Corrigendum to 'Level of MFAP4 in ascites independently predicts 1-year transplant-free survival in patients with cirrhosis' [JHEP Reports 3 (2021) 100287]

Background & Aims

Prognostic models of cirrhosis underestimate disease severity for patients with cirrhosis and ascites. Microfibrillar-associated protein 4 (MFAP4) is an extracellular matrix protein linked to hepatic neoangiogenesis and fibrogenesis. We investigated ascites MFAP4 as a predictor of transplant-free survival in patients with cirrhosis and ascites.

Methods

A dual-centre observational study of patients with cirrhosis and ascites recruited consecutively in relation to a paracentesis was carried out. Patients were followed up for 1 year, until death or liver transplantation (LTx). Ascites MFAP4 was tested with the model for end-stage liver disease (MELD-Na), CLIF Consortium Acute Decompensation (CLIF-C AD), and Child-Pugh score in Cox regression models.

Results

Ninety-three patients requiring paracentesis were included. Median ascites MFAP4 was 29.7 U/ml [22.3–41.3], and MELD-Na was 19 [16–23]. A low MELD-Na score (<20) was observed in 49 patients (53%). During follow-up, 20 patients died (22%), and 6 received LTx (6%). High ascites MFAP4 (>29.7 U/ml) was associated with 1-year transplant-free survival (p = 0.002). In Cox regression, ascites MFAP4 and MELD-Na independently predicted 1-year transplant-free survival (hazard ratio [HR] = 0.97, p = 0.03, and HR = 1.08, p = 0.01, respectively). Ascites MFAP4 and CLIF-C AD also predicted survival independently (HR = 0.96, p = 0.02, and HR = 1.05, p = 0.03, respectively), whereas only ascites MFAP4 did, controlling for the Child-Pugh score (HR = 0.97, p = 0.03, and HR = 1.18, p = 0.16, respectively). For patients with MELD-Na <20, ascites MFAP4 but not ascites protein predicted 1-year transplant-free survival (HR 0.91, p = 0.02, and HR = 0.94, p = 0.17, respectively).

Conclusions

Ascites MFAP4 predicts 1-year transplant-free survival in patients with cirrhosis and ascites. In patients with low MELD-Na scores, ascites MFAP4, but not total ascites protein, significantly predicted 1-year transplant-free survival.

Lay summary

Patients with cirrhosis who have fluid in the abdomen, ascites, are at an increased risk of death and in need for liver transplantation. Our study identified patients with ascites and a poor prognosis by measuring microfibrillar associated protein 4 (MFAP4), a protein present in the abdominal fluid. Patients with low levels of the MFAP4 protein are at particularly increased risk of death or liver transplantation, suggesting that clinical care should be intensified in this group of patients.

•

MFAP4 is a protein linked to liver fibrosis that can be found in the ascitic fluid in patients with cirrhosis.

•

MFAP4 in the ascitic fluid correlates with MELD-Na, Child-Pugh, and CLIF-C AD.

•

Ascites MFAP4 independently predicts 1-year transplant-free survival in patients with cirrhosis and ascites.

•

Ascites MFAP4 but not total ascites protein is associated with transplant-free survival in patients with MELD-Na <20.

•

Future prognostic models in decompensated cirrhosis may be enhanced by the incorporation of ascites MFAP4.

Clinical efficacies, underlying mechanisms and molecular targets of Chinese medicines for diabetic nephropathy treatment and management

