curve (AUROC) analysis. Results:A total of 110 children were included in the study, among whom significant fibrosis (F ≥ 2) was present in 36.3% (40/110), including 12.7% with F3 and 2.7% with cirrhosis (F4). When analyzing the correlations between indices and fibrosis stages, only modest positive correlations were observed for APRI (r = 0.32), FIB-4 (r = 0.23), PNFI (r = 0.24) and TyG (r = 0.24) (all P < 0.05), while AAR, API and NFS had no significant correlations (all P > 0.05). All indices exhibited poor diagnostic accuracy, with AUROCs ranging from 0.49 to 0.69 across all fibrosis stages. Specifically, APRI, FIB-4 and TyG showed analogous AUROCs (0.60-0.69) for diagnosing any (F ≥ 1), significant (F ≥ 2) and severe (F ≥ 3) fibrosis. Conversely, AAR, API and NFS demonstrated even poorer performance, with AUROCs ranging from 0.49 to 0.60. Conclusion:The non-invasive fibrosis indices that have been validated demonstrated poor diagnostic accuracy and unreliable performance in Chinese children with MASLD. This diagnostic gap emphasizes the urgent need for the development of pediatric-specific diagnostic algorithms tailored for MASLD-related liver fibrosis.

BACKGROUND:The impacts of sex on treatment response in paediatric patients with chronic hepatitis B virus (HBV) infection remains incompletely understood. We aimed to analyse sex differences in antiviral treatment response in children with HBV infection. METHODS:We performed a retrospective cohort study on 236 treatment-naive children with chronic HBV infection at the Liver Disease Centre of Hunan Children's Hospital. The Cox proportional hazard regression was used to estimated treatment outcome differences between males and females. RESULTS:Of the 236 subjects, the median age at treatment initiation was 4 (2,7) years, and 155 (65.68%) were male. After the median follow-up (IQR) of 27 (18, 43) months, the crude cumulative incidence of HBsAg loss, HBeAg clearance and HBV DNA undetectability in patients were 48.73%, 61.02% and 89.36%, respectively. Kaplan-Meier curve showed that female patients were more likely to achieving HBsAg loss compared to male patients (58.02% vs. 43.87%, Plog-rank=0.001). After adjustment for other covariates, female sex was significantly associated with the higher possibility of HBsAg loss (female vs. male: Adjusted HR: 2.03, 95% CI: 1.35-3.06) in children with chronic HBV infection. Furthermore, the landmark analysis revealed that the relationship between sex and HBsAg loss became more pronounced beyond the first year (female vs. male: adjusted HR (95%CI): 2.18(1.29-3.69)). CONCLUSION:Children with chronic HBV infection receiving antiviral treatment are frequently observed to achieve functional cure. Sex plays an important role in treatment response among paediatric patients, with female patients exhibiting a higher likelihood of achieving HBsAg loss, particularly after one- year of follow-up.

