About

Estella M Alonso holds the position of Sally Burnett Searle Professor of Pediatric Transplantation at Northwestern University Feinberg School of Medicine. She is also a professor in the Department of Pediatrics, specializing in Gastroenterology, Hepatology, and Nutrition, as well as in the Medical Social Sciences with a focus on Outcome and Measurement Science. Her work is associated with multiple institutes and centers, including the Center for Human Immunobiology, the Comprehensive Transplant Center, the Institute for Public Health and Medicine (IPHAM) - Center for Patient-Centered Outcomes, the Northwestern University Clinical and Translational Sciences Institute (NUCATS), and the Stanley Manne Children's Research Institute. Her research focuses on pediatric transplantation, outcomes measurement, and health sciences, contributing to the advancement of clinical and social sciences in pediatric transplantation and related fields.

Research topics

• Internal medicine
• Medicine
• Pediatrics
• Surgery
• Gastroenterology

Selected publications

• Demographic Factors and Biliary Atresia: A Childhood Liver Disease Research Network Study

  PEDIATRICS · 2026-02-19

  article

  OBJECTIVE: To test the hypothesis that community deprivation, race, and ethnicity lead to decreased likelihood of undergoing hepatoportoenterostomy, older age at surgery, decreased likelihood of achieving successful bile drainage, and lower rates of native liver survival for infants with biliary atresia. METHODS: We analyzed a prospectively enrolled cohort of infants with biliary atresia from the Childhood Liver Disease Research Network (ChiLDReN) that reflects the demographics of the US population. We tested the association between demographic, clinical, and anatomic variables and the probability of undergoing hepatoportoenterostomy, age at surgery, success of surgical intervention, and native liver survival using linear and logistic regression. RESULTS: Seven hundred nineteen infants with biliary atresia from 15 centers met study inclusion criteria and 672 (93.5%) underwent hepatoportoenterostomy. After adjusting for potential confounders, Asian race (odds ratio [OR] = 0.21, 0.06-0.77), Hispanic ethnicity (OR = 0.33, 0.14-0.76), and community deprivation (0.71 per 0.1 increase, 0.52-0.97) were independently associated with decreased probability of undergoing hepatoportoenterostomy. Each 10% increase in community deprivation increased the age at hepatoportoenterostomy by approximately two-and-one-third days (estimate 2.31; P = .48). Black/African American infants were approximately 9 days older than white infants at the time of operation (estimate 9.19; P = .01), while age at hepatoportoenterostomy (OR = 0.90, P = .01) and successful bile drainage at 3 months (OR = 26.15, P < .01) were independently associated with native liver survival. CONCLUSIONS: Community deprivation, race, and ethnicity are associated with both lower hepatoportoenterostomy rates and older age at the time of operation, whereas clinical and anatomic variables are associated with successful biliary drainage and native liver survival.

  PublisherDOI

• Lack of clinical change in longitudinal vibration controlled transient elastography among children with cystic fibrosis and poor association with non-invasive biomarkers of liver disease

  Journal of Cystic Fibrosis · 2026-04-01

  article
  PublisherDOI

• CD8 TRM-like T cells expressing perforin and IFN-γ define a pediatric activated T-cell acute liver failure endotype

