Otoemisiones en los niños tratados con gentamicina de un hospital comarcal / Otoacoustic emissions in children treated with gentamicin in a secondary hospital

INTRODUCCIÓN: Las recomendaciones de la Comisión Nacional para la Detección Precoz de la Hipoacusia (CODEPEH) aconsejan re-valorar la audición de aquellos niños que hayan sufrido algún evento potencialmente dañino para la audición como es la utilización de antibióticos ototóxicos como la gentamicina. Las otoemisiones evocadas son un buen método de evaluación de la integridad de la función coclear. MATERIAL Y MÉTODO: Se presenta un estudio prospectivo que incluye a 92 niños, sin otros factores de riesgo auditivo, en los que se pautó tratamiento con gentamicina intravenosa por riesgo séptico/sepsis o infección urinaria y en los que se realizaron otoemisiones seriadas: al ingreso, al finalizar el tratamiento y al mes del alta (si estaban alteradas). RESULTADOS: Ningún sujeto presentó otoemisiones alteradas al final del seguimiento. CONCLUSIÓN: La gentamicina parece un antibiótico seguro en tratamientos con una duración < 10 días y a las dosis descritas. Las otoemisiones son un método barato, rápido, incruento y fiable para comprobar la posible ototoxicidad por gentamicina. Su realización podría ahorrar la determinación de niveles del fármaco

INTRODUCTION: The National Commission for the Early Detection of Hearing Loss (CODEPEH) recommends the re-evaluation of hearing in children who have suffered any potentially harmful event, such as the prescription of ototoxic antibiotics such as gentamicin. The evoked otoacoustic emissions (EOAE) are a good method for assessing the integrity of cochlear functionality. MATERIAL AND METHOD: A prospective study is presented, including 92 children who were treated with intravenous gentamicin for septic risk/sepsis or urinary tract infection. The children underwent serial EOAE: on admission, at the end of treatment and one month later (if altered on discharge). RESULTS: In the end, none of the subjects were affected by the treatment. CONCLUSION: Gentamicin appears to be a safe antibiotic in treatments lasting < 10 days and at the doses described. EOAE are an inexpensive, fast, non-invasive and reliable method to check for gentamicin ototoxicity. This could save in the determination of drug levels

Otoacoustic emissions in children treated with gentamicin in a secondary hospital. / Otoemisiones en los niños tratados con gentamicina de un hospital comarcal.

INTRODUCTION: The National Commission for the Early Detection of Hearing Loss (CODEPEH) recommends the re-evaluation of hearing in children who have suffered any potentially harmful event, such as the prescription of ototoxic antibiotics such as gentamicin. The evoked otoacoustic emissions (EOAE) are a good method for assessing the integrity of cochlear functionality. MATERIAL AND METHOD: A prospective study is presented, including 92 children who were treated with intravenous gentamicin for septic risk/sepsis or urinary tract infection. The children underwent serial EOAE: on admission, at the end of treatment and one month later (if altered on discharge). RESULTS: In the end, none of the subjects were affected by the treatment. CONCLUSION: Gentamicin appears to be a safe antibiotic in treatments lasting <10days and at the doses described. EOAE are an inexpensive, fast, non-invasive and reliable method to check for gentamicin ototoxicity. This could save in the determination of drug levels.

Estudio de un método inmunoturbidimétrico para la cuantificación de procalcitonina y su capacidad para el diagnóstico de sepsis / Study of an immunoturbidimetric method for quantifying procalcitonin and its ability to diagnose sepsis

