Childhood Liver Disease Research Network (ChiLDReN): FibroScan™ in Pediatric Cholestatic Liver Disease (FORCE) Study Protocol
Conditions: Biliary Atresia, Alagille Syndrome, Alpha1 Anti-Trypsin Deficiency, Portal Hypertension, Liver Fibrosis, Cholestasis
Sponsor: Arbor Research Collaborative for Health

ChiLDReN: Childhood Liver Disease Research Network FORCE Protocol, v 1.3 
Date Approved: December 12, 2019 
  
 
 
 
 
 
 
 
 
Childhood Liver Disease Research Network 
(ChiLDReN) 
FibroScan™ in Pediatric Cholestatic Liver 
Disease (FORCE)  
Study Protocol 
 
Version 1.3 
 
 
Steering Committee Approval Dates 
Version 1.0: February 29, 2016 
Version 1.1:  May 10, 2016 
Version 1.2: July 10, 2018 
Version 1.3: December 12, 2019 

ChiLDReN: Childhood Liver Disease Research Network FORCE Protocol, v 1.3 
Date Approved: December 12, 2019 
 
 
 
FORCE Development Committee: 
Benjamin Shneider, Texas Children’s Hospital, Houston 
Saul Karpen, Children’s Healthcare of Atlanta, Atlanta 
Lee Bass, Ann & Robert Lurie Children’s Hospital of Chicago, Chicago 
Ronald Sokol, Children’s Hospital of Colorado, Aurora 
Daniel Leung, Texas Children’s Hospital, Houston 
Binita Kamath, The Hospital for Sick Children, Toronto, Ontario 
Jean Molleston, Riley Hospital for Children, Indianapolis 
Laurel Cavallo, Texas Children’s Hospital, Houston 
Cindy Sawyers, Riley Hospital for Children, Indianapolis 
Cathie Spino, University of Michigan, Ann Arbor 
Wen Ye, University of Michigan, Ann Arbor 
John Magee, University of Michigan, Ann Arbor 
Peg Hill-Callahan, Arbor Research Collaborative for Health

ChiLDReN: Childhood Liver Disease Research Network FORCE Protocol, v 1.3 
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Table of Contents 
 
1 
Introduction and Overview of ChiLDReN Studies ................................................................................. 5 
2 
FORCE Study Overview ......................................................................................................................... 5 
3 
Background, Study Rationale ................................................................................................................ 5 
4 
Study Objectives ................................................................................................................................... 9 
 
Primary Objective.......................................................................................................................... 9 
 
Secondary Objectives .................................................................................................................... 9 
 
Exploratory Objectives .................................................................................................................. 9 
5 
Methods .............................................................................................................................................. 10 
 
Study Schema .............................................................................................................................. 10 
 
Study Population, Participant Selection and Recruitment ......................................................... 10 
5.2.1 
Inclusion criteria: ................................................................................................................. 10 
5.2.2 
Exclusion criteria: ................................................................................................................ 11 
5.2.3 
Participant Selection ........................................................................................................... 11 
5.2.4 
Duration of enrollment ....................................................................................................... 11 
5.2.5 
Number of Participants ....................................................................................................... 11 
5.2.6 
Participant Discontinuation/Withdrawal ............................................................................ 12 
 
Schedule of Visits ........................................................................................................................ 12 
 
Data Collected ............................................................................................................................. 13 
5.4.1 
FibroScan™ measurements ................................................................................................. 13 
5.4.2 
Biosample Collection ........................................................................................................... 14 
 
Sample Size and Power Calculations ........................................................................................... 14 
 
Statistical Analysis ....................................................................................................................... 17 
5.6.1 
Primary Aim ......................................................................................................................... 17 
5.6.2 
Secondary Aims ................................................................................................................... 17 
5.6.3 
Exploratory Aims ................................................................................................................. 18 
6 
Human Subjects .................................................................................................................................. 19 
 
Protection of Human Subjects .................................................................................................... 19 
6.1.1 
Institutional Review Board .................................................................................................. 19 
6.1.2 
Patient Confidentiality ........................................................................................................ 19 
6.1.3 
Recruitment and Informed Consent/Assent ....................................................................... 20 
6.1.4 
Risks to the Patient and Adequacy of Protection Against Risk ........................................... 20 
6.1.5 
Unauthorized Data Release ................................................................................................ 21 
6.1.6 
Adverse Event Monitoring and Reporting .......................................................................... 21 
6.1.6.1 
Definition of an Adverse Event ................................................................................... 21 
6.1.6.2 
Reporting Responsibility ............................................................................................. 22 
 
Benefits to the Participant .......................................................................................................... 22 
 
Inclusion of Women .................................................................................................................... 22 
 
Inclusion of Minorities ................................................................................................................ 22 
 
Inclusion of Children ................................................................................................................... 22 
 
Data Safety and Monitoring Plan ................................................................................................ 23 

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7 
Study Organization .............................................................................................................................. 23 
 
Clinical Centers ............................................................................................................................ 23 
 
Data Coordinating Center ........................................................................................................... 23 
 
Steering Committee .................................................................................................................... 24 
8 
Study Management ............................................................................................................................. 24 
 
Data Collection, Data Collection Forms, Data Entry ................................................................... 24 
 
Data Management ...................................................................................................................... 24 
 
Quality Control and Database Management .............................................................................. 25 
 
Data Security/ Data Transfer ...................................................................................................... 25 
 
Resource Sharing Plan ................................................................................................................. 26 
9 
References .......................................................................................................................................... 27 
10 Appendices .......................................................................................................................................... 28 
 

ChiLDReN: Childhood Liver Disease Research Network FORCE Protocol, v 1.3 
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1 
Introduction and Overview of ChiLDReN Studies 
 
ChiLDReN is a National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK) sponsored 
consortium of leading clinical centers that provide care for children with various forms of cholestatic 
liver disease. The network has been in existence since 2002 and has developed advanced infrastructure 
for the conduct of clinical investigations in 8 rare pediatric liver diseases. The primary disorders under 
study by ChiLDReN are Alagille syndrome, alpha-1 antitrypsin deficiency, bile acid synthesis defects, 
biliary atresia, cystic fibrosis liver disease, idiopathic neonatal hepatitis, mitochondrial hepatopathies 
and progressive familial intrahepatic cholestasis. These cholestatic disorders collectively comprise a 
large proportion of infants and young children with chronic liver disease who develop significant 
morbidity and mortality.   
 
2 
FORCE Study Overview 
 
Noninvasive monitoring of liver fibrosis is an unmet and critical need within the clinical management of 
children with chronic liver disease. While liver biopsy is often used in the initial diagnostic evaluation of 
children with liver disease, subsequent surveillance liver biopsy is rarely performed in children because 
of its inherent invasiveness and risks. Therefore, our understanding of the natural history of fibrosis 
progression in children is limited. The patchy nature of fibrosis in many important pediatric liver 
diseases [e.g. biliary atresia (BA) and cystic fibrosis liver disease (CFLD)] limits the utility of sequential 
liver biopsy even if it were to be employed in clinical practice in pediatrics. Thus, non-invasive means of 
assessing liver fibrosis throughout the liver would be highly desirable and clinically useful in pediatric 
hepatology. ChiLDReN is poised and uniquely qualified to conduct a comprehensive longitudinal 
assessment of the utility of FibroScan™-specific elastography, liver stiffness measurement (LSM) as a 
measure of hepatic fibrosis in children with serious chronic cholestatic liver disease. 
   