  Hepatology Communications · 2026-03-31

  articleOpen access

  BACKGROUND: Activated T-cell pediatric acute liver failure (TC-PALF) is the most common cause of non-acetaminophen PALF, with poor transplant-free survival. Livers in TC-PALF are infiltrated by effector cytotoxic T lymphocytes with markers of tissue-resident memory function (CD8 Trm) and an interferon gamma (IFNγ) transcriptional signature. The PALF-Immune Response Network (PALF-IRN) and the prospective TReatment for ImmUne-Mediated PathopHysiology (TRIUMPH) clinical trial (NCT04862221) aim to characterize the TC-PALF immune pathology and utility of T-cell directed therapy to improve transplant-free survival. METHODS: TRIUMPH patients with TC-PALF were compared with healthy children and disease controls utilizing multiparameter flow cytometry and 3' single-cell RNA sequencing from peripheral blood mononuclear cells. TC-PALF patient serum was compared with healthy children and those with PALF from other causes, utilizing the Olink Inflammation I 384 protein assay. RESULTS: Two distinct endotypes of TC-PALF were identified, which differed in flow cytometry CD8+ Perforin1 (Prf) expression and liver biopsy staining of Prf. TC-PALF patients with high CD8+ Prf (TC-PALF High Prf) had monocytosis, with a unique circulating CD8 IFNγ+ Trm-like population and IFNγ-responsive CD14/CD16 monocyte ligand-receptor interaction. TC-PALF patients with normal CD8+ Prf expression had hypergammaglobulinemia, an increase in class-switched B-cells, and a decrease in serum inflammatory proteins associated with myeloid activation. CONCLUSIONS: TC-PALF high Prf patients have a unique circulating CD8+ IFNγ+ Trm-like population accompanied by monocyte proliferation and activation. Further understanding of the role of IFNγ in TC-PALF High Prf may provide a therapeutic target for this endotype to improve transplant-free survival.

  PublisherDOI

• Assessment of Liver Fibrosis Through Shear Wave Elastography in Pediatric Liver Transplant Recipients

  Pediatric Transplantation · 2025-03-06 · 1 citations

  articleOpen access

  BACKGROUND: Liver transplantation (LT) is the standard therapy for end-stage liver disease. Liver allografts are at risk for fibrosis, for which biopsy is the gold standard for evaluation but carries risks. There is a need for noninvasive modalities to track the trajectory of fibrosis. METHODS: We evaluated the diagnostic accuracy of shear wave elastography (SWE) liver stiffness (LS) measurements to quantify fibrosis in pediatric liver transplant recipients. RESULTS: Between 2007 and 2024, 93 patients had 106 liver biopsies performed within 13 months of elastography. LS values were significantly higher in patients with moderate (F2-3) fibrosis compared to those with no significant fibrosis (F0-1) (7.5 ± 0.48 kPa vs. 6.09 ± 0.18 kPa, p = 0.0015). LS values were significantly higher in patients with moderate fibrosis compared to those with no significant fibrosis in both whole (8.4 ± 0.95 kPa vs. 6.6 ± 0.54 kPa, p = 0.02) and segmental allografts (7.1 ± 0.52 kPa vs. 5.9 ± 0.17 kPa, p = 0.02). There was no significant difference in LS values according to allograft type or donor status. The AUROC for LS measurements was 0.71, indicating a good discriminative ability between no significant and moderate fibrosis. A cut-point of 6.09 kPa for SWE was identified, distinguishing between no significant and moderate fibrosis (sensitivity of 81%). A SWE cut-point of 10.40 kPa had a high specificity of 99% in determining moderate fibrosis. CONCLUSION: We demonstrated a significant association between biopsy fibrosis and SWE LS values and conclude that SWE provides a noninvasive option for monitoring liver a fibrosis.

  PublisherOA PDFDOI

• Increased serum GM-CSF at diagnosis of biliary atresia is associated with improved biliary drainage

  Pediatric Research · 2025-01-29 · 3 citations

  articleOpen access
  PublisherOA PDFDOI

• Impact of elexacaftor/tezacaftor/ivacaftor on biomarkers of cystic fibrosis hepatobiliary involvement in the PUSH study