Diabetic nephropathy (DN) has been recognized as a severe complication of diabetes mellitus and a dominant pathogeny of end-stage kidney disease, which causes serious health problems and great financial burden to human society worldwide. Conventional strategies, such as renin-angiotensin-aldosterone system blockade, blood glucose level control, and bodyweight reduction, may not achieve satisfactory outcomes in many clinical practices for DN management. Notably, due to the multi-target function, Chinese medicine possesses promising clinical benefits as primary or alternative therapies for DN treatment. Increasing studies have emphasized identifying bioactive compounds and molecular mechanisms of reno-protective effects of Chinese medicines. Signaling pathways involved in glucose/lipid metabolism regulation, antioxidation, anti-inflammation, anti-fibrosis, and podocyte protection have been identified as crucial mechanisms of action. Herein, we summarize the clinical efficacies of Chinese medicines and their bioactive components in treating and managing DN after reviewing the results demonstrated in clinical trials, systematic reviews, and meta-analyses, with a thorough discussion on the relative underlying mechanisms and molecular targets reported in animal and cellular experiments. We aim to provide comprehensive insights into the protective effects of Chinese medicines against DN.

Level of MFAP4 in ascites independently predicts 1-year transplant-free survival in patients with cirrhosis

Background & Aims

Prognostic models of cirrhosis underestimate disease severity for patients with cirrhosis and ascites. Microfibrillar-associated protein 4 (MFAP4) is an extracellular matrix protein linked to hepatic neoangiogenesis and fibrogenesis. We investigated ascites MFAP4 as a predictor of transplant-free survival in patients with cirrhosis and ascites.

Methods

A dual-centre observational study of patients with cirrhosis and ascites recruited consecutively in relation to a paracentesis was carried out. Patients were followed up for 1 year, until death or liver transplantation (LTx). Ascites MFAP4 was tested with the model for end-stage liver disease (MELD-Na), CLIF Consortium Acute Decompensation (CLIF-C AD), and Child-Pugh score in Cox regression models.

Results

Ninety-three patients requiring paracentesis were included. Median ascites MFAP4 was 29.7 U/L [22.3–41.3], and MELD-Na was 19 [16–23]. A low MELD-Na score (<20) was observed in 49 patients (53%). During follow-up, 20 patients died (22%), and 6 received LTx (6%). High ascites MFAP4 (>29.7 U/L) was associated with 1-year transplant-free survival (p = 0.002). In Cox regression, ascites MFAP4 and MELD-Na independently predicted 1-year transplant-free survival (hazard ratio [HR] = 0.97, p = 0.03, and HR = 1.08, p = 0.01, respectively). Ascites MFAP4 and CLIF-C AD also predicted survival independently (HR = 0.96, p = 0.02, and HR = 1.05, p = 0.03, respectively), whereas only ascites MFAP4 did, controlling for the Child-Pugh score (HR = 0.97, p = 0.03, and HR = 1.18, p = 0.16, respectively). For patients with MELD-Na <20, ascites MFAP4 but not ascites protein predicted 1-year transplant-free survival (HR 0.91, p = 0.02, and HR = 0.94, p = 0.17, respectively).

Conclusions

Ascites MFAP4 predicts 1-year transplant-free survival in patients with cirrhosis and ascites. In patients with low MELD-Na scores, ascites MFAP4, but not total ascites protein, significantly predicted 1-year transplant-free survival.

Lay summary

Patients with cirrhosis who have fluid in the abdomen, ascites, are at an increased risk of death and in need for liver transplantation. Our study identified patients with ascites and a poor prognosis by measuring microfibrillar associated protein 4 (MFAP4), a protein present in the abdominal fluid. Patients with low levels of the MFAP4 protein are at particularly increased risk of death or liver transplantation, suggesting that clinical care should be intensified in this group of patients.

•

MFAP4 is a protein linked to liver fibrosis that can be found in the ascitic fluid in patients with cirrhosis.

•

MFAP4 in the ascitic fluid correlates with MELD-Na, Child-Pugh, and CLIF-C AD.

•

Ascites MFAP4 independently predicts 1-year transplant-free survival in patients with cirrhosis and ascites.

•

Ascites MFAP4 but not total ascites protein is associated with transplant-free survival in patients with MELD-Na <20.

•

Future prognostic models in decompensated cirrhosis may be enhanced by the incorporation of ascites MFAP4.