3 
 Background, Study Rationale 
 
Fibrosis and severity of disease in pediatric liver disease is clinically important  
 
The progression and resolution of liver fibrosis is an intricate process involving both parenchymal and 
non-parenchymal liver cells in addition to infiltrating immune cells. Repetitive or chronic hepatocyte 
turnover is a critical step in activating inflammatory and pro-fibrogenic pathways [1]. The fibrogenic 
response, characterized by scar formation due to increased production and deposition of extracellular 
matrix proteins, has mechanical and physical consequences [2] , including increased stiffness of the liver. 
Progressive hepatic fibrosis occurs in most children with BA and in a subset of children with alpha-1 
antitrypsin deficiency (A1AT) and Alagille syndrome (ALGS). This progressive fibrosis ultimately results in 
cirrhosis, portal hypertension and well-known, significant clinical complications (including ascites, 
variceal hemorrhage, spontaneous bacterial peritonitis and end-stage liver disease) [3, 4].  In BA, fibrosis 
is prominent early in the course of disease and would be an ideal target for newly developed anti-
fibrotic pharmacotherapies. 
 
At what, if any, point fibrosis becomes irreversible is not fully understood. However, increasing evidence 
has shown that early stages of cirrhosis may be reversible independent of underlying etiology [5-8]. The 

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early detection of fibrosis and significant liver disease is challenging as clinically available serum 
chemistries to measure liver inflammation or damage can often be normal even in advanced cirrhosis 
[9]. Understanding the degree of injury and the stage and rate of progression of fibrosis in children with 
chronic liver disease is vital in the complex decision-making of initiating novel medical or surgical 
therapies and the timing of liver transplant evaluation. 
 
The current gold standard for detecting liver fibrosis is invasive 
 
Liver biopsy is generally accepted as the most sensitive and relied upon procedure to assess degree of 
liver fibrosis (F0-F4 histological staging) [10]. However, liver biopsy has risks including pain, limited 
physical activity for up to 2 weeks, hemorrhage and occasional hypotension, infection, inconvenience, 
and cost of an overnight admission or prolonged observation period, child and parental anxiety, need 
for sedation or general anesthesia, and in rare cases, mortality [11, 12]. While regarded as both a 
necessary and relatively low-risk procedure, significant complications have been reported in children 
[13-15]. It is limited by sampling error (small tissue core size, limited area of liver sampled) and inter-
observer variability in interpretation of biopsy histology. Lastly, standard scoring systems have a 
maximal reading of F4 or F6 (cirrhosis), without the ability to routinely quantify fibrosis beyond cirrhosis.  
It has been presumed, without proof, that liver biopsy would be a gold standard for any trial of an anti-
fibrotic agent. This presumption may be flawed based upon the patchy nature of fibrosis and may be 
impractical due to issues related to sequential liver biopsy in children, especially those with advanced 
disease, thrombocytopenia and/or coagulopathy. 
 
 
FibroScan™ is a non-invasive modality to detect and quantify global liver fibrosis  
 
Traditional gray scale ultrasound imaging (sonography) uses high-frequency sound waves to view soft 
tissues and organs and is an excellent imaging modality for the pediatric population, limiting the use of 
radiation. However, conventional ultrasound is limited by operator experience and technique, 
interpretation bias, poor correlation with liver histological fibrosis, and by the inability to differentiate 
between liver steatosis and fibrosis, a particularly important distinction given the childhood obesity 
epidemic [16, 17]. Further, a non-invasive imaging modality that can differentiate between mild and 
moderate fibrosis (i.e. F1/F2 vs F2/F3) has not yet been validated in pediatric liver disease.  
 
FibroScan™ (Echosens), a complementary non-invasive ultrasound tool, measures the inherent elasticity 
of the liver, which may be altered by pathologic processes such as inflammation, tumor, hepatic 
congestion, and importantly fibrosis [18, 19]. Elasticity of tissue in the context of elastography is the 
ratio of tension (stress) needed to produce a relative change in length (strain), and quantifies how much 
pressure must be placed on tissue in order to cause elastic deformation [20, 21].  FibroScan™ has the 
ability to assess small changes in pliability of liver tissue across the entire liver, thus providing a more 
global assessment of liver fibrosis than a single core of liver tissue. A noninvasive method to capture this 
information is desperately needed to advance the care of children with significant liver disease and to 
provide for measurements during clinical trials. Moreover, global assessment of fibrosis might serve as 
both a predictor/descriptor of disease course but also as a critical biomarker for clinical research. 
FibroScan™ and obtained liver stiffness measurement (LSM) have great potential to fill this void. There 
are limited large-scale cross-sectional data on the correlation of FibroScan™ LSM in children with clinical 

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status and no data on changes in FibroScan™ LSM over time in pediatric liver diseases. One of the major 
limitations is the availability of correlative liver biopsies.  
  
FibroScan™ data are available for 116 children from France, although liver biopsy histology for 
comparison was available for only 33 children [22]. Despite this limitation there was strong correlation 
of FibroScan™ LSM and fibrosis stage (AUROC 0.88 [0.68-0.95]).  A recent cross-sectional study of 31 
Chinese children with BA comparing LSM with Metavir fibrosis stage demonstrated a similar AUROC of 
0.866 for ≥ F4, further suggesting a cut-off value of 15.15 kPa for ≥ F4, with a sensitivity, specificity, 
positive predictive value and negative predictive value of 0.857, 0.917, 0.750, and 0.957, respectively 
[23].  In addition, FibroScan™ LSM in children with BA following hepatoportoenterostomy appears to 
correlate with important clinical features of portal hypertension (PHT), including splenomegaly and/or 
the presence of esophageal varices (EV) or gastric varices (GV) [24, 25]. In this study from Thailand, 73 
patients with BA (male:female=32:41; age 9.11 ± 5.64 years) were compared with 50 normal controls 
(male:female = 19:31; age 11.00 ± 3.31 years). The LSM of patients with BA was significantly higher than 
controls (27.37 ± 22.48 and 4.69 ± 1.03 kPa; p < 0.001). Patients with EV or GV also had significantly 
higher LSM than those without (37.7 + 21.6 [n = 39] vs 11.0 + 8.7 [n = 34], p<0.001). Similar findings 
were observed for children with splenomegaly relative to those without (38.9 + 22.0 [n = 39] vs 9.9 + 6.0 
[n = 34], p <0.001), [25].  As for EV/GV diagnosis, the AUC’s were 0.89 (95% CI 0.80 to 0.98) for transient 
elastography (TE) and 0.87 (95% CI 0.78 to 0.96) for Aspartate Aminotransferase (AST) to Platelet Ratio 
Index (APRI), respectively. The sensitivity (and specificity) of TE (cut-off value of 12.7 kPa) and APRI (cut-
off value of 1.92) in predicting EV/GV were 84% (77%) and 84% (83%), respectively, whereas the 
sensitivity (and specificity) of splenomegaly in predicting EV/GV were 92% (85%). Small studies in 
children with CF liver disease have also shown FibroScan™’s efficacy as a tool to detect and quantify 
severity of CFLD [26] as well as its correlation with development of EV [24].   
 
FibroScan™ technology can also now provide simultaneous determination of liver steatosis measured by 
controlled attenuation parameter (CAP) and LSM, in children of any age [27].  FibroScan™ among obese 
children predicted clinically significant fibrosis (≥ 2) well in a cohort of children with nonalcoholic fatty 
liver disease, although none of the children had cirrhosis [28].  
 
Notably, none of the aforementioned studies describe the longitudinal capture of LSM in children using 
FibroScan™, while studying its correlation with varying stages of PHT (i.e. Early PHT: splenomegaly OR 
thrombocytopenia, Late PHT: splenomegaly, thrombocytopenia, AND variceal bleed OR ascites). In 
addition, there are no published studies specifically investigating ALGS or A1AT. As such there is an 
urgent need to begin to characterize elastrography in children with these disorders.    
 