  Journal of Pediatric Gastroenterology and Nutrition · 2025-11-26 · 1 citations

  article

  Abstract Objectives The impact of elexacaftor/tezacaftor/ivacaftor (ETI) on cystic fibrosis (CF) hepatobiliary involvement (CFHBI) is uncertain. The goal of this study was to investigate the changes in key liver parameters in PUSH study participants who started ETI compared to those who did not (noETI). Methods PUSH was a prospective observational study of persons with CF (pwCF) (3–12 yo at PUSH entry). Linear mixed effect model (LMEM) with one knot tested if ETI changed the slope of trajectories of clinical parameters by comparing ETI to noETI. Index time (IT) for ETI was ETI start and time of ETI availability for noETI. Time zero in the LMEM was index time. Results One hundred forty‐seven participants (104 ETI, 43 noETI). At IT, the groups were similar, for age, and liver parameters. Mean duration of ETI use was 22 months. The annual rate of change over time after IT in ETI compared to noETI was significantly improved for FEV 1 % pre (+3.4/yr p = 0.02) and wt z score (+0.06/yr, p = 0.006). There was improvement for ETI vs noETI for GGT (−15%/yr, p = 0.01) and ALT (−12%/yr, p = 0.02). Participants with CFHBI on ETI demonstrated similar trends and also had improvements in GGT and GGT to platelet ratio (GPR), but there were no differences in liver stiffness or US classification changes. Conclusions GGT and GPR improve in pwCF and CFHBI who received ETI compared to noETI. There were no changes in other liver parameters. This suggests an early signal for positive impact on CFHBI, but no early improvement in fibrosis.

  PublisherDOI

• Defining a Histologic Scoring System for Gestational Alloimmune Liver Disease

  The American Journal of Surgical Pathology · 2025-07-23

  articleOpen access

  Gestational alloimmune liver disease (GALD) is a leading cause of neonatal acute liver failure (ALF) with unique histologic features but no established histologic scoring criteria. This study aimed to develop an accurate histologic scoring system to distinguish GALD from non-GALD neonatal ALF. A preliminary system using 6 histologic features characteristic of GALD was created. Four pathologists from 2 institutions applied this system to GALD (n=11) and non-GALD (n=20) neonatal ALF cases from 2008 to 2020. Four cases of Trisomy 21-associated transient myeloproliferative disorder were analyzed separately, as these patients can present with neonatal ALF and display GALD histologic features but are clinically distinguishable. Area under the receiver operating curve (AUROC) was fitted for stepwise combinations of features to determine the most accurate scoring system. GALD histologic features included extensive parenchymal fibrosis and neotubules, and a paucity of healthy hepatocytes, portal tract involvement, extramedullary hematopoiesis, and inflammation. A revised 3-feature system including parenchymal fibrosis, neotubules, and hepatocyte characterization established highest accuracy with an AUROC of 0.891 ( P <0.001). Importantly, there were no significant interinstitutional differences in scores assigned to GALD versus non-GALD cases. A 3-factor score of <2 had 100% sensitivity (95% CI: 74%-100%) to exclude GALD and a score >5 had 95% specificity (95% CI: 76%-100%) to diagnose GALD. This study establishes a highly accurate histologic scoring system to differentiate GALD from non-GALD neonatal ALF. Findings may aid in accurate diagnosis of index cases, reducing recurrence risk in subsequent pregnancies and lowering morbidity and mortality associated with GALD.

  PublisherOA PDFDOI

• What are we waiting for: Serious bacterial infections in children prior to liver transplant are associated with high morbidity but not expedited transplant