Background Paediatric Metabolic dysfunction-associated steatotic liver disease (MASLD) is a metabolic disorder resulting from chronic hepatic steatosis. Ganoderma lucidum polysaccharide (GLP) have several pharmacological effects. However, comprehensive investigations into the mechanistic basis of GLP's therapeutic effects in paediatric MASLD remained limited. This study investigates the underlying mechanisms of GLP in the treatment of pediatric MASLD through an integrated approach combining network pharmacology and Animal experiment. Methods To investigate the underlying mechanisms of Ganoderma lucidum polysaccharide (GLP) in the treatment of pediatric MASLD through an integrated approach combining network pharmacology and animal experiment. Differentially expressed genes (DEGs) in the GSE185051 dataset and GLP-targeted genes were overlapped to identify candidate genes. Intersecting genes from nine Cytohubba algorithms were identified as key genes. GGI network analysis, gene set enrichment analysis (GSEA), and gene set variation analysis (GSVA) demonstrated pathways influencing paediatric MASLD. Transcription factor (TF) regulation analysis of the key genes was performed, and a molecular regulatory network. Molecular docking was performed for GLP components and key genes. Animal experiments were performed to further substantiate the outcomes. Results Five key genes (ADRA2A, HTR2A, FGF2, MMP2, and TLR4) were selected as key genes through nine algorithms. Pentose and glucuronate interconversion and propanoate metabolism were significantly upregulated in paediatric MASLD patients. The Creb and Atf TF families play crucial roles in regulating key genes. The predicted lncRNA‒miRNA–key gene regulatory network contains 19 miRNAs (such as hsa-mir-15b-5p) and 39 lncRNAs (such as MALAT1). The binding energy of HTR2A to the GLP component β-glucan was − 6.0 kJ/mol, suggesting a favourable binding effect. Animal experiment result showed that GLP treatment could significantly reduce the levels of TG, TC, ALT and AST, alleviate hepatic lipid deposition and reduce pathological injury in MASLD mice. Western blot and QPCR results showed that the above beneficial effects could be achieved by regulating protein and the mRNA expression levels of ADRA2A, FGF2, MMP2, and TLR4 in the liver. Conclusions The study identified four key genes (ADRA2A, FGF2, MMP2, TLR4) play a role in GLP treatment of paediatric MASLD through the application of network pharmacology and Animal experiment. A perspective strategy is provided to offer the scientific foundations and healing mechanism of GLP for paediatric MASLD treatment.

OBJECTIVE:To explore the clinical characteristics and genetic cause of a child with gastrointestinal hemorrhage and Cerebroretinal microangiopathy with calcifications and cysts (CRMCC) and to review the literature. METHODS:Clinical data of a child with gastrointestinal hemorrhage with CRMCC admitted to the Hepatology Department of Hunan Children's Hospital in September 2019 were collected, and peripheral blood DNA of the child and his parents were analyzed by whole exome sequencing. Candidate variants were validated by Sanger sequencing, followed by bioinformatics analysis, American College of Medical Genetics and Genomics (ACMG) Standards and Guidelines for the Interpretation of Sequence Variants pathogenicity classification, and protein structure prediction. A literature search with "Coats Plus syndrome" or "Cerebroretinal microangiopathy with calcifications and cysts" as keywords was conducted at PubMed, China National Knowledge Infrastructure and Wanfang databases to include recently published studies (up to December 2023). This study has been approved by the Ethics Committee of Hunan Children's Hospital (Ethics No. KY2020-07). Informed consent for clinical research was obtained from the guardian of the child. RESULTS:The proband was a 10-year-10-month-old boy. The clinical manifestations were intrauterine and postnatal growth retardation, gastrointestinal hemorrhage, liver fibrosis, panhemopenia, bilateral exudative retinopathy, intracranial lesions and facial pigmentation. WES and Sanger sequencing revealed two novel heterozygous variants in the CTC1 gene: c.787G>A (p.Val263Met) in exon 5 and c.2930C>G (p.Ser977Cys) in exon 17, which were inherited from his mother and father, respectively. According to ACMG pathogenicity classification, both missense variants were classified as variants of uncertain significance (VUS). Protein structure prediction showed the absence of LIG_SH3_3 motif and LIG_SH3_3 motif, and the p.Ser977Cys mutation may affect the binding between CST (CTC1-STN1-TEN) complex and DNA strand. The child had continued to experience recurrent gastrointestinal bleeding episodes despite propranolol treatment, but the condition was controlled after liver transplantation. According to the predefined literature search strategy of this study, a total of 10 relevant articles on pediatric CRMCC patients were retrieved, involving 11 children with gastrointestinal bleeding. Pharmacological and endoscopic therapies play a certain role in the management of CRMCC children complicated with gastrointestinal bleeding. CONCLUSION:The CTC1 gene c.787G>A and c.2930C>G variants probably underlay CRMCC in this child. This study has broadened the variation spectrum of CTC1-related diseases and provided a basis for genetic counseling. Liver transplantation may be an important treatment for gastrointestinal hemorrhage in children who do not respond well to medication and endoscopic therapy.