Non-invasive liver biomarkers may complement FibroScan™ in detecting, monitoring progression or 
regression of fibrosis, or in predicting clinical outcome 
The rapid progression of liver disease in some children indicates a need to identify early markers of liver 
fibrosis to help facilitate early intervention. Empirically identified markers identified by genomic, 
proteomic, and metabolomic technologies, as well as targeted serum marker analysis, offer new 
strategies with which to diagnose and predict outcomes in pediatric liver diseases [29-32]. Preliminary 
studies in children with fibrotic liver diseases have identified specific markers reflecting matrix re-
modeling, hepatic stellate cell activation, collagen turnover, and chemoattractant expression in this age 

ChiLDReN: Childhood Liver Disease Research Network FORCE Protocol, v 1.3 
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group [30-33]. These include Tissue Inhibitor of Metalloproteinase-1 (TIMP-1), Lysyl hydroxylase (LH), 
Prolyl hydroxylase (PH), hyaluronic acid (HA), and interleukin-8 (IL-8), among others. FibroScan™ LSM has 
also correlated well with APRI in 100 children with BA, particularly when using size specific probes in 
children with varying thoracic circumferences [34].   
 
The FORCE protocol includes the collection of serum and plasma at the time of FibroScan™ LSM. This 
rich resource will position the network to conduct future investigations to correlate LSM with known 
and to-be-identified serum biomarkers of fibrosis. The ability of these biomarkers to predict change in 
LSM over time will also be assessed. In addition, unbiased investigations using techniques like SomaLogic 
(Boulder, CO) may identify new biomarkers that correlate with and explain the pathophysiology of liver 
stiffness (e.g. fibrosis) in pediatric cholestatic liver disease. 
 
ChiLDReN’s unique position 
 
Biliary atresia is the leading indication for liver transplantation in children, accounting for approximately 
30% -40% of all pediatric liver transplants. Longitudinal studies that have enrolled large numbers of 
patients with BA and the aforementioned liver diseases (A1AT and ALGS) are well established and on-
going in ChiLDReN, and have successfully coupled prospectively collected clinical data with laboratory 
data and a rich biorepository of specimens. These databases are subsumed within the following 
protocols registered on ClinicalTrials.gov; PROBE = NCT 00061828, BASIC = NCT00345553 and LOGIC = 
NCT00571272.  As of November 30, 2015, 569 participants with BA have been enrolled in PROBE, 563 
pre-transplant participants with BA have been enrolled in BASIC, and 377 participants with alpha-1- 
antitrypsin deficiency (A1AT) and 314 participants with Alagille Syndrome (ALGS) have been enrolled in 
LOGIC. Baseline cross-sectional analyses of features and clinical associations of portal hypertension in BA 
and A1AT deficiency have been published by ChiLDReN [3,4]. The protocols for PROBE, BASIC, and LOGIC 
incorporate the collection of biosamples at fixed intervals using standard operating procedures, including 
liver tissue (when clinically obtained or at the time of transplant), plasma/serum, genomic DNA and 
urine. A rich bank of clinical information exists and will be continually collected and will be available for 
correlation with FibroScan™ LSM.      
 
This study will pioneer evaluating and possibly validating the role of non-invasive and radiation-free 
FibroScan™ technology to detect and quantify liver fibrosis in children with chronic liver disease, while 
also investigating the prognosticating ability of LSM, serum and simple biomarkers of fibrosis. The 
potential to offer non-invasive alternatives for assessing liver fibrosis in children may provide much 
needed insight into the natural history of pediatric liver disease.  Evaluation/correlation of these 
diagnostic tools in a multi-center setting have far-reaching implications.  
The underlying hypothesis of this proposal is that FibroScan™-based elastographic LSM in children with 
BA can differentiate those with clinical features of portal hypertension from those without. In addition, 
it is presumed that fibrosis is progressive in BA and FibroScan™ can identify that progression over a two-
year time period in children with BA. Exploratory analyses of the same concepts will be conducted in 
ALGS and A1AT, where there is a marked paucity of high quality data.     
 
 
 

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4 
Study Objectives 
 
 
Primary Objective 
 
- 
Aim 1 - To prospectively assess whether FibroScan™ LSM are associated with the clinical and 
laboratory features of portal hypertension in children with BA. 
 
Hypothesis 1: FibroScan™ LSM results can differentiate children with clinical features of 
portal hypertension from those without. 
 
 
Secondary Objectives 
 
-   Aim 2 - To prospectively measure changes in LSM over time by FibroScan™ in children 
with BA. 
 
Hypothesis 2:  FibroScan™-based LSM in children with BA will reliably reveal increases 
over 2 years of follow-up. 
 
- 
Aim 3 - To confirm the feasibility of obtaining valid FibroScan™ LSM in children with 
cholestatic liver diseases. 
 
Hypothesis 3: Valid results of FibroScan™-based LSM can be obtained in more than 80% 
of children with BA, A1AT, and ALGS. 
 
- Aim 4 - To prospectively assess whether FibroScan™ LSM are associated with conventional 
laboratory determinants of liver disease. 
 
Hypothesis 4:  FibroScan™-based LSM in children with BA, A1AT, and ALGS will correlate 
with conventional laboratory determinants of liver disease including but not limited to, 
PELD score, total bilirubin, albumin and INR that are components of the PELD score, 
platelet count, and the APRI. 
 
 
Exploratory Objectives 
 
- 
Aim 5 - To prospectively assess whether FibroScan™ LSM are associated with the clinical and 
laboratory features of portal hypertension in children with A1AT and ALGS. 
 
Hypothesis 5: FibroScan™ LSM results can differentiate children with clinical features of 
portal hypertension from those without. 
 
- 
Aim 6 - To collect a set of biosamples that correspond to the prospectively assessed 
FibroScan™ LSM and clinical data.  
 
 
 
Hypothesis 6 -  FibroScan™-based LSM will correlate with serum biomarkers of fibrosis. 

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- 
Aim 7 - To prospectively explore changes in LSM over time by FibroScan™ in children with 
A1AT and ALGS. 
 
Hypothesis 7:  FibroScan™-based assessment of LSM in children with A1AT and ALGS will 
reliably reveal increases over 2 years of follow- up. 
 
5 
Methods 
 
 
Study Schema 
 
The research protocol will encompass the prospective longitudinal analysis of FibroScan™ LSM in 
children with BA, A1AT, or ALGS. FibroScan™ Liver Stiffness Measurement’s (LSM) are non-invasive and 
painless. Eligible participants must be actively followed at participating ChiLDReN sites and be 
concurrently enrolled in PROBE, BASIC, or LOGIC. There will be three assessments: one at baseline and 
two subsequent annual follow-up visits. At each visit, comprehensive clinical data and biosamples will be 
collected according to the PROBE, BASIC, or LOGIC protocols. Clinical data in these longitudinal studies 
include but are not limited to interval clinical events, history of clinical symptoms of liver disease, 
physical examination findings, and routine laboratory and imaging studies. Liver biopsy samples, when 
clinically indicated, are also captured by these longitudinal databases. Specialized clinical information 
specifically relevant to FORCE and FibroScan LSM will also be recorded. These parameters will generally 
not overlap with the parent protocols, with the exception of spleen size assessment on physical 
examination, which will be specifically assessed for FORCE. Information relevant to the performance of 
FibroScan LSM will be collected (e.g. thoracic diameter, duration fasting prior to the study, ability of 
participant to cooperate with the LSM). In addition there will be collection of serum/plasma samples, 
available for future study of serum biomarkers as described above.  
 
