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Original Investigation |

Use of Corticosteroids After Hepatoportoenterostomy for Bile Drainage in Infants With Biliary Atresia:  The START Randomized Clinical Trial

Jorge A. Bezerra, MD1; Cathie Spino, DSc2; John C. Magee, MD2; Benjamin L. Shneider, MD3; Philip Rosenthal, MD4; Kasper S. Wang, MD5; Jessi Erlichman, MPH6; Barbara Haber, MD6,17; Paula M. Hertel, MD7; Saul J. Karpen, MD8; Nanda Kerkar, MD9,18; Kathleen M. Loomes, MD6; Jean P. Molleston, MD10; Karen F. Murray, MD11; Rene Romero, MD8; Kathleen B. Schwarz, MD12; Ross Shepherd, MD7; Frederick J. Suchy, MD13; Yumirle P. Turmelle, MD14; Peter F. Whitington, MD15; Jeffrey Moore, MS2; Averell H. Sherker, MD, FRCP(C)16; Patricia R. Robuck, PhD, MPH16; Ronald J. Sokol, MD13 ; for the Childhood Liver Disease Research and Education Network (ChiLDREN)
[+] Author Affiliations
1Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
2University of Michigan, Ann Arbor
3Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
4UCSF Benioff Children’s Hospital, San Francisco, California
5Children’s Hospital Los Angeles and University of Southern California, Los Angeles
6Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
7Baylor College of Medicine and Texas Children’s Hospital, Houston
8Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
9Mount Sinai School of Medicine, New York, New York
10Indiana University School of Medicine and Riley Hospital for Children, Indianapolis
11Seattle Children’s Hospital, Seattle, Washington
12Johns Hopkins University School of Medicine, Baltimore, Maryland
13University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
14Washington University School of Medicine, St Louis, Missouri
15Lurie Children’s Hospital of Chicago, Chicago, Illinois
16National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
17Dr Haber is now with Merck Research Laboratories, Upper Gwynedd, Pennsylvania
18Dr Kerkar is now with Children’s Hospital Los Angeles and University of Southern California, Los Angeles
JAMA. 2014;311(17):1750-1759. doi:10.1001/jama.2014.2623.
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Importance  Biliary atresia is the most common cause of end-stage liver disease in children. Controversy exists as to whether use of steroids after hepatoportoenterostomy improves clinical outcome.

Objective  To determine whether the addition of high-dose corticosteroids after hepatoportoenterostomy is superior to surgery alone in improving biliary drainage and survival with the native liver.

Design, Setting, and Patients  The multicenter, double-blind Steroids in Biliary Atresia Randomized Trial (START) was conducted in 140 infants (mean age, 2.3 months) between September 2005 and February 2011 in the United States; follow-up ended in January 2013.

Interventions  Participants were randomized to receive intravenous methylprednisolone (4 mg/kg/d for 2 weeks) and oral prednisolone (2 mg/kg/d for 2 weeks) followed by a tapering protocol for 9 weeks (n = 70) or placebo (n = 70) initiated within 72 hours of hepatoportoenterostomy.

Main Outcomes and Measures  The primary end point (powered to detect a 25% absolute treatment difference) was the percentage of participants with a serum total bilirubin level of less than 1.5 mg/dL with his/her native liver at 6 months posthepatoportoenterostomy. Secondary outcomes included survival with native liver at 24 months of age and serious adverse events.

Results  The proportion of participants with improved bile drainage was not statistically significantly improved by steroids at 6 months posthepatoportoenterostomy (58.6% [41/70] of steroids group vs 48.6% [34/70] of placebo group; adjusted relative risk, 1.14 [95% CI, 0.83 to 1.57]; P = .43). The adjusted absolute risk difference was 8.7% (95% CI, −10.4% to 27.7%). Transplant-free survival was 58.7% in the steroids group vs 59.4% in the placebo group (adjusted hazard ratio, 1.0 [95% CI, 0.6 to 1.8]; P = .99) at 24 months of age. The percentage of participants with serious adverse events was 81.4% [57/70] of the steroids group and 80.0% [56/70] of the placebo group (P > .99); however, participants receiving steroids had an earlier time of onset of their first serious adverse event by 30 days posthepatoportoenterostomy (37.2% [95% CI, 26.9% to 50.0%] of steroids group vs 19.0% [95% CI, 11.5% to 30.4%] of placebo group; P = .008).

Conclusions and Relevance  Among infants with biliary atresia who have undergone hepatoportoenterostomy, high-dose steroid therapy following surgery did not result in statistically significant treatment differences in bile drainage at 6 months, although a small clinical benefit could not be excluded. Steroid treatment was associated with earlier onset of serious adverse events in children with biliary atresia.

Trial Registration  clinicaltrials.gov Identifier: NCT00294684

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Figure 1.
Enrollment, Randomization, and Follow-up of Participants in START Through 24 Months of Age

START indicates Steroids in Biliary Atresia Randomized Trial.aDefined as participants who did not receive at least 80% of their protocol-prescribed study medication.

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Figure 2.
Kaplan-Meier Analysis of Key Secondary End Points by Treatment Group

Vertical tick marks indicate censored observations. Participants were censored at time of earlier withdrawal from the study or at the age of 24 months.aDefined as period when total bilirubin level of less than 1.5 mg/dL achieved for the first time to the first time total bilirubin increased to 1.5 mg/dL or higher, participants underwent liver transplant, or died. Participants that never achieved good bile drainage were considered treatment failures at time 0.

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Figure 3.
Time to First Serious Adverse Event

Vertical tick marks indicate censored observations.aDefined as the time from initiation of study medication to the earliest first serious adverse event or liver transplantation, exit from the study, or last day taking study medication (censored). Serious adverse events occurred significantly earlier in participants receiving steroids compared with placebo.bDefined as the time from the end of study medication to the earliest first serious adverse event after completion of study drug or placebo (event) or liver transplantation, or exit from the study (censored).

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