OBJECTIVES:The coexistence of hepatitis B e antigen (HBeAg) and hepatitis B e antibody (HBeAb) during antiviral therapy is considered atypical in patients with chronic hepatitis B (CHB), and its clinical implications remain inadequately understood, particularly in pediatric patients. This study aimed to investigate the clinical characteristics of this coexistence pattern and its impact on the outcomes of combined antiviral therapy in children with CHB. METHODS:A total of 254 treatment-naïve children diagnosed with HBeAg-positive CHB were retrospectively enrolled. All patients received combination therapy with entecavir and interferon-alpha/pegylated-interferon-alpha. Participants were categorized into a coexistence group and a control group based on whether HBeAg and HBeAb coexisted during treatment period. Clinical characteristics and treatment outcomes were compared, and Cox regression analysis was used to evaluate factors influencing the coexistence pattern and its association with antiviral responses. RESULTS:The incidence of HBeAg and HBeAb coexistence during antiviral therapy was 35.43% (90/254). This pattern was associated with the higher HBV DNA levels (hazard ratio [HR] = 1.25, p = 0.009) at baseline. Notably, children in the coexistence group demonstrated a greater likelihood of achieving HBsAg loss (HR = 2.58, p < 0.001), HBeAg loss (HR = 2.23, p < 0.001) and HBV-DNA undetectability (HR = 1.42, p = 0.034). CONCLUSIONS:The HBeAg/HBeAb coexistence pattern is relatively common during antiviral therapy in children and is associated with significantly improved treatment outcomes. These findings highlight the importance of monitoring HBeAg/HBeAb dynamics and continuing treatment during this critical phase.

Pathogenic HSD17B10 gene variants cause HSD10 mitochondrial disease (HSD10 MD), which results in a wide spectrum of symptoms ranging from mild to severe. Typical symptoms include intellectual disability, choreoathetosis, cardiomyopathy, neurodegeneration, and abnormal behavior. This study investigated a novel c.59 C > T variant of the HSD17B10 gene and the clinical phenotypic features of HSD10 MD (neonatal form) patients. We describe a Chinese boy 2 months and 12 days old with intellectual disability, metabolic acidosis, hyperlactatemia, hypoglycemia, cholestatic hepatitis and myocardial enzyme levels, slightly elevated 2-methyl-3-hydroxybutyric acid (2M3HBA) levels and early death. Although full-length sequencing of the mitochondrial genome was normal, whole-exome sequencing of the proband and his parents revealed a novel de novo hemizygous variant, c.59 C > T (p.S20L), of the HSD17B10 gene. Molecular dynamics simulation analysis and protein structural analysis suggested that the c.59 C > T (p.S20L) variant may disrupt the conformational stability of the protein. On the basis of the combined results of phenotypic analysis, molecular genetic analysis, protein structural analysis and molecular dynamics simulation analysis, this novel variant is currently considered a likely pathogenic variant. HSD10 MD (neonatal form) can lead to hepatic dysfunction. HSD10 MD (neonatal form) can lead to hepatic dysfunction. The de novo c.59 C > T HSD17B10 variant suggested a neonatal form of the HSD10 mitochondrial disease phenotype in a patient 2 months and 12 days old, broadening the variant spectrum of HSD17B10-related disease.

In children with chronic hepatitis B(CHB), HBsAg loss is a critical indicator of functional cure. However, little is known about the correlation between the kinetics of HBcrAg and HBsAg loss in the pediatric population. The aim of this study was to investigate whether the HBcrAg change in children CHB patients receiving antiviral therapy is associated with the occurrence of HBsAg loss. A prospective cohort study was conducted on 86 pediatric patients with treatment-naive CHB. The speed of HBcrAg change was calculated during the treatment period, and the patients were divided into two groups (rapid decline, slow decline) according to the median speed (0.0221 log10 U/mL/week). The primary outcome is the serological HBsAg loss in CHB children after antiviral therapy. In 86 participants, 26 (30.2%) achieved HBsAg loss at the end of follow-up. Baseline HBsAg levels (HR = 0.36, 95% CI: 0.19-0.68) and the speed of HBcrAg decline during treatment (HR = 1.30, 95% CI: 1.10-1.40) were found to be independent predictors of the occurrence of HBsAg loss. The Kaplan-Meier curve showed that the cumulative incidence of HBsAg loss in the rapid decline group was significantly higher than that in the slow decline group. Also, receiver operating characteristic curve showed that the speed of HBcrAg decline could effectively predict the occurrence of HBsAg loss (AUC: 0.735, p < 0.001). Moreover, when combining the baseline HBsAg levels for prediction, the AUC increased to 78.4%. The speed of HBcrAg decline during antiviral therapy was significantly associated with HBsAg loss in pediatric CHB patients.