 
Study Population, Participant Selection and Recruitment 
 
All children with an established diagnosis of BA (excluding those with known situs inversus or 
polysplenia/asplenia), who are actively followed at participating ChiLDReN sites and enrolled in PROBE 
or BASIC will be eligible for the trial. In addition, all children with A1AT or ALGS actively followed at one 
of these sites and enrolled in LOGIC will also be eligible. No lower limit age restrictions are incorporated 
in this protocol to afford an accurate assessment of feasibility in children of all ages. The number of 
evaluable participants to be entered in the study at all clinical sites will be 450 (250 BA, 100 A1AT, 100 
ALGS). An evaluable participant is a participant with a Baseline visit with at least 10 consecutive valid 
measurements and an IQR/median <30%. We will recruit to replace those participants who do not 
complete the initial LSM of the study. 
 
5.2.1 
Inclusion criteria: 
 
- 
Age 21 years or less at the time of enrollment 
- 
Participants enrolled in a ChiLDReN based prospective observational cohort study (PROBE, 
BASIC, or LOGIC) 
- 
Willingness and ability to participate in the study for up to 24 months 

ChiLDReN: Childhood Liver Disease Research Network FORCE Protocol, v 1.3 
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- 
One of the following three diagnoses 
o Biliary atresia per ChiLDReN criteria (see Appendix A) or, 
o Alpha-1 antitrypsin deficiency (PiZZ or SZ) per ChiLDReN criteria (see Appendix A) or,  
o Alagille Syndrome per ChiLDReN criteria (see Appendix A) 
 
5.2.2 
Exclusion criteria: 
 
- 
BA with known situs inversus or polysplenia/asplenia 
- 
Presence of clinically significant ascites detected on physical examination 
- 
Open wound near expected FibroScan probe application site  
- 
Use of implantable active medical device such as a pacemaker or defibrillator 
- 
Known pregnancy 
- 
Prior liver transplant 
- 
Unable to give informed consent or assent 
 
5.2.3 
Participant Selection  
 
Enrollment into this study will potentially be offered to all current and future participants enrolled into 
PROBE, BASIC, and LOGIC at participating ChiLDReN sites who have a diagnosis of BA, A1AT, or ALGS, 
who have their native liver and who meet the inclusion and exclusion criteria for this study. Once the 
target enrollment number for each disease (BA 250, A1AT 100, ALGS 100) is reached, new enrollment 
will cease. Each site’s investigators and coordinators will work with the ChiLDReN Data Coordinating 
Center (DCC) to identify potential participants for this study who are already enrolled in ChiLDReN 
longitudinal studies and who meet all of the inclusion and exclusion criteria for this study. Potential 
participants will be contacted by mail or by phone prior to their scheduled follow-up visit to minimize 
visits to the study center involved in participation in FORCE.  
 
5.2.4 
Duration of enrollment  
 
Initial enrollment in FORCE will occur over the first two years of this study, with continued participation 
for the 2-year follow-up duration of this study. Liver transplantation and/or presence of clinically 
significant ascites at the time of the 1-year or 2-year follow-up visit will be a study terminating event. 
 
5.2.5 
Number of Participants 
 
During the 4-year duration of this study, the plan is to enroll up to 600 participants to ensure a total of 
450 evaluable participants; 250 with biliary atresia, 100 with alpha-1 antitrypsin deficiency, and 100 with 
Alagille syndrome. We anticipate that most of those enrolled will be existing participants in PROBE, 
BASIC, or LOGIC, however new participants in these studies will also be eligible for enrollment in this 
study as long as they meet enrollment criteria. The following are estimates of the number of 
participants with each disorder that will be enrolled into the study as existing PROBE, BASIC, or LOGIC 
participants and as new PROBE, BASIC, and LOGIC participants to be enrolled each year: 
 

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 
Biliary Atresia – 282 existing PROBE and BASIC participants and 30 new PROBE and BASIC 
enrollees per year 
 
1-AT deficiency – 87 existing LOGIC participants and 6 new LOGIC enrollees per year 
 
Alagille syndrome – 84 existing LOGIC participants and 8 new LOGIC enrollees per year.  
 
5.2.6 
Participant Discontinuation/Withdrawal 
 
Participants are free to withdraw from participation in the study at any time upon request.  An 
investigator may discontinue or withdraw a participant from the study for the following reasons: 
 
Pregnancy 
 
Significant non-adherence 
 
Lost to follow-up 
 
Inability to obtain a valid baseline scan 
 
Development of significant clinical ascites detectable on physical exam 
 
Receipt of a liver transplant 
 
Appropriate FibroScan probe unavailable 
 
If the participant meets an exclusion criterion (either newly developed or not previously 
recognized) that precludes further study participation 
 
Investigator believes that participation is not in the best interest of the participant 
 
The reason for participant discontinuation or withdrawal from the study will be recorded in the study 
database. Participants who sign the informed consent form, and subsequently withdraw, or are 
withdrawn or discontinued from the study, will be replaced. 
 
 
Schedule of Visits 
 
Baseline 
 
Informed consent 
 
 
 
FibroScan measurement 
 
FORCE clinical data and serum/plasma collection 
 
 
 
Clinical data collection & biosamples per PROBE,  
BASIC, or LOGIC  
12 month f/u 
 
FibroScan measurement 
 
 
FORCE clinical data and serum/plasma collection  
 
 
 
Clinical data collection & biosamples per PROBE,  
 
 
 BASIC, 
or LOGIC  
 
 
24 month f/u 
 
FibroScan measurement 
 
 
FORCE clinical data and serum/plasma collection  
Clinical data collection & biosamples per PROBE, 
 
 
 
 
BASIC or LOGIC  
 

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Data Collected 
 
Clinical data including interval events, medical history, physical examination data and laboratory values, 
along with biosamples will be collected at each of the 3 visits per the PROBE, BASIC, or LOGIC study 
protocols. 
 
5.4.1 
FibroScan™ measurements 
 
Operators will be trained and certified at each site to perform FibroScan™ measurements to ensure 
consistent and standardized acquisition of complete data. Training will take place at each site by a 
designated trainer from Echosens. 
 
Fasting will not be specified for these procedures. No sedation will be administered for these 
FibroScan™ assessments. The exam time is estimated to be 10 to 20 minutes. 
 
The thoracic perimeter of the patient will be measured and recorded. The thoracic perimeter value 
along with the skin to capsule distance (determined by the FibroScan device) will determine 
probe selection and exam type. The device records and displays the validity of each measurement 
based on standardized criteria determined by the FibroScan device. Ten valid measurements are 
obtained. Repeated measurements are performed until 10 valid values are obtained.  
 
After the end of the examination the gel is removed from the participant’s chest wall with a soft tissue. 
Gel is also removed from the probe with a soft towel and it is then disinfected with a solution containing 
quaternary ammonia. The report is printed and a non-identifying study ID label is applied. The report 
will be placed in the research binder and not in the clinical chart. 
 
FibroScan™ is based on vibration controlled transient elastography at 50Hz. FibroScan 
measures 2 parameters: 
1. “Liver stiffness” quantifies liver fibrosis and is measured in kPa. 
2. “Controlled Attenuation Parameter (CAP)” quantifies liver steatosis and is measured in dB/m. 
 