Introducción. La procalcitonina (PCT) es un marcador bioquímico para el diagnóstico de sepsis. La electroquimioluminiscencia se considera actualmente el método de referencia para cuantificar PCT. El objetivo de este trabajo es estudiar un método inmunoturbidimétrico para cuantificar la PCT, comprobar su correlación analítica con el método electroquimioluminiscente y establecer su capacidad para el diagnóstico de sepsis bacteriana. Material y métodos. El método inmunoturbidimétrico fue el Diazyme® Procalcitonin Assay (Diazyme Laboratories, Poway, CA, EE. UU.) y el método electroquimioluminiscente fue el Elecsys Brahms PCT (Roche Diagnostics®). El estudio comparativo se realizó con muestras de plasma de pacientes provenientes de diferentes servicios del Hospital Francesc de Borja. Las muestras se analizaron en paralelo en un modular Cobas 6000 (Roche Diagnostics®). Resultados. Se analizaron 97 muestras. Se obtuvo un coeficiente de correlación intraclase de 0,86 (IC 95%: 0,80-0,91). Comparando los dos métodos según los rangos aceptados en la literatura, se observó un acuerdo total del 79,4%, con un coeficiente k no ponderado de 0,72 (IC 95%: 0,61-0,83) y de 0,82 (IC 95%: 0,74-0,90) tras ponderación con pesos lineales. Se obtuvo un área bajo la curva de 0,88 para el método electroquimioluminiscente y de 0,86 para el método inmunoturbidimétrico. Las odds ratio para la PCT fueron 1,19 (IC 95%: 1,06-1,33) y 1,06 (IC 95%: 1,00-1,11) medida por electroquimioluminiscencia y por inmunoturbidimetría, respectivamente. Conclusiones. El método inmunoturbidimétrico de Diazyme® es un método fiable para el diagnóstico y manejo de los pacientes con sospecha de sepsis tal y como lo es en la actualidad el método electroquimioluminiscente de Brahms® (AU)

Introduction. Procalcitonin (PCT) is a biochemical marker for the diagnosis of sepsis. Electrochemiluminescence is currently considered the reference method for quantifying PCT. The aim of this work is to study an immunoturbidimetric method to measure PCT, compare it with electrochemiluminescence method, and establish its capacity for diagnosis of bacterial sepsis. Material and methods. The immunoturbidimetric method was the Diazyme® Procalcitonin Assay (Diazyme Laboratories, Poway, CA, USA), and the electrochemiluminescence method was the Elecsys Brahms PCT. The comparative study was performed with patient plasma samples from different services of the Hospital Francesc de Borja. Samples were analysed in parallel on a Cobas 6000 modular. Results. A total of 97 samples were analysed. Intraclass correlation coefficient of 0.86 (95% CI: 0.80-0.91) was obtained. Comparing the two methods according to the ranges accepted in the literature, total agreement of 79.4% was observed, with an unweighted k coefficient of 0.72 (95% CI: 0.61 - 0.83) and 0.82 (95% CI: 0.74 - 0.90) after weighting with linear weights. An Area under the curve of 0.88 was obtained for the electrochemiluminescence method and 0.86 for the immunoturbidimetric method. The odds ratio for the PCT were 1.19 (95% CI: 1.06 - 1.33) and 1.06 (95% CI: 1.00 - 1.11) measured by electrochemiluminescence and immunoturbidimetry, respectively. Conclusions. Diazyme® immunoturbidimetric method seems to be as reliable a method for the diagnosis and management of patients with suspected sepsis as the current Brahms® electrochemiluminescence method (AU)

Valor pronóstico comparativo del pro-péptido natriurético tipo B aminoterminal urinario en pacientes con insuficiencia cardiaca aguda descompensada / Comparative Prognostic Value of Plasma and Urinary N-Terminal Pro-B-Type Natriuretic Peptide in Patients With Acute Destabilized Heart Failure

Introducción y objetivos: Se ha sugerido que las concentraciones urinarias de la porción aminoterminal del pro-péptido natriurético tipo B (NT-proBNP) pueden tener valor pronóstico en pacientes con insuficiencia cardiaca estable, pero hasta ahora no se ha realizado una comparación directa con las concentraciones plasmáticas de este marcador en pacientes con una insuficiencia cardiaca aguda descompensada (ICAD). El objetivo de este estudio fue comparar el valor pronóstico de la concentración plasmática de NT-proBNP con el de la concentración urinaria de este marcador en la estratificación del riesgo de los pacientes con ICAD.Métodos: Se estudió prospectivamente a pacientes consecutivos hospitalizados con ICAD. A la llegada al hospital, se obtuvieron simultáneamente muestras de sangre y orina, para determinar las concentraciones de NT-proBNP. Se realizó un seguimiento clínico, y se registraron la mortalidad y la hospitalización por insuficiencia cardiaca.Resultados: Se incluyó un total de 138 pacientes (mediana de edad, 74 años [rango intercuartiles, 67-80]; 54 varones). Durante una mediana de seguimiento de 387 días [rango intercuartiles, 161-559], 65 pacientes (47%) presentaron eventos clínicos adversos. La concentración plasmática de NT-proBNP fue más alta en los pacientes que presentaron eventos clínicos adversos (4.561 pg/ml [2.191-8.631] frente a 2.906 pg/ml [1.643-5.823]; p=0,03), mientras que la concentración urinaria de NT-proBNP fue similar en ambos grupos (p=0,62). En los análisis de regresión de Cox multivariable, la concentración plasmática de NT-proBNP se asoció a un mayor riesgo de eventos clínicos adversos, tanto como variable continua (por 100 pg/ml; razón de riesgos [HR]=1,004; intervalo de confianza [IC] del 95%, 1,001-1,007; p=0,003) o categórica (≥3.345 pg/ml; HR; IC del 95%, 1,41-3,93; p=0,001). En cambio, la concentración urinaria de NT-proBNP no se asoció a una evolución clínica adversa.Conclusiones: La concentración plasmática de NT-proBNP es superior a la concentración urinaria de este marcador en la predicción de los resultados clínicos adversos en pacientes con ICAD (AU)

