Die präoperative Nierenfunktion und der EuroSCORE II als Prädiktoren für Komplikationen und Mortalität nach elektiven kardiochirurgischen Eingriffen

Die Abschätzung der postoperativen 30-Tage-Mortalität nach einer Herzoperation erfolgt seit 2012 anhand des EuroSCORE II. Dieser umfasst insgesamt 18 Risikofaktoren wie Alter, Geschlecht, Art des Eingriffes und den kardialen Zustand Auf der Basis einer prospektiven Kohortenstudie zwischen 02/2010 und 03/2011 sollte die prognostische Wertigkeit der eingehenden Risikofaktoren für die postoperative Mortalität und Komplikationen im Vergleich zum präoperativ gemessenen Cystatin C untersucht werden, In die Studie gingen 860 Patienten ein. Endpunkte waren die postoperative Mortalität, ein akutes Nierenversagen und eine nicht-okklusive Darmischämie. Ein postoperatives akutes Nierenversagen trat in 26,2 % auf, nicht-okklusive Darmischämie in 9,1 % und Tod in 3,1 %. Der EuroSCORE II überschätzte die Mortalität mit 6,2% und wies damit eine prädiktorische Wertigkeit in der ROC-Analyse mit einer AUC von 0,761 auf. Eine einzelne präoperative Bestimmung des Cystatin C erwies sich als prädiktorisch wenigstens gleichwertig (AUC 0,770). Im Hinblick auf die Komplikationen NOD und ANV war das Cystatin C dem EuroSCORE II sogar überlegen. Im Gegensatz hierzu erwiesen sich einige der Risikoparameter, die in den EuroSCORE II eingehen als wenig prädiktiv für Komplikationen oder Outcome. Interessanterweise zeigte das in den EuroSCORE II eingehende Kreatinin, bzw. die GFR auf Basis der Berechnung nach Cockrofft-Gault eine geringere prädiktorische Kapazität für die Endpunkte als das Cystatin C. Die Nierenfunktion als guter Prädiktor für Outcome und Komplikationen nach kardiochirurgischem Eingriff ist seit langem bekannt. Eine mögliche Erklärung für die unterschiedliche prädiktorische Wertigkeit von Cystatin C und Kreatinin wäre, dass durch das Cystatin C die renale Funktion exakter abgebildet wird und damit eine bessere Prädiktion verbunden sein könnte. Dies würde letztlich auch erklären können, weshalb das Cystatin C eine dem 18 Parameter umfassenden EuroSCORE II vergleichbare prognostische Wertigkeit für das Auftreten von Komplikationen und outcome nach kardiochirurgischen Eingriffen aufweist.The EuroSCORE II has been used since 2012 to predict early mortality in cardiosurgical patients. It is based on a specific range of risk factors including age, gender, type of surgical intervention and heart function. A prospective cohort study was carried out from 02/2010 to 03/2011 with the aim to determine the prognostic significance of the included risk factors when it comes to predicting postsurgical mortality as well as complications compared to measuring the cystatin C pre-surgery. The study included 860 patients. The endpoints were postoperative mortality, acute renal failure and non-occlusive bowel ischemia. Postoperative renal failure occurred in 26.2% of the patients, non-occlusive bowel ischemia in 9.1% and death in 3.1% of patients. The EuroSCORE II overestimated the mortality by 6.2% and delivered a predictive significance in the ROC analysis with 0.761 AUC. The individual preoperative measurement of cystatin C proved to be of similar accuracy with AUC 0.770. If cystatin C was used to predict the outcome in cases of renal failure or non-occlusive bowel ischemia it was even superior to the EuroSCORE II. At the same time it was found that a number of risk factors that are included in the EuroSCORE II had very little significance in predicting complications or outcome. Interestingly, it was found that the creatinine that is included in the EuroSCORE II or the GFR using the Cockroft-Gauck method, had a less accurate predictive significance than the cystatin C. It has been known for some time that the renal function can be used as a valid predictor for outcome and complications following a cardiac surgical intervention. The difference in the predictive significance of cystatin C and creatinine could be explained with the fact that cystatin C more closely mirrors the renal function and therefore offers a better prediction. This could also explain why the cystatin C on its own has a similar prognostic significance to the EuroSCORE II including its 18 parameters when looking to predict outcome and complications of post-cardiac interventions