BACKGROUND:Neonatal Intrahepatic Cholestasis (NICCD), as the early-age stage of Citrin deficiency involving liver dysfunction, lacks efficient diagnostic markers. Procalcitonin (PCT) has been identified as a biomarker for infection as well as various organ damage. This study aimed to explore the potential of PCT as a biomarker for NICCD.METHODS:In a single-center retrospective case-control study. Serum PCT concentrations before and after treatment of 120 NICCD patients, as the study group, were compared to the same number of cholestatic hepatitis patients, as the control group. The potential value of PCT to discriminate NICCD from control disease was further explored using Receiver Operating Characteristic (ROC) curve analysis and compared to those of other inflammatory markers.RESULTS:There was a significantly higher level of PCT in NICCD patients than in the control group. PCT concentrations were only weakly correlated with neutrophil counts and CRP levels (p ˂ 0.05). At a cut-off value of 0.495 ng/mL, PCT exhibited a significantly higher diagnostic value compared to other inflammatory markers for discriminating NICCD from the control, with a sensitivity of 90.8 % and specificity of 98.3 %.CONCLUSION:PCT might be used as an initial biomarker to discriminate children with NICCD from another hepatitis disease.

Introduction:Biliary atresia (BA) is an obliterating fibrous inflammatory bile duct disease in infants. Interleukin 17A (IL-17A) is abnormally expressed in patients with BA; however, the mechanism of its expression is unclear. Material and methods:Liver tissues from patients with BA and those with anicteric choledochal cysts (non-BA) were collected. The expression of genes and proteins was determined using RT-qPCR and western blot. Cell biological activities, including viability and proliferation, were evaluated by Cell Counting Kit-8 (CCK-8) and 5-ethynyl-2 '-deoxyuridine (EdU) assay. Glucose uptake and lactate and ATP levels were examined using commercial kits. The extracellular acidification rate (ECAR) level was evaluated by the XF96 Extracellular Flux analyzer. The interactions among TRAF2, TRAF5, and human antigen R (HuR) were validated using co-immunoprecipitation (Co-IP), RNA immunoprecipitation (RIP), and RNA pull-down. Results:In BA patients, IL-17A, TRAF2, TRAF5, and PFKFB3 were highly expressed, and IL-17A expression was positively correlated with PFKFB3, TRAF2, and TRAF5 expression, respectively. IL-17A elevated PFKFB3 expression and promoted glycolysis and the proliferation and fibrosis of hepatic stellate cells (HSCs), which were abolished by 2-deoxy-D-glucose (2-DG) and PFKFB3/TRAF2/TRAF5 silencing. Mechanistically, IL-17A promoted the interactions among HuR, TRAF2 and TRAF5 to form the TRAF2/TRAF5/HuR complex, thereby enhancing PFKFB3 expression. Conclusions:IL-17A facilitates glycolysis and HSC fibrosis by promoting TRAF2/TRAF5/HuR complex formation to regulate PFKFB3 expression.