Introduction and objectives: Urinary concentrations of amino-terminal pro-B type natriuretic peptide (NT-proBNP) may be prognostically meaningful; however, direct comparison to plasma concentrations of this marker have not been performed in patients with acutely decompensated heart failure (ADHF). The aims of this study were to compare the prognostic value of plasma versus urinary NT-proBNP concentration for the risk stratification of patients with ADHF. Methods: Consecutive hospitalized patients with ADHF were prospectively studied. Blood and urine samples were simultaneously collected on hospital arrival to determine NT-proBNP concentrations. Clinical follow-up was obtained, and the occurrence of mortality and heart failure hospitalization was registered. Results: The study included 138 patients (median, 74 years [interquartile range, 67-80]; 54% men). During a median follow-up period of 387 days [interquartile range, 161-559], 65 patients (47%) suffered adverse clinical events. Plasma NT-proBNP concentration was higher among patients who presented adverse events (4561 pg/mL [2191-8631] vs 2906 pg/mL [1643-5823]; P=.03), whereas urinary NT-proBNP was similar in both groups (P=.62). After multivariable Cox regression analyses, plasma NT-proBNP concentration was associated with a higher risk of adverse events, whether considered continuously (per 100 pg/mL; hazard ratio [HR]=1.004; 95% confidence interval [CI], 1.001-1.007; P=.003) or categorically (≥3345 pg/mL; HR=2.35; 95% CI, 1.41-3.93; P=.001). In contrast, urinary NT-proBNP concentration was not associated with adverse outcomes. Conclusions: Plasma NT-proBNP concentration is superior to urinary NT-proBNP concentration for the prediction of adverse clinical outcomes among unselected patients with ADHF (AU)

[Comparative prognostic value of plasma and urinary N-terminal pro-B-type natriuretic peptide in patients with acute destabilized heart failure]. / Valor pronóstico comparativo del pro-péptido natriurético tipo B aminoterminal urinario en pacientes con insuficiencia cardiaca aguda descompensada.

INTRODUCTION AND OBJECTIVES: Urinary concentrations of amino-terminal pro-B type natriuretic peptide (NT-proBNP) may be prognostically meaningful; however, direct comparison to plasma concentrations of this marker have not been performed in patients with acutely decompensated heart failure (ADHF). The aims of this study were to compare the prognostic value of plasma versus urinary NT-proBNP concentration for the risk stratification of patients with ADHF. METHODS: Consecutive hospitalized patients with ADHF were prospectively studied. Blood and urine samples were simultaneously collected on hospital arrival to determine NT-proBNP concentrations. Clinical follow-up was obtained, and the occurrence of mortality and heart failure hospitalization was registered. RESULTS: The study included 138 patients (median, 74 years [interquartile range, 67-80]; 54% men). During a median follow-up period of 387 days [interquartile range, 161-559], 65 patients (47%) suffered adverse clinical events. Plasma NT-proBNP concentration was higher among patients who presented adverse events (4561 pg/mL [2191-8631] vs 2906 pg/mL [1643-5823]; P=.03), whereas urinary NT-proBNP was similar in both groups (P=.62). After multivariable Cox regression analyses, plasma NT-proBNP concentration was associated with a higher risk of adverse events, whether considered continuously (per 100 pg/mL; hazard ratio [HR]=1.004; 95% confidence interval [CI], 1.001-1.007; P=.003) or categorically (≥3345 pg/mL; HR=2.35; 95%CI, 1.41-3.93; P=.001). In contrast, urinary NT-proBNP concentration was not associated with adverse outcomes. CONCLUSIONS: Plasma NT-proBNP concentration is superior to urinary NT-proBNP concentration for the prediction of adverse clinical outcomes among unselected patients with ADHF.