Laparoscopic renal surgery is here to stay

Objectives

To review the current literature comparing the outcomes of renal surgery via open, laparoscopic and robotic approaches.

Materials and methods

A comprehensive literature search was performed on PubMed, MEDLINE and Ovid, to look for studies comparing outcomes of renal surgery via open, laparoscopic, and robotic approaches.

Results

Limited good-quality evidence suggests that all three approaches result in largely comparable functional and oncological outcomes. Both laparoscopic and robotic approaches result in less blood loss, analgesia requirement, with a shorter hospital stay and recovery time, with similar complication rates when compared with the open approach. Robotic renal surgeries have not shown any significant clinical benefit over a laparoscopic approach, whilst the associated cost is significantly higher.

Conclusion

With the high cost and lack of overt clinical benefit of the robotic approach, laparoscopic renal surgery will likely continue to remain relevant in treating various urological pathologies.

Robotic partial nephrectomy: The new horizon

Background

There has been an exponential growth in the reporting of series of robotic partial nephrectomy (RPN). We review the technique of RPN and the outcomes from large single-centre series of RPN.

Methods

We searched databases to identify original articles related to RPN. For the technical aspects, we describe our technique and provide a general review of previous work. For outcomes, we reviewed previous reports using more rigid criteria, including only single-institution studies with at least 50 patients undergoing RPN.

Results

We found seven retrospective studies that met our criteria, with a total of 701 patients. Mean tumour size was 2.8 cm, with an average R.E.N.A.L. score (Radius, tumour size as maximum diameter; Exophytic/endophytic properties of the tumour, Nearness of tumour deepest portion to the collecting system or sinus, Anterior, a/posterior, p, descriptor, and the Location relative to the polar line) of 6.8. The mean warm ischaemia time was 21 min and mean operative duration was 196 min. The mean estimated blood loss was 182 mL, with a 7.4% transfusion rate. The conversion rate was 1.7% and the postoperative complication rate was 14%. The mean length of stay was 3.6 days. There were positive surgical margins in 1.7% of patients. The mean decrease in renal function was 5.4% and the mean follow-up was 8.4 months.

Conclusions

RPN is feasible and safe for different levels of complexity of renal tumours. Perioperative outcomes are comparable to those found with more established techniques. Future studies should compare different approaches and prioritise prospective and randomised designs.

Controversies related to living kidney donors

Background

Increasing the living-donor pool by accepting donors with an isolated medical abnormality (IMA) can significantly decrease the huge gap between limited supply and rising demand for organs. There is a wide range of variation among different centres in dealing with these categories of donors. We reviewed studies discussing living kidney donors with IMA, including greater age, obesity, hypertension, microscopic haematuria and nephrolithiasis, to highlight the effect of these abnormalities on both donor and recipient sides from medical and surgical perspectives.

Methods

We systematically searched MEDLINE, ISI Science Citation Index expanded, and Google scholar, from the inception of each source to January 2011, using the terms ‘kidney transplant’, ‘renal’, ‘graft’, ‘living donor’, ‘old’, ‘obesity’, ‘nephrolithiasis’, ‘haematuria’ and ‘hypertension’. In all, 58 studies were found to be relevant and were reviewed comprehensively.

Results

Most of the reviewed studies confirmed the safety of using elderly, moderately obese and well-controlled hypertensive donors. Also, under specific circumstances, donors with nephrolithiasis can be accepted. However, persistent microscopic haematuria should be considered seriously and renal biopsy is indicated to exclude underlying renal disease.

Conclusion

Extensive examination and cautious selection with tailored immunosuppressive protocols for these groups can provide a satisfactory short- and medium-term outcome. Highly motivated elderly, obese, controlled hypertensive and the donor with a unilateral small stone (<1.5 cm, with normal metabolic evaluation) could be accepted. Donors with dysmorphic and persistent haematuria should not be accepted. A close follow-up after donation is crucial, especially for obese donors who developed microalbuminuria.