  Journal of Pediatric Gastroenterology and Nutrition · 2025-06-27

  articleSenior author

  OBJECTIVES: Children with end-stage liver disease (ESLD) are at risk for complications including serious bacterial infections (SBI). We used the linkage of the Scientific Registry of Transplant Recipients (SRTR) and Pediatric Health Information System (PHIS) databases to examine frequency and morbidity of SBI and identify patient-specific risk factors. METHODS: We identified children listed for liver transplant between 2003 and 2019 who were hospitalized before transplant. Hospitalizations were characterized by SBI status using International Classification of Diseases (ICD) codes and healthcare utilization was compared using Chi-square and t tests. Univariate and multivariate logistic regression were performed to identify patient variables associated with pre-transplant SBI. RESULTS: A total of 1849 patients had 7601 hospitalizations and the majority (85%) were without SBI. Hospitalizations with SBI had longer length of stay (p < 0.001) and greater likelihood of needing therapies in the intensive care (p < 0.001). Almost one-third (32%) had hospitalization with SBI; in multivariate analysis, those with ascites (odds ratio [OR] 1.54 95% confidence interval [CI] 1.16-2.03) and nonprivate insurance (OR 1.40 95% CI 1.10-1.78) had higher odds of SBI. Patients with SBI had longer time on the waiting list (p = 0.023) despite being more likely to have approved exception (p = 0.006). CONCLUSIONS: Despite experiencing a life-threatening complication of ESLD, patients with SBI do not undergo more expeditious transplant. They are more likely to have approved exception requests but have longer waitlist time. The current organ allocation system does not effectively prioritize these high-risk patients. SBI risk varies by insurance status, highlighting ongoing health disparities in pediatric transplantation.

  PublisherDOI

• Frailty in Pediatric Liver Disease May Be Associated With an Increased Incidence of Readmissions After Pediatric Liver Transplantation

  Pediatric Transplantation · 2025-04-14 · 1 citations

  articleOpen access

  BACKGROUND: Frailty is a phenotype of cumulative decline leading to decreased physiologic reserve and vulnerability to stressors. Frailty is associated with adverse outcomes after liver transplantation (LT) in adults, but similar data are not available in children. A prospective multicenter study previously determined that frailty is present in 46% of children with end-stage liver disease (ESLD). We utilized this cohort to evaluate the impact of pre-transplant frailty on post-LT outcomes. METHODS: The study included pediatric participants from the original frailty study across 10 North American transplant centers who had subsequently undergone LT. Clinical outcomes were collected up to 1 year post LT. Participants were stratified by their pre-transplant frailty score (defined by a pre-LT frailty score of ≥ 6.0) and long-term outcomes were compared between groups. RESULTS: 28 (60.7% female, 46.4% biliary atresia) pediatric LT recipients were included, and 54% of children met criteria for frailty (n = 15). Baseline characteristics were comparable between groups; however, those with frailty were significantly more likely to have pre-transplant failure to thrive (33.3% vs. 0%, p = 0.044). Thirty-four hospital readmissions (22 in frail and 12 in non-frail children) occurred in 20 patients. Higher pre-transplant frailty scores were also significantly associated with an increased number of readmissions after transplantation (p = 0.034). CONCLUSIONS: Pediatric frailty may be associated with the adverse outcome of increased frequency of hospitalization in the first year after pediatric liver transplantation. These data support the concept that frail children should be identified and targeted for prehabilitation prior to LT.

  PublisherOA PDFDOI

• Identification of pediatric activated T-cell hepatitis using clinical immune studies

  Clinics and Research in Hepatology and Gastroenterology · 2024-06-25 · 7 citations

  articleOpen accessSenior author
  PublisherOA PDFDOI

Recent grants

• NIH Grant R03HS013270

  NIH · $100k · 2005

• Childhood Liver Disease Research Network (ChiLDReN) Clinical Centers

  NIH · $7.0M · 2002–2025

• NIH Grant R01HD045694

  NIH · $2.2M · 2011

Frequent coauthors

• Jean P. Molleston

  Riley Hospital for Children

  389 shared

• Simon C. Ling

  University of Toronto

  311 shared

• Marilyn J. Siegel

  New York Medical College

  310 shared

• John C. Magee

  University of Michigan–Ann Arbor

  308 shared

• Jennifer L. Nicholas

  Rainbow Babies & Children's Hospital

  308 shared

• Michael R. Narkewicz

  University of Colorado Denver

  304 shared

• Adina Alazraki

  Emory University

  296 shared

• Oscar M. Navarro

  Hospital for Sick Children

  296 shared

Labs

• Department of Medical Social SciencesPI