ß-trace protein and cystatin C as predictors of long-term outcomes in patients with acute heart failure.

OBJECTIVES: The purpose of this study was to evaluate the prognostic importance of novel markers of renal dysfunction among patients with acutely destabilized heart failure (ADHF). BACKGROUND: ß-trace protein (BTP) and cystatin C are newer biomarkers for renal dysfunction; the prognostic importance of these tests, particularly BTP, relative to standard measures of renal function remains unclear. METHODS: A total of 220 consecutive hospitalized patients with ADHF were prospectively studied. Blood samples were collected on presentation. In-hospital worsening renal function, as well as mortality and/or heart failure (HF) hospitalization, over a median follow-up period of 500 days was examined as a function of BTP or cystatin C concentrations; results were compared with creatinine, estimated glomerular filtration rate, and blood urea nitrogen. RESULTS: Neither BTP nor cystatin C was associated with worsening renal function during the index hospitalization. A total of 116 patients (53%) either died or were hospitalized for HF during follow-up. Those with adverse outcomes had higher BTP (1.04 mg/l [range 0.80 to 1.49 mg/l] vs. 0.88 mg/l [range 0.68 to 1.17 mg/l], p = 0.003) and cystatin C (1.29 mg/l [range 1.00 to 1.71 mg/l] vs. 1.03 mg/l [range 0.86 to 1.43 mg/l], p = 0.001). After multivariable adjustment, both BTP (hazard ratio: 1.41, 95% confidence interval: 1.06 to 1.88; p = 0.018) and cystatin C (hazard ratio: 1.50, 95% confidence interval: 1.13 to 2.01; p = 0.006) were significant predictors of death/HF hospitalization, whereas serum creatinine, estimated glomerular filtration rate, and blood urea nitrogen were no longer significant. In patients with an estimated glomerular filtration rate >60 ml/min/1.73 m(2), elevated concentrations of BTP and cystatin C were still associated with significantly higher risk of adverse clinical events (p < 0.05). Net reclassification index analysis suggested cystatin C and BTP deliver comparable information regarding prognosis. CONCLUSIONS: Among patients hospitalized with ADHF, BTP and cystatin C predict risk of death and/or HF hospitalization and are superior to standard measures of renal function for this indication.

Impact of kidney dysfunction on plasma and urinary N-terminal pro-B-type natriuretic peptide in patients with acute heart failure.

The precise mechanism explaining the increased N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations among patients with concomitant acute heart failure (AHF) and kidney dysfunction is not fully understood. The aim of this study was to assess the impact of kidney dysfunction on simultaneous measures of plasma and urinary NT-proBNP in an unselected cohort of patients with AHF. One hundred thirty-eight consecutive hospitalized patients (median age: 74 years; interquartile range: 67-80 years; 54% male) with a diagnosis of AHF were prospectively studied. Blood and urine samples were collected on hospital arrival to determine NT-proBNP concentrations. Both plasma and urinary NT-proBNP concentrations increased with declining estimated glomerular filtration rate (eGFR; P<.001 for both). However, after multivariate adjustment, eGFR was found to be an independent predictor of plasma (but not urinary) NT-proBNP concentration (eGFR: ß=-0.19; P=.016). Indeed, plasma NT-proBNP was the main independent determinant of its urinary concentration (ß=0.42; P<.001), and the ratio of urine/plasma NT-proBNP was independent of kidney function and similar across the range of eGFR examined (P=.368). In patients with AHF and concomitant kidney dysfunction, the increased circulating NT-proBNP may be mainly related to increased cardiac secretion and not decreased renal clearance.

Evaluación de la eficacia del cribado prenatal del primer trimestre de embarazo en la Región de Murcia / Assessing the effectiveness of prenatal first trimester screening of pregnancy in the Region of Murcia