In addition, quality control data are collected: 
 
Invalid measurements and success rate 
 
Number and list of valid measurements 
 
Inter quartile range (IQR) (kPa or dB/m) of all valid measurements within the examination 
(reflects the dispersion of stiffness or CAP measurements) 
 
IQR/med. (%) indicates the IQR/median ratio and should remain as low as possible to ensure 
reliable results (goal < 30%). An exam with an IQR/median of ≥ 30% will be considered an invalid 
exam. Participants with an invalid exam at Baseline will be withdrawn from the study.  
Participants with an IQR/median of > 30% at the Year 1 exam will remain in the study. 
 
 
 

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5.4.2 
Biosample Collection 
 
Blood will be drawn on the same day as the FibroScan™ assessment for routine clinical evaluation and 
for biobanking for future assessment of serum/plasma biomarkers of fibrosis.  The relevant laboratory 
parameters for FORCE (total bilirubin, ALT, AST, alkaline phosphatase, gGTP, albumin, CBC with platelet 
count and PT/INR) are considered to be standard of care for children with chronic liver disease and will 
be obtained as part of routine clinical practice.   
 
 
Sample Size and Power Calculations 
 
The sample size for this study is based on logistical considerations – the number of participants in 
PROBE, BASIC, and LOGIC who meet FORCE eligibility criteria and are willing to enroll in the study at the 
participating ChiLDReN sites in the two-year recruitment period (we based these considerations on an 
estimate of at least 9 sites). Thus, this section describes the magnitude of effects possible to be detected 
with adequate power, or the possible power to detect meaningful group effects, for Aims 1 (primary) 
and 2 (key secondary). 
 
Aim 1:  To prospectively assess whether FibroScan™ LSM are associated with the clinical and laboratory 
features of portal hypertension in children with biliary atresia.  
 
Hypothesis 1: FibroScan™results can differentiate children with clinical features of portal 
hypertension from those without. 
 
The definitions of PHT and no PHT that we will use for the primary analysis are termed “definite” vs 
“absent” based on the research definition adopted by the Network. Clinically evident PHT (CEPHT) is 
defined as “definite” (dCEPHT) when there is either (1) a history of a complication of PHT (esophageal or 
gastric variceal (EV) bleed or ascites [as defined by prescription of diuretics]) or (2) clinical findings 
consistent with PHT (both splenomegaly [spleen palpable > 2 cm below the costal margin] and 
thrombocytopenia [platelet count < 150,000/ml]). CEPHT is denoted as “possible” (pCEPHT) if only one 
of the two clinical findings is present in the absence of a complication; while CEPHT is “absent” if none 
of the criteria is met.  (Note that secondary analyses will consider the comparison of “definite” + 
“possible” CEPHT vs. “absent” CEPHT and comparisons of each category, i.e., “definite” vs “possible” vs 
“absent” CEPHT). 
 
We estimate the proportion of participants with PHT, based on the literature, preliminary data from the 
ChiLDReN database, and clinical experience (for estimates for normal liver), in Table 1.  We apply these 
estimates to the overall expected number of eligible participants to define the sample sizes for the 
dCEPHT and absent CEPHT groups, assuming that 80% of eligible participants will consent to enroll in the 
Echosens study. 
 
 
 

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Table 1.  Estimates of PHT prevalence in biliary atresia 
Disease Group 
dCEPHT 
pCEPHT 
No CEPHT  
(cirrhosis without features of CEPHT, ~normal liver) 
BA [3] 
49% 
17% 
34% (34%, 0%) 
 
For the power calculation, we conservatively assume the true difference in population mean FibroScan™ 
LSM between definite and no clinically evident portal hypertension is 12 kPa.  This estimate is based on 
an integration of data from studies of children with BA [25] and of adults with cirrhosis.  Chongrisawat 
studied 73 BA patients (mean age 9 years [SD=5.6]) and 50 normal controls (mean age 11 years [SD=3.3].  
The mean difference in liver stiffness scores between the BA participants with and without 
splenomegaly is 29 kPa (95% CI:  21.6, 36.4) [see Table 2]. In adults with cirrhosis, mean liver stiffness 
score is about 12 kPa, while for adults with normal livers their mean score is in the range of 4-6 kPa.   
 
Table 2.  Mean (SD) liver stiffness FibroScan™ scores in BA patients and normal controls*  
 
Sample 
N 
Mean + SD, kPa 
BA with splenomegaly 
39 
38.9 + 22.0 
BA without splenomegaly 
34 
9.9 + 6.0 
BA 
73 
27.4 + 22.5 
Normal controls 
50 
4.7 + 1.0  
*[25] 
 
We assume the standard deviation (SD) is 22.0 kPa and 6.0 kPa for participants with and without 
clinically evident portal hypertension, respectively. Using a 2-sided Type I error rate of 5% under these 
assumptions, there will be more 99% power to detect a 12 kPa difference between participants with and 
without clinically evident portal hypertension in the BA disease group. Alternatively, there is at least 
80% power to detect mean group differences of 6.2 kPa in BA participants [see Table 3]. Note that these 
assumptions are conservative because they do not account for new enrollees into the PROBE and BASIC 
studies. 
 
Table 3.  Power and mean group differences, assuming Type 1 error = 5% (2-sided), SD = 22 kPa 
(dCEPHT group) and 6 kPa (absent CEPHT group) 
 
Disease Group 
(Study[ies]) 
Total 
Sample 
Size1 
Projected 
Sample 
Size2 
Projected Sample 
Size in  
dCEPHT, Absent 
CEPHT Groups2 
Power to detect 12 kPa 
Group Difference3 
Group Difference for > 
80% Power3 
BA 
(PROBE, 
BASIC) 
282 
192 
 
112, 79 
>99% 
6.2 
1 Based on 12/31/2015 database that does not include projected enrollment in studies 
2 Assumes 80% of eligible participants will consent to enroll in FORCE study, as well as proportions of participants 
with dCEPHT and absent CEPHT from Table 2 
3 Based on two-sample t test for mean difference with unequal variance [SAS 9.3] 
 
 

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Aim 2:  To prospectively measure changes in liver stiffness over time by FibroScan™ in children with BA. 
 
Hypothesis 2:  FibroScan™-based assessment of liver stiffness in children with BA will reliably 
reveal increases over 2 years of follow-up. 
 
From the projected 226 participants with BA who will enroll in this study, we assume that up to 15% will 
drop-out by 2 years (liver transplant, death, or lost to follow-up), resulting in 192 participants for whom 
we can estimate the change from baseline to 2 years.  For this within-patricipant assessment, the degree 
of correlation between the two FibroScan™ values affects the power --- greater correlation results in 
greater power under equivalent assumptions. We assume that the range of correlation ranges between 
0.3 and 0.6. Conservatively, we estimate that the SD of the change from baseline is 22 kPa. With these 
assumptions, we have sufficient power (>80%) to detect mean changes from baseline to 2 years of 5.3 
kPa for correlation = 0.3 to 4.0 kPa for correlation = 0.6 (based on paired t test, SAS 9.3); see Figure 1. If 
the correlation is greater or if the SD is less, then a smaller mean change can be detected with sufficient 
power.  Our approach for assessing power and effect sizes is conservative; utilizing all measurements via 
more complicated statistical models can provide greater power or equivalently smaller mean changes in 
FibroScan™ LSM. 
 
Figure 1.  Power for Various Changes from Baseline to 2 Years in FibroScan Values for Correlations 
Ranging from 0.3 to 0.6, N=192 
 
 
Correlation = 0.3 
Correlation = 0.6 

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Statistical Analysis 
 
Descriptive statistics, both tabular and graphical, will be used to characterize the distribution of 
FibroScan™ values at enrollment into the FORCE study and at 1 and 2 years of follow-up, by disease 
group (BA, A1AT, ALGS). In addition, changes from enrollment to year 1 and to year 2 will be 
summarized. A detailed Statistical Analysis Plan will be prepared prior to the completion of the study. 
 
