Aspartate aminotransferase-based risk stratification for liver injury in pediatric patients: developing a simple rule for predicting adverse outcomes.

UNLABELLED: Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are the most commonly used biomarkers for liver injury, but they are insufficient on their own as prognostic indicators. This study aims to develop a simple method that combines aminotransferases with other routinely available liver function parameters to identify pediatric patients at high risk of adverse outcomes. Medical records from 144,044 pediatric patients with ALT and AST test results were analyzed. The trend in the change of adverse outcome rates by percentiles of AST and ALT was examined to identify a sub-population potentially at risk of liver injury. Within this sub-population, a logistic regression-based prediction rule was developed using liver injury and function markers to predict adverse outcomes. Results showed that an AST level of 80 IU/L can serve as a threshold to identify pediatric patients at higher risk for adverse outcomes. The prediction rule for AST-based risk stratification for liver injury (ASTLI) was developed as follows: among patients with AST > 80 IU/L, the presence of up to two abnormalities in total protein (or albumin), lactate dehydrogenase, or international normalized ratio (or prothrombin time) can help further stratify those at high risk for adverse outcomes (training set: sensitivity = 76%, specificity = 73%; validation set: sensitivity = 76%, specificity = 79%). Age and disease subgroup analysis demonstrated potential for broad applicability across various pediatric populations.

CONCLUSION: The stratification rule could serve as a fast risk stratification tool for liver injury among pediatric patients.

WHAT IS KNOWN: • ALT and AST are the most commonly used biomarkers for liver injury. • An elevation in AST and ALT does not always necessitate specific therapeutic intervention nor does it necessarily correlate with disease severity or prognosis.

WHAT IS NEW: • A stratification rule was developed to identify pediatric patients at high risk for adverse outcomes. It incorporates AST > 80 IU/L and up to two abnormalities in total protein (or albumin), lactate dehydrogenase, or international normalized ratio (or prothrombin time).