Haemodialysis session: The perfect storm for vascular calcification

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Pacientes agrupados según calcio basal y baño de calcio empleado. Aquellos dializados con baño Ca++ 1,25 mM presentan productos Ca++ × P finales significativamente más bajos (10,1±3,84 vs. 13,99±4,41; p=0,02). En este grupo, el descenso del producto Ca++ × P es significativamente mayor (−13,79±7,09 vs. −8,74±4,17; p=0,04)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Miguel Seras, Ángel Luis Martín de Francisco, Celestino Piñera, Simón Gundin, Marta García-Unzueta, Maria Kislikova, Zoila Albines, Mara Serrano, Manuel Arias" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Miguel" "apellidos" => "Seras" ] 1 => array:2 [ "nombre" => "Ángel Luis" "apellidos" => "Martín de Francisco" ] 2 => array:2 [ "nombre" => "Celestino" "apellidos" => "Piñera" ] 3 => array:2 [ "nombre" => "Simón" "apellidos" => "Gundin" ] 4 => array:2 [ "nombre" => "Marta" "apellidos" => "García-Unzueta" ] 5 => array:2 [ "nombre" => "Maria" "apellidos" => "Kislikova" ] 6 => array:2 [ "nombre" => "Zoila" "apellidos" => "Albines" ] 7 => array:2 [ "nombre" => "Mara" "apellidos" => "Serrano" ] 8 => array:2 [ "nombre" => "Manuel" "apellidos" => "Arias" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S201325141500070X" "doi" => "10.1016/j.nefroe.2015.09.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S201325141500070X?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699515000727?idApp=UINPBA000064" "url" => "/02116995/0000003500000005/v1_201511030046/S0211699515000727/v1_201511030046/es/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2013251415000978" "issn" => "20132514" "doi" => "10.1016/j.nefroe.2015.11.004" "estado" => "S300" "fechaPublicacion" => "2015-09-01" "aid" => "84" "copyright" => "Sociedad Española de Nefrología" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2015;35:457-64" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5369 "formatos" => array:3 [ "EPUB" => 334 "HTML" => 4347 "PDF" => 688 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Clinical evolution of chronic renal patients with HIV infection in replacement therapy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "457" "paginaFinal" => "464" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evolución clínica de los enfermos renales crónicos en tratamiento sustitutivo con infección por VIH" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2906 "Ancho" => 3270 "Tamanyo" => 330065 ] ] "descripcion" => array:1 [ "en" => "Causes of primary renal disease in incident patients with HIV, according to the EDTA classification groups and codes." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ramón Saracho, Eduardo Martín Escobar, Jordi Comas Farnés, Emma Arcos, Auxiliadora Mazuecos Blanca, Miguel Ángel Gentil Govantes, Pablo Castro de la Nuez, Óscar Zurriaga, Manuel Ferrer Alamar, Encarnación Bouzas Caamaño, Teresa García Falcón, José Portolés Pérez, José A. Herrero Calvo, Carlos Chamorro Jambrina, Íñigo Moina Eguren, María Teresa Rodrigo de Tomás, José María Abad Díez, José I. Sánchez Miret, Rafael Alvarez Lipe, Rafael Díaz Tejeiro, Inmaculada Moreno Alía, Marta Torres Guinea, Enma Huarte Loza, Marta Artamendi Larrañaga, Carlos Fernández Renedo, Raquel González Fernández, Emilio Sánchez Álvarez, Ramón Alonso de la Torre" "autores" => array:28 [ 0 => array:2 [ "nombre" => "Ramón" "apellidos" => "Saracho" ] 1 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Martín Escobar" ] 2 => array:2 [ "nombre" => "Jordi" "apellidos" => "Comas Farnés" ] 3 => array:2 [ "nombre" => "Emma" "apellidos" => "Arcos" ] 4 => array:2 [ "nombre" => "Auxiliadora" "apellidos" => "Mazuecos Blanca" ] 5 => array:2 [ "nombre" => "Miguel Ángel" "apellidos" => "Gentil Govantes" ] 6 => array:2 [ "nombre" => "Pablo" "apellidos" => "Castro de la Nuez" ] 7 => array:2 [ "nombre" => "Óscar" "apellidos" => "Zurriaga" ] 8 => array:2 [ "nombre" => "Manuel" "apellidos" => "Ferrer Alamar" ] 9 => array:2 [ "nombre" => "Encarnación" "apellidos" => "Bouzas Caamaño" ] 10 => array:2 [ "nombre" => "Teresa" "apellidos" => "García Falcón" ] 11 => array:2 [ "nombre" => "José" "apellidos" => "Portolés Pérez" ] 12 => array:2 [ "nombre" => "José A." "apellidos" => "Herrero Calvo" ] 13 => array:2 [ "nombre" => "Carlos" "apellidos" => "Chamorro Jambrina" ] 14 => array:2 [ "nombre" => "Íñigo" "apellidos" => "Moina