5.6.1 
Primary Aim   
 
The primary aim of the study seeks to compare the distribution of FibroScan™ LSM at enrollment 
between participants with and without portal hypertension.  A linear model will be fit to FibroScan™ 
values at enrollment to assess the impact of portal hypertension on LSM, controlling for important 
covariates such as age, gender, and race. The coefficient for the clinically evident portal hypertension 
effect will provide the difference in FibroScan™values associated with clinically evident portal 
hypertension. If the distributional assumptions of the models are not met, transformations (e.g., log of 
the FibroScan™ values) or rank-based (non-parametric) methods may be employed.    
 
Secondary analyses will be performed to compare “definite” + “possible” CEPHT vs. “absent” CEPHT and 
compare each category, i.e., “definite” vs “possible” vs “absent” CEPHT. The same approach (linear 
models) will be used to test for differences in FibroScan™ measurements among the CEPHT groups, with 
an omnibus test used for the comparison of the three CEPHT groups. 
 
5.6.2 
Secondary Aims   
 
The key secondary aim (Aim 2) compares the one- and two-year FibroScan™ values to those at 
enrollment in participants with BA. A linear mixed effects model will be used to assess whether mean 
LSM changes significantly over time, with FibroScan™ measurements as the dependent variable, fixed 
effect of time (enrollment [year 0], Year 1, Year 2) and subject-specific random effects to account for 
both heterogeneity among subjects, and correlation among measurements taken on the same subject as 
independent variables. To test whether there is a significant change in LSM over time, we will test the 
coefficient for the time is significantly different from zero. We will also explore the impact of other 
factors on the changes in FibroScan™ by incorporating other independent variables (e.g., age at 
hepatoportoenterostomy, baseline total bilirubin, number of interval episodes of cholangitis) and their 
interaction with time into the linear model. To test whether there is a significant difference in the way 
FibroScan™ values change over time between two groups (e.g., younger vs older at time of 
hepatoportoenterostomy) or with a factor (e.g., baseline total bilirubin), we will test whether the 
interaction term is significantly different from zero. The main analytic approach will use restricted 
maximum likelihood methods and an unstructured variance-covariance structure. Extensions of the 
linear mixed model (e.g., inclusion of polynomial time factors) or other semiparametric (e.g., piecewise 
linear) methods will be used if LSM does not change linearly.  
 
For Aim 3, we will estimate the proportion of participants in whom a valid FibroScan™ LSM can be 
obtained, by disease group. 
 

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Per Goldschmidt 2013 [35] we will define two measures of the feasibility of FibroScans™ in our 
populations:  “technically possible” and “acceptable quality”. The proportion of participants with a 
“technically possible” FibroScan™ is defined as the number of subjects with at least 10 FibroScan™ 
measurements obtained divided by the number assessed. The proportion of participants with 
FibroScans™ of “acceptable quality” is defined as the number of participants with FibroScan™ LSM with 
the ratio of the interquartile range and median of the 10 measurements <30%, of which at least 6 are 
completed, divided by the number assessed. The proportions and their 95% confidence intervals will be 
provided using the Wald method; however, the Wilson-Score methods will be used if the sample sizes 
are small or the proportion is small for a disease group. We will perform separate analyses for 
participants <2 years of age and for those >2 years of age. 
 
In Aim 4, we will correlate FibroScan™ LSM values at enrollment with PELD score, total bilirubin, 
albumin, INR, platelet count, and APRI by disease group. The analysis will be limited to participants for 
whom a PELD can be calculated (i.e., those for whom the individual components of the PELD score are 
available). Note that PELD will be calculated for all pediatric participants including those greater than 12 
years of age.  PELD is calculated as 
 
PELD = 4.80 x [ln serum bilirubin (mg/dL)] + 18.57 x [ln INR] – 6.87 x [ln albumin (g/dL)] 
+ 4.36(<1 year old) + 6.67(growth failure)  [www.unos.org] 
 
APRI is calculated as 
 
APRI = AST/upper limit of normal AST x 100 [U/L] 
Platelet Count (109/L) [U/L]) 
 
Descriptively, we will use scatterplots to graphically explore the relationships between FibroScan™ LSM 
and the clinical features of these liver diseases, with Pearson correlation coefficients (or Spearman, if 
the distributions are skewed). Linear mixed effects models (akin to that described for Aim 2) will be used 
to assess the relationship between FibroScan™ LSM and each parameter over time (i.e., time-varying 
covariate), controlling for other important covariates (such as gender, age, race). We will explore the 
nonlinearity assumption of these models using more flexible methods, such as LOESS (locally weighted 
scatterplot smoothing, a nonparametric approach).  
 
5.6.3 
Exploratory Aims 
 
In Aim 5, we will use methods comparable to Aim 1 (for BA participants) to assess whether FibroScan™ 
LSM can differentiate children with and without clinical features of portal hypertension. Separate 
analyses will be conducted for participants with A1AT and with ALGS. 
 
In Aim 6, we will develop a biorepository of serum/plasma samples for future correlative analyses with 
FibroScan™ LSM. 
 
In Aim 7, we will use methods comparable to Aim 2 (for BA participants) to summarize the changes in 
FibroScan™ LSM in participants with A1AT and with ALGS (separately).    

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6 
Human Subjects 
 
 
Protection of Human Subjects 
 
6.1.1 
Institutional Review Board 
 
This study and analysis will be performed under single Institutional Review Board (sIRB) oversight. It was 
initiated under local IRB approval and will continue under sIRB approval.  Prior to the initiation of the 
study, local IRB approval for study of human subjects was obtained from the IRB for each of the 
participating FORCE clinical study centers and the DCC. As of November 11, 2019 revisions to the study 
protocol and changes in the study design will be submitted to the sIRB for approval prior to 
implementation.  
 
Participants will be enrolled in the FORCE protocol with full and written informed consent, which will 
include the gathering of protected health information (PHI). Each participating center will be responsible 
for obtaining such human subjects research authorization from the sIRB and will utilize an informed 
consent document detailing the procedures described above in the language required by the sIRB. All 
key personnel at the participating centers will have successfully completed sIRB-required training and 
certification for human subjects research. Additionally, participants will satisfy HIPAA researchers’ 
privacy requirements. 
 
6.1.2 
Patient Confidentiality 
 
Special procedures for ensuring patient confidentiality will be implemented. Data transmission and the 
distributed data systems will have multiple layers of security as discussed in Section 8, Study 
Management. Each study participant will be assigned an identification number. Only this number will be 
used to identify participants in any individual tabulation. The PHI that is collected will represent the 
minimum necessary to successfully execute the study. 
 
PHI entered into the database at the site level will only be visible to study personnel accessed through a 
triple password regimen. The PHI is encrypted at the site level. Site personnel will have the decryption 
key and it will not be available to the DCC. It is expected that only group data will be published. If 
individual participant data are to be published, no identifying information will be included. The study 
files will be maintained in a secure location. Access to computerized data will be restricted to study 
personnel. Password authorization will be enforced. Previous use of this security system and a secured 
server indicates that this technique is very successful in assuring the protection of confidential 
information. 
 
Authorized representatives of the Sponsor, the NIDDK, National Institutes of Health (NIH), participating 
FORCE clinical study centers, DCC monitoring staff, as well as the sIRB at each site will have access to 
medical records and records from participants in this study. Such access is necessary to ensure the 
accuracy of the findings. 
 