This study aimed to assess the predictive capacity of emerging serological markers, serum HBV RNA and HBcrAg, for HBeAg seroconversion in children with HBeAg-positive chronic hepatitis B (CHB). Treatment-naïve HBeAg-positive CHB children who admitted to the Liver Disease Center of Hunan Children's Hospital between April 2021 and September 2022 and received treatment with the combined entecavir and interferon-alpha treatment were recruited. Serum HBV RNA and HBcrAg were measured at baseline and Weeks 12, 24, and 48 of treatment. Our study showed that serum HBV RNA (HR = 0.71, 95% CI: 0.56-0.91, p = 0.006), HBcrAg (HR = 0.60, 95% CI: 0.43-0.84, p = 0.003), and HBsAg (HR = 0.49, 95%CI: 0.36-0.69, p < 0.001) at Week 12 were independent predictors of HBeAg seroconversion. ROC curve analysis presented that serum HBV RNA decline value (ΔHBV RNA) at Week 36 and HBcrAg decline value (ΔHBcrAg) at Week 12 (AUC = 0.871, p = 0.003 and AUC = 0.810, p = 0.003, respectively) could effectively predict HBeAg seroconversion. Furthermore, the optimal critical values were determined and the children with ΔHBV RNA > 3.759 log10 copies/mL at Week 36 or ΔHBcrAg >0.350 log10 U/mL at Week 12 more likely to achieve HBeAg seroconversion. The serum HBV RNA and HBcrAg provide new insights into the treatment of CHB in children. Early assessment of serum HBV RNA and HBcrAg during treatment can assist clinical decision-making and optimize individualized therapeutic approaches.

Serological pattern of simultaneous positivity for hepatitis B surface antigen (HBsAg) and antibody against HBsAg (anti-HBs) is considered a specific and atypical phenomenon among patients with chronic hepatitis B virus (HBV) infection, especially in pediatric patients. Unfortunately, there is limited understanding of the clinical and virological characteristics among children having chronic HBV infection and the coexistence of HBsAg and anti-HBs. Hence, our objective was to determine the prevalence of coexistent HBsAg and anti-HBs and to explore the associated clinical and virological features in this patient population. The researchers conducted a retrospective cohort study on the 413 pediatric patients with chronic HBV infection from December 2011 to June 2022. The patients were stratified into two groups based on their anti-HBs status. Demographic, serum biochemical and virological parameters of two group were compared. Of the total 413 enrolled subjects, 94 (22.8%) were tested positive for both HBsAg and anti-HBs. Patients with anti-HBs were younger and demonstrated significantly higher ratio of albumin to globulin (A/G), elevated serum levels of alanine transaminase (ALT), lower ratio of aspartate transaminase (AST)/ALT (AST/ALT) and reduced serum levels of globulin, HBsAg and HBV DNA, Additionally, these patients were more likely to show coexistent HBeAg and anti-HBe when compared to patients without anti-HBs. The results of multivariate logistical analysis revealed that AST/ALT, serum levels of globulin and HBsAg were negatively associated with coexistence of HBsAg and anti-HBs. Our data demonstrated a considerable prevalence of coexisting HBsAg and anti-HBs in pediatric patients. Children with this specific serological pattern were commonly of a younger age, seemly predisposing them to early liver impairment and lower HBV replication activity.

BACKGROUND AND AIMS:Achieving HBsAg loss is a critical clinical milestone in the management of chronic hepatitis B (CHB) towards the eradication of hepatitis B. However, there are limited researches on the incidence and determinants of HBsAg loss in paediatric CHB patients undergoing antiviral treatment. Therefore, we aimed to analyse the incidence and potential determinants of HBsAg loss in children who suffered from CHB and received antiviral treatment. METHODS:This retrospective cohort study was performed on paediatric patients with progressive CHB who initiated either monotherapy or combination therapy using interferon/peg-interferon and entecavir. We utilised Cox regression models to evaluate the relationships between HBsAg loss and various determining factors. RESULTS:In total of 306 subjects with an average age of 4.99 years (range 1-15) were identified in this study, of whom 200 (65.4%) were male. After a median follow-up of 26 months, HBsAg loss occurred in 135 participants. The accumulated rate of HBsAg loss was 67.8% at the end of the follow-up evaluation. Multivariate Cox regression analysis revealed that older age (HR = 0.84, 95% CI: 0.79-0.90), female sex (HR = 1.61, 95% CI: 1.13-2.30), baseline HBsAg levels (HR = 0.72, 95% CI: 0.62-0.84), HBsAb positivity (HR = 1.77, 95% CI: 1.20-2.59) and serum bilirubin levels (HR = 0.96, 95% CI: 0.92-0.99) were statistically significant predictors of HBsAg loss. CONCLUSION:The incidence of HBsAg loss continues to increase in paediatric patients with CHB after antiviral treatment. Age, sex, baseline HBsAg and bilirubin levels and HBsAb positivity are found to be associated with sustained HBsAg loss.