Introducción. El test combinado del primer trimestre permite seleccionar a las gestantes con un riesgo elevado de portar un feto con cromosomopatía con una sensibilidad y especificidad elevadas. Estas gestantes tras consejo genético pueden decidir someterse a una técnica invasiva para confirmar el diagnóstico. El objetivo de este trabajo es calcular la sensibilidad, el valor predictivo negativo y la tasa de falsos positivos del test combinado del primer trimestre en nuestro laboratorio. Material y métodos. Se estudiaron 4.494 gestantes (incluidas tanto las de embarazo único como gemelar) a las que se realizó el test combinado del primer trimestre: PAPP-A, b-HCG libre y translucencia nucal. Se comprobó el resultado del cariotipo en las gestantes cuyo cribado fue de riesgo elevado para Síndrome de Down (SD), de Edwards (SE) o ambos. En aquellas gestantes que decidieron no someterse a técnicas diagnósticas invasivas, se utilizó el cariotipo de los recién nacidos. El riesgo se calculó con el programa Prisca v.4.0.15.9® de DPC Dipesa® considerándose elevado un riesgo >1/270. Resultados. De todas las gestantes estudiadas, 260 mostraron un riesgo elevado: 201 para SD, 39 para SE y 20 para ambos. Se obtuvieron para SD y SE, respectivamente: verdaderos positivos (VP): 5 y 5; falsos positivos (FP): 216 y 54; verdaderos negativos (VN): 4273 y 4435; falsos negativos (FN): 0 y 0; Sensibilidad (S): 100% para ambos; Especificidad (E): 95% y 99%. Valor predictivo positivo (VPP): 2% y 8%; valor predictivo negativo(VPN): 100% para ambos. La tasa de falsos positivos fue del 4,83% para SD y de 1,20% para SE. Conclusiones. El cribado del primer trimestre es una herramienta eficaz que permite seleccionar a las gestantes con un riesgo >1/270 de portar un feto con cromosomopatía con una sensibilidad, especificidad y valor predictivo negativo elevados. Además su realización conlleva una disminución del número de técnicas diagnósticas invasivas (AU)

Introducción. El test combinado del primer trimestre permite seleccionar a las gestantes con un riesgo elevado de portar un feto con cromosomopatía con una sensibilidad y especificidad elevadas. Estas gestantes tras consejo genético pueden decidir someterse a una técnica invasiva para confirmar el diagnóstico. El objetivo de este trabajo es calcular la sensibilidad, el valor predictivo negativo y la tasa de falsos positivos del test combinado del primer trimestre en nuestro laboratorio. Material y métodos. Se estudiaron 4.494 gestantes (incluidas tanto las de embarazo único como gemelar) a las que se realizó el test combinado del primer trimestre: PAPP-A, b-HCG libre y translucencia nucal. Se comprobó el resultado del cariotipo en las gestantes cuyo cribado fue de riesgo elevado para Síndrome de Down (SD), de Edwards (SE) o ambos. En aquellas gestantes que decidieron no someterse a técnicas diagnósticas invasivas, se utilizó el cariotipo de los recién nacidos. El riesgo se calculó con el programa Prisca v.4.0.15.9(R) de DPC Dipesa(R) considerándose elevado un riesgo >1/270. Resultados. De todas las gestantes estudiadas, 260 mostraron un riesgo elevado: 201 para SD, 39 para SE y 20 para ambos. Se obtuvieron para SD y SE, respectivamente: verdaderos positivos (VP): 5 y 5; falsos positivos (FP): 216 y 54; verdaderos negativos (VN): 4273 y 4435; falsos negativos (FN): 0 y 0; Sensibilidad (S): 100% para ambos; Especificidad (E): 95% y 99%. Valor predictivo positivo (VPP): 2% y 8%; valor predictivo negativo (VPN): 100% para ambos. La tasa de falsos positivos fue del 4,83% para SD y de 1,20% para SE. Conclusiones. El cribado del primer trimestre es una herramienta eficaz que permite seleccionar a las gestantes con un riesgo >1/270 de portar un feto con cromosomopatía con una sensibilidad, especificidad y valor predictivo negativo elevados. Además su realización conlleva una disminución del número de técnicas diagnósticas invasivas (AU)

Evaluación de un método electroforético para el subfraccionamiento de las partículas plasmáticas de lipoproteínas de baja densidad / Evaluation of an electrophoresis method to obtain plasma low density lipoproteins subfractions