Clinical trial of ABCB5+ mesenchymal stem cells for recessive dystrophic epidermolysis bullosa

BACKGROUND. Recessive dystrophic epidermolysis bullosa (RDEB) is a rare, devastating, and lifethreatening inherited skin fragility disorder that comes about due to a lack of functional type VII collagen, for which no effective therapy exists. ABCB5+ dermal mesenchymal stem cells (ABCB5+ MSCs) possess immunomodulatory, inflammation-dampening, and tissue-healing capacities. In a Col7a1-/-mouse model of RDEB, treatment with ABCB5+ MSCs markedly extended the animals\u27 lifespans. METHODS. In this international, multicentric, single-arm, phase I/IIa clinical trial, 16 patients (aged 4-36 years) enrolled into 4 age cohorts received 3 i.v. infusions of 2 × 106ABCB5+ MSCs/kg on days 0, 17, and 35. Patients were followed up for 12 weeks regarding efficacy and 12 months regarding safety. RESULTS. At 12 weeks, statistically significant median (IQR) reductions in the Epidermolysis Bullosa Disease Activity and Scarring Index activity (EBDASI activity) score of 13.0% (2.9%-30%; P = 0.049) and the Instrument for Scoring Clinical Outcome of Research for Epidermolysis Bullosa clinician (iscorEB-c) score of 18.2% (1.9%-39.8%; P = 0.037) were observed. Reductions in itch and pain numerical rating scale scores were greatest on day 35, amounting to 37.5% (0.0%-42.9%; P = 0.033) and 25.0% (-8.4% to 46.4%; P = 0.168), respectively. Three adverse events were considered related to the cell product: 1 mild lymphadenopathy and 2 hypersensitivity reactions. The latter 2 were serious but resolved without sequelae shortly after withdrawal of treatment. CONCLUSION. This trial demonstrates good tolerability, manageable safety, and potential efficacy of i.v. ABCB5+ MSCs as a readily available disease-modifying therapy for RDEB and provides a rationale for further clinical evaluation

A single preoperative FGF23 measurement is a strong predictor of outcome in patients undergoing elective cardiac surgery: a prospective observational study

Abstract Introduction Several scoring systems have been developed to predict postoperative mortality and complications in patients undergoing cardiac surgery. However, these computer-based calculations are time- and cost-intensive. A simple but highly predictive test for postoperative risk would be of clinical benefit with respect to increasingly scarce hospital resources. We therefore assessed the predictive power of fibroblast growth factor 23 (FGF23) measurement compared with an established scoring system. Methods We conducted a prospective interdisciplinary observational study at the Saarland University Medical Centre that included 859 patients undergoing elective cardiac surgery between January 2010 and March 2011 with a median follow-up after discharge of 822 days. We compared a single preoperative measurement of FGF23 as a prognostic tool with the 18 parameters comprising EuroSCORE II with respect to postoperative mortality, acute kidney injury, non-occlusive mesenteric ischemia, clinical course and long-term outcome. Results Preoperative FGF23 levels were highly predictive of postoperative outcome and complications. The predictive value of FGF23 for mortality in the receiver operating characteristic curve was greater than the EuroSCORE II (area under the curve: 0.800 versus 0.725). Moreover, preoperative FGF23 independently predicted postoperative acute kidney injury and non-occlusive mesenteric ischemia comparably to the EuroSCORE II. Finally, FGF23 was found to be an independent predictor of clinical course parameters, including duration of surgery, ventilation time and length of stay. Conclusions In patients undergoing elective cardiac surgery, a simple preoperative FGF23 measurement is a powerful indicator of surgical mortality, postoperative complications and long-term outcome. Its utility compares to the widely used EuroSCORE II. </jats:sec