OBJECTIVE:To explore the characteristics of SLCO1B1/SLCO1B3 gene variants among children with Rotor syndrome (RS).METHODS:Four children who were admitted to the Department of Hepatology of Hunan Children's Hospital between January 2019 and January 2022 were selected as the study subjects. Trio-whole exome sequencing was carried out for the four families, and gel electrophoresis was used to verify an insertional variant of long-interspersed element-1 (LINE-1).RESULTS:Genetic testing has identified three variants of the SLCO1B1 gene, including c.1738C>T (p.R580*), c.757C>T (p.R253*) and c.1622A>C (p.Q541P), and two variants of the SLCO1B3 gene, including c.481+22insLINE-1 and c.1747+1G>A among the children. Three of them were found to harbor homozygous variants of the SLCO1B1/SLCO1B3 genes, and one has harbored compound heterozygous variants. Sanger sequencing confirmed the existence of all variants, and gel electrophoresis has confirmed the existence of the LINE-1 insertional variant of about 6 kb within intron 6 of the SLCO1B3 gene in all children.CONCLUSION:The pathogenesis of the RS among the four children may be attributed to the variants of the SLCO1B1/SLCO1B3 genes. The LINE-1 insertion variant of the SLCO1B3 gene may be common among Chinese RS patients.

LINKED CONTENT This article is linked to Wu et al papers. To view these articles, visit https://doi.org/10.1111/apt.17667 and https://doi.org/10.1111/apt.17830

Objective To investigate the change in mucosal-associated invariant T（MAIT） lymphocytes in peripheral blood of children with metabolic associated fatty liver disease（MAFLD） and its clinical significance. Methods A total of 18 children with MAFLD who attended Hunan Children’s Hospital from March to May, 2022, were enrolled as MAFLD group, and 20 normal children who attended the hospital during the same period of time were enrolled as control group. Peripheral blood samples were collected, and flow cytometry was used to measure the percentages of MAIT lymphocytes（CD3 + CDl61 + TCRVα7.2 + cells）, different MAIT lymphocyte subsets（CD4 + CD8 - MAIT cells, CD4 - CD8 - MAIT lymphocytes, CD4 - CD8 + MAIT lymphocytes, and CD4 + CD8 + MAIT lymphocytes）, and MAIT lymphocytes expressing PD-1, CD69, perforin, CD107α, CXCR3, CXCR6, and CCR6. The correlation of MAIT lymphocyte frequency with liver inflammation, fat content, and fibrosis degree was analyzed. The t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups. The Spearman correlation analysis was used for correlation analysis. Results Compared with the control group, the MAFLD group had significant increases in the percentage of MAIT lymphocytes in peripheral blood, the percentages of MAIT cells expressing PD-1, CD69, CD107α, CXCR3, CXCR6 and CCR6, and the percentages of CD4 + CD8 - MAIT cells and CD4 + CD8 + MAIT lymphocytes among MAIT cell subsets（all P＜0.05）, as well as a significant reduction in the percentage of CD4 - CD8 + MAIT cells among MAIT cell subsets（P＜0.001）. The percentages of CD4 + CD8 + MAIT lymphocytes and CD107α-positive MAIT lymphocytes were negatively correlated with alanine aminotransferase（r=-0.474 and-0.550, P=0.047 and 0.018）. Conclusion The migration of peripheral blood MAIT lymphocytes to the liver plays a protective role against liver inflammation in children with MAFLD.