 

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6.1.3 
Recruitment and Informed Consent/Assent  
 
Each site will contact the parents/guardians or the potential participant (if 18 years or older) to provide 
information about this study and offer enrollment. Initial contact with the family/participant may be 
conducted by one or more of the following: phone contact by a study coordinator or investigator/co-
investigator, direct mailing to the family, or by an investigator/co-investigator or study coordinator 
during an outpatient clinical or research visit, or during admission to the hospital. If the 
family/participant is interested in possibly enrolling in this study, the parents/guardian/participant will 
then meet with the study investigator(s) and study coordinator. The investigator and coordinator will 
discuss the objectives of the study and the study design, possible benefits, and potential risks with the 
family, and review the sIRB approved consent form. Printed information about the study and the 
consent form will be provided to the family. The sIRB-approved consent form will include the purpose of 
the trial, the responsible parties and investigators, potential benefits, risks of participation, the right to 
refuse to be in the study, the right to withdraw from the study under no penalty, contact numbers and 
information about the responsibility for injury and payment for medical care. If the participant, parent 
or guardian consents to enroll into the study, written informed consent will be obtained from the 
parents or guardians and written assent will be obtained from the participant in accordance with local 
sIRB regulations. For participants 18 years of age and older, consent will be obtained directly from the 
participant. Affected siblings with A1AT or ALGS and evidence of liver disease who are enrolled in LOGIC 
are eligible to participate in this study. The study team will endeavor to arrange the baseline visit for this 
study so that it coincides with the visit schedule of the other ChiLDReN longitudinal study for which the 
participant is already enrolled.   
 
If desired by the parent/legal guardians, the results of the FibroScan™ LSM will be provided.  These 
results will not be placed in the official clinical record. Guidance will be given to the family as to current 
understanding of the measurement results and that the clinical implications of the findings are not clear 
(see appendix document – lay explanation of FibroScan™ measurement). 
 
6.1.4 
Risks to the Patient and Adequacy of Protection Against Risk 
 
Participants enrolled in the FORCE Study will experience more than the normal amount of testing that is 
customary for patients with pediatric liver disease. Venipuncture carries risks of pain and bruising at the 
puncture site as well as syncope. Individuals may experience minor discomfort or soreness over the area 
where the ultrasound probe contacts the abdomen. There is also a small risk of allergic reaction to the 
water-based gel used to improve conduction between the probe and the participant’s skin during the 
procedure. All scans will be performed by a FibroScan™certified operator. There is a potential risk of 
breach of confidentiality that is inherent in all research protocols, and steps to minimize this risk are 
described above. Steps to minimize risk and address any discomfort are addressed below. 
 
Risks of FibroScan™:  There are no known direct risks from the FibroScan™ medical device, which uses 
ultrasound waves. Participants may experience minor pain or soreness during the scan. There is a small 
risk of allergic reaction to the water-based gel used during the procedure.  There is no radiation 
exposure. All scans will be performed by FibroScan™-certified operators. 
 
 

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If the participant experiences excessive discomfort from a study procedure, the procedure will be 
stopped. 
 
6.1.5 
Unauthorized Data Release 
 
The data sets will be stored on a secure server with restricted access (requires a unique username and 
password) at the DCC and every precaution will be taken to keep the information private. However, 
there is always the possibility of unauthorized release of data about participants. Such disclosure would 
be extremely unlikely to involve a threat to life, health, or safety. It is conceivable that such disclosure 
could have psychological, social, or legal effects on the patient. Using the standard security procedures 
(described above under patient confidentiality) can effectively minimize the risk of unauthorized 
disclosure of data. All study personnel who have access to patient data will be educated regarding the 
need to protect confidentiality and the procedures to be followed to ensure such protection. All staff 
will also be required to sign a standard medical record confidentiality agreement. The computer system 
on which data are maintained uses standard password protection procedures to limit access to 
authorized users. After the study is completed, the database will be stored on the NIDDK Data 
Repository. The database in the Repository will be de-identified to obviate further privacy and security 
considerations. 
 
6.1.6 
Adverse Event Monitoring and Reporting 
 
6.1.6.1 
Definition of an Adverse Event 
 
An adverse event (AE) is any untoward medical occurrence or unfavorable and unintended sign in a 
research participant that occurs during or as a result of a research procedure. For this study, each center 
will review the list of study procedures and identify the specific procedures that are not standard-of-
care at their institution and these will be considered research procedures. Complications that are a 
result of research procedures will be reported and tracked as adverse events.  
 
The research procedures (ultrasound scanning and phlebotomy) present minimal risk; we anticipate few 
adverse events. All adverse events must be recorded. The onset and end dates, severity and relationship 
to study procedure(s) will be recorded for each adverse event. All adverse events will be reported by 
FORCE investigators to the DCC. Any action or outcome (e.g., hospitalization, additional therapy, etc.) 
will also be recorded for each adverse event. Participants will be questioned and/or examined by the 
investigator or his/her designee for evidence of adverse events. 
 
Serious Adverse Event. The term serious is based on patient outcomes associated with events that could 
threaten a patient’s life or functioning. An event should be considered serious if it results in any of the 
following: 
 
Death, 
 
Life-threatening (patient was at risk of death as a result of the event, does not include 
hypothetical risk of death if the event had been more severe), 
 
Inpatient hospitalization or prolongation of existing hospitalization, 
 
Persistent or significant disability or incapacity, 

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 
Congenital anomaly or birth defect, 
 
Medical or surgical interventions required to prevent one of the outcomes listed above. 
 
The phrase “related to study” implies causality or attribution to the study procedures. For purposes of 
defining a serious adverse event (SAE), if a causal relationship cannot be ruled out, then an AE should be 
considered ‘related to the study procedure(s)’. As noted above, it is very unlikely that any adverse 
events will be attributable to this study. 
 
6.1.6.2 
Reporting Responsibility 
 
All adverse events must be recorded. The onset and end dates, severity and relationship to study 
procedure(s) will be recorded for each adverse event. Any action or outcome (e.g., hospitalization, 
additional therapy, etc.) will also be recorded for each adverse event. 
All Adverse Events (AEs) and Serious Adverse Events (SAEs) must be reported by the investigator to the 
DCC. The DCC will review reports of all related SAEs and other relevant information immediately, and 
may request additional information from sites for analysis of these events. Sites will report SAEs 
according to the time frames outlined below. All events that are serious and related (possibly or 
probably) must be reported to the DCC within 24 hours of the investigator being informed of the event. 
Follow-up information about a previously reported serious and related adverse event may be reported 
to the DCC within 7 working days of the investigator receiving the information; however, important 
follow-up information must be submitted within 24 hours. All deaths connected to a study procedure 
must be reported to the DCC within 24 hours of the investigator being informed of the event. The NIH 
will appoint an independent Data and Safety Monitoring Board (DSMB) that will provide study oversight. 
SAEs will also be reviewed by the study’s DSMB during its regular meetings. 
 
 
Benefits to the Participant 
 
There are no direct benefits to the participants for participation in the study. 
 
 
Inclusion of Women 
 
This study includes women up to and including age 21 at the time of enrollment. 
 
 
Inclusion of Minorities 
 
Racial and ethnic minorities will be recruited into the study. We anticipate that the representation of 
racial and ethnic minorities will correspond to the fraction of minorities in the population presenting to 
the participating clinics’ pediatric liver disease patients. 
 
 
Inclusion of Children 
 
Since this is a pediatric study, children under the age of 18 will be enrolled into this study. 
 
 

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 Data Safety and Monitoring Plan 
 
Accepted principles of data and safety monitoring will be observed throughout the conduct of the 
FORCE study. The DSMB will review the study protocol prior to enrollment and will review all 
subsequent protocol revisions. The DSMB will also evaluate the occurrence of adverse events related to 
study participation as well as study accrual updates. 
 