Desde que el NCEP ATP III (National Cholesterol Education Program. Adult Treatment Panel III) aceptó el predominio de partículas LDL (low density lipoproteins "lipoproteínas de baja densidad") pequeñas y densas como factor de riesgo emergente de desarrollo de enfermedad cardiovascular, el interés por los métodos para fraccionar las LDL ha aumentado. Por eso, el presente trabajo pretende valorar la utilidad de un sistema de electroforesis en gel de poliacrilamida (Lipoprint(R)) para separar LDL en nuestra población. Se recogieron 194 muestras de sangre de personas de entre 15 y 94 años (el 49%, hombres) y se calculó la imprecisión del ensayo, así como los valores de referencia por sexo. Además, se realizaron correlaciones entre los distintos parámetros lipídicos. Se obtuvieron resultados aceptables para el estudio de imprecisión mediante el sistema Lipoprint®. Al correlacionar el diámetro medio de las partículas LDL con otros marcadores del metabolismo lipídico, destacamos una asociación inversamente proporcional con la concentración de triglicéridos y apolipoproteína (apo) B100 y directamente proporcional con la de colesterol ligado a lipoproteínas de alta densidad (cHDL). Encontramos diferencias entre sexos en los niveles de triglicéridos y colesterol ligado a LDL (mayores en hombres), y cHDL y diámetro medio de las partículas LDL (mayores en mujeres). Al comparar el diámetro medio de las partículas LDL con los parámetros lipídicos encontramos que está asociado inversamente con la concentración de triglicéridos y apo B100, y directamente con la de cHDL, lo que se asocia a un mayor riesgo cardiovascular. El sistema Lipoprint® es útil para la medida de la concentración y diámetro medio de las partículas LDL debido a su sencillez y rapidez de resultados. Aún así faltan estudios que relacionen los resultados obtenidos con los parámetros clínicos que se emplean en la valoración del riesgo cardiovascular (AU)

Since NCEP ATP III accepted the small and dense LDL particle as an emergent risk factor of cardiovascular disease, the methods to calculate LDL subfractions have increased. The present report attempts to evaluate the usefulness of a polyacrylamide gel electrophoresis system (LipoprintTM) to separate LDL in our population. 194 blood samples were collected from subjects between 15–94 years old (49% men). Imprecision and lipid parameter study population ranges by sex, and the correlations between them were calculated. Imprecision study results were acceptable. When correlating the average diameter of particle LDL with other lipid markers, we observed an inverse association with triglyceride concentration and Apo B100, and a direct association with HDL-cholesterol. We found differences between sex in triglyceride and LDL-cholesterol levels (greater in men) and HDL-cholesterol and average diameter of LDL particles (greater in women). When comparing the average LDL particle diameter with the lipid parameters, we found that it is inversely associated with the triglyceride and Apo B100 concentration, and directly with HDL-cholesterol, which is associated with a greater cardiovascular risk. We believe that LipoprintTM system is useful for the measurement of the concentration and average diameter of LDL particles, due to its simplicity and speed of results. Nevertheless, studies are needed that can associate the results obtained to the clinical parameters that are used in the evaluation of cardiovascular risk (AU)

Complementary prognostic value of cystatin C, N-terminal pro-B-type natriuretic Peptide and cardiac troponin T in patients with acute heart failure.

The aims of this study were to compare the prognostic value of cystatin C over creatinine and the Modification of Diet in Renal Disease (MDRD) equation and to evaluate whether it provides complementary information to cardiac biomarkers in the risk stratification of an unselected cohort of patients with acute heart failure. Consecutive hospitalized patients with established diagnoses of acute heart failure were prospectively studied. Blood samples were collected on hospital arrival to determine cystatin C, cardiac troponin T, and N-terminal-pro-brain natriuretic peptide. Clinical follow-up was obtained, and the occurrence of mortality and/or heart failure readmission was registered. One hundred thirty-eight patients (median age 74 years, interquartile range 67 to 80; 54% men) were studied. During a median follow-up period of 261 days (interquartile range 161 to 449), 60 patients (43.5%) presented with adverse events. After multivariate adjustment, cystatin C, N-terminal-pro-brain natriuretic peptide, cardiac troponin T, New York Heart Association functional class III or IV, and diabetes mellitus were identified as independent predictors of mortality and/or heart failure readmission. In contrast to creatinine and the MDRD equation, the highest cystatin C tertile (>1.50 mg/L) was a significant independent risk factor for adverse events (hazard ratio 3.08, 95% confidence interval 1.54 to 6.14, p = 0.004). A multimarker approach combining cardiac troponin T, N-terminal-pro-brain natriuretic peptide, and cystatin C improved risk stratification further, showing that patients with 2 (hazard ratio 2.37, 95% confidence interval 1.10 to 5.71) or 3 (hazard ratio 3.64, 95% confidence interval 1.55 to 8.56) elevated biomarkers had a higher risk for adverse events than patients with no elevated biomarkers (p for trend = 0.015). In conclusion, in this unselected cohort, cystatin C was a stronger predictor of adverse events than conventional measures of kidney function. In addition, cystatin C offered complementary prognostic information to cardiac biomarkers and could help clinicians perform more accurate risk stratification of patients with acute heart failure.

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