FORCE Principal Investigators will be responsible for monitoring the enrollment of participants, 
submission of data to the DCC, and monitoring and reporting of adverse events related to study 
participation. The DCC will be responsible for monitoring for effective conduct of the protocol and 
accurate and timely data submission. 
 
The sIRB will be provided feedback on a regular basis. 
 
A minimum of two people will be trained and certified in the FibroScan™ exam at each clinical center by 
Echosens™, the maker of the FibroScan™ device. At the time of the initial training, the Echosens 
representative will assemble and calibrate the FibroScan™ medical device.   
 
Training of study coordinators and study monitoring activities will be conducted by the DCC to ensure 
patient confidentiality and privacy and to maximize the reliability, accuracy, and timeliness of study 
data. 
 
The FORCE clinical sites, the DCC, and relevant research center staff will conduct regular meetings to 
review recruitment/enrollment progress, data collection activities, and participant retention. The DCC 
will produce regular reports regarding enrollment, data quality, and timeliness and share the reports 
with NIDDK, the Steering Committee, and the participating clinical center. Data will be routinely 
exported from the system, examined for accuracy and completeness, and backed up to secure storage 
devices. Upon completion of data collection, final processing and cleaning of data will be conducted. A 
technical report detailing specific project methodology, response rates, and other details will be 
produced. 
 
7 
Study Organization 
 
 
Clinical Centers 
 
The participating FORCE clinical study centers, made up of the ChiLDReN clinical centers, will have 
primary responsibility for developing the study protocol, maintaining high rates of follow-up and data 
collection, obtaining data of high quality, and interpreting, presenting, and publishing findings from the 
study. 
 
Data Coordinating Center 
 
The DCC contributes biostatistical expertise and shares in scientific leadership of the research group. The 
DCC has developed a communication infrastructure that includes meetings, teleconferences, email and 
bulletins, interactive Web-based encounters, and written correspondence. The DCC assists in protocol 

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development and preparation of scientific publications. The DCC has the major responsibility of creating 
a database and data collection systems for the participating FORCE clinical study centers, ongoing 
evaluation of data quality, performance monitoring of the FORCE clinical study centers, and statistical 
analyses of the data. The DCC has also created a comprehensive Manual of Operations (MOO) that will 
govern the conduct of the study. The manual details the protocols, protocol clarifications and 
amendments, summary of the regulatory requirements for the study, instructions for enrollment, data 
collection, data management, visit schedules, and detailed instructions on the use of the electronic data 
submission. The DCC is responsible for clinical monitoring of the study. 
 
University of Michigan 
Arbor Research Collaborative for Health 
Ann Arbor, MI 
Principal Investigators:  John C. Magee, MD, FACS and Robert M. Merion, MD, FACS 
 
 
Steering Committee 
 
The primary governing body of the ChiLDReN study is the Steering Committee, consisting of each of the 
Principal Investigators of the ChiLDReN clinical study centers, the Principal Investigators of the DCC, and 
the NIDDK Project Scientist. The Steering Committee develops policies for the study pertaining to access 
to patient data, performance standards, and publications and presentations. It approves study protocols 
and meets to discuss the progress of the study and to consider problems arising during its conduct. The 
Steering Committee may establish subcommittees to further develop specific components of the study 
protocol. Small working groups may be established to prepare manuscripts and presentations. 
 
8 
Study Management 
 
 
Data Collection, Data Collection Forms, Data Entry 
 
The DCC will utilize the Web-based ChiLDReNLink as the data management nucleus for the FORCE study. 
ChiLDReNLink is a database platform developed by Arbor Research Collaborative for Health (Arbor 
Research). The DCC will utilize ChiLDReNLink to create electronic case report forms to capture all 
relevant study data for all investigational/research protocols that are developed and implemented 
during the course of FORCE. The ChiLDReNLink system allows real-time monitoring of study data for 
protocol adherence, quality assurance, adverse event reporting, discrepancy reporting, and other 
trends.  
 
 
Data Management 
 
Study data will be entered into the electronic data entry system by study coordinators at each study site. 
These data will be encrypted and transferred to the DCC and stored on a secure server at Arbor 
Research. Access to the server and data entry system is limited and requires a unique username and 
password combination. The servers are backed up daily and physically stored in a locked facility. 
 
All analysis of the data sets will utilize de-identified (coded) data sets. 

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Quality Control and Database Management 
 
The first steps in ensuring protocol compliance are good protocol design and careful orientation of study 
personnel. Following final agreement on protocols, and prior to study initiation at any of the FORCE 
clinical study centers, the DCC and Echosens will organize a Training and Certification session for FORCE 
study coordinators/data entry personnel. 
 
The electronic data entry system will have built-in data checks as part of study quality assurance. 
Protocol compliance will be assessed by monitoring the submission of data at required intervals. Data 
inconsistencies and discrepancy reports will be reviewed by the Clinical Monitors so that necessary 
queries can be generated and sent to the FORCE clinical study centers for verification and resolution. 
 
Periodic requests may be generated for the submission of random source documents to assess the 
quality of data acquisition and data entry at each site. Additionally, the Clinical Monitor or Clinical Study 
Process Manager will visit each site at least once a year to review source documents, monitor regulatory 
compliance, and assess protocol adherence. 
 
In addition to source document verification, the Clinical Monitor and Clinical Study Process Manager will 
produce reports from the database to look for inconsistencies in submitted data, particularly for 
repeated measures data elements, even if data do not fall outside of built-in validation routines. 
 
Studies of intra-subject and inter-subject data variability by FORCE clinical study center as well as intra-
center and inter-center data variability will be used to further ascertain random or systematic data 
quality issues. 
 
 
Data Security/ Data Transfer 
 
For this study, personnel at each study center will collect and enter data into the web-based data entry 
system. The following data security contingencies are in place: 
 
Compliance with Industry Standards Regarding Data Security (HIPAA and 21 CFR Part 11) 
 
Audit trails are maintained for all activity and all changes to any data element 
 
All servers, web servers, firewalls, etc. are configured and maintained according to industry best 
practice guidelines for backup, security, continuity of operations, and protection of PHI 
 
All data are available only to authorized users from each site after secure login with encryption, 
with all site activity audited at the user level 
 
All transmissions between the internet and the database are encrypted using a 128-bit 
encryption algorithm 
 
There is a comprehensive security plan in place  
 
Detailed instructions on the use of the database platform, data element definitions, and a code list will 
be provided in a MOO. Each study site will be provided a copy of the MOO and the entire manual will be 

ChiLDReN: Childhood Liver Disease Research Network FORCE Protocol, v 1.3 
Date Approved: December 12, 2019 
Page | 26  
 
available on the study website, and in the Help area of the database user interface. 
 
 
Resource Sharing Plan 
 
During the study, data and biosamples will be shared with internal and external investigators according 
to the guidelines agreed upon by the Steering Committee. Upon study completion, study data and 
materials will be transferred to the NIDDK Data Repository. Minutes of the meetings of the Steering 
Committee, Project Executive Committee, subcommittees, and the DSMB will be kept on file at the DCC. 
 
 
 

ChiLDReN: Childhood Liver Disease Research Network FORCE Protocol, v 1.3 
Date Approved: December 12, 2019 
Page | 27  
 
9 
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10 Appendices 
 
Appendix A: ChiLDReN diagnostic criteria for Biliary Atresia, Alpha-1 antitrypsin deficiency and Alagille 
Syndrome 
 
Appendix B: Lay Explanation of FibroScan™ Liver Stiffness Measurement