Eguren" ] 15 => array:2 [ "nombre" => "María Teresa" "apellidos" => "Rodrigo de Tomás" ] 16 => array:2 [ "nombre" => "José María" "apellidos" => "Abad Díez" ] 17 => array:2 [ "nombre" => "José I." "apellidos" => "Sánchez Miret" ] 18 => array:2 [ "nombre" => "Rafael" "apellidos" => "Alvarez Lipe" ] 19 => array:2 [ "nombre" => "Rafael" "apellidos" => "Díaz Tejeiro" ] 20 => array:2 [ "nombre" => "Inmaculada" "apellidos" => "Moreno Alía" ] 21 => array:2 [ "nombre" => "Marta" "apellidos" => "Torres Guinea" ] 22 => array:2 [ "nombre" => "Enma" "apellidos" => "Huarte Loza" ] 23 => array:2 [ "nombre" => "Marta" "apellidos" => "Artamendi Larrañaga" ] 24 => array:2 [ "nombre" => "Carlos" "apellidos" => "Fernández Renedo" ] 25 => array:2 [ "nombre" => "Raquel" "apellidos" => "González Fernández" ] 26 => array:2 [ "nombre" => "Emilio" "apellidos" => "Sánchez Álvarez" ] 27 => array:2 [ "nombre" => "Ramón" "apellidos" => "Alonso de la Torre" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0211699515001368" "doi" => "10.1016/j.nefro.2015.06.027" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699515001368?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251415000978?idApp=UINPBA000064" "url" => "/20132514/0000003500000005/v2_201602120114/S2013251415000978/v2_201602120114/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2013251415000991" "issn" => "20132514" "doi" => "10.1016/j.nefroe.2015.11.006" "estado" => "S300" "fechaPublicacion" => "2015-09-01" "aid" => "83" "copyright" => "Sociedad Española de Nefrología" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "ssu" "cita" => "Nefrologia (English Version). 2015;35:421-47" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 18189 "formatos" => array:3 [ "EPUB" => 351 "HTML" => 16111 "PDF" => 1727 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "An update for atypical haemolytic uraemic syndrome: Diagnosis and treatment. A consensus document" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "421" "paginaFinal" => "447" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Actualización en síndrome hemolítico urémico atípico: diagnóstico y tratamiento. Documento de consenso" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1646 "Ancho" => 2250 "Tamanyo" => 182265 ] ] "descripcion" => array:1 [ "en" => "Complement dysregulation in atypical haemolytic uraemic syndrome. Complement activation by any of the 3 pathways (detection of foreign antigens, alternative pathway; of antibodies, classical; or mannan polysaccharides, lectin) leads to the build-up of large quantities of C3b on the activator cell membrane, causing opsonisation and C5 activation (terminal or lytic pathway), resulting in the formation of the membrane attack complex and cell lysis. Complement activation results in inflammation and leucocyte recruitment. The key process in complement activation is C3b formation, which depends on unstable enzymatic complexes – C3-convertases – catalysing the rupture of C3 to create C3b. In turn, C3b has the ability to form further C3-convertase of the alternative pathway (C3bBb), thus enhancing the initial activation. The mediation of C3B production is two-fold: dissociation of C3-convertases and proteolytic inactivation of C3b and C4b. Several regulatory proteins in plasma and the cell membrane carry out this regulatory activities, including, factor H, MCP and factor I, which play an essential role in the dissociation of C3-convertase of the alternative pathway (C3bBb) and the proteolytic degradation of C3b. Mutations in these proteins found in patients with aHUS interfere with this regulatory activity of the alternative pathway activation. Some patients with aHUS are carriers of mutations in proteins C3 and factor B organising C3-convertase. These mutations are particular, as they increase the activity of mutated proteins (gain-of-function mutations), resulting in increased complement activation and exceeding the capacity of regulatory proteins." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Josep M. Campistol, Manuel Arias, Gema Ariceta, Miguel Blasco, Laura Espinosa, Mario Espinosa, Josep M. 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"apellidos" => "Grinyó" ] 7 => array:2 [ "nombre" => "Manuel" "apellidos" => "Macía" ] 8 => array:2 [ "nombre" => "Santiago" "apellidos" => "Mendizábal" ] 9 => array:2 [ "nombre" => "Manuel" "apellidos" => "Praga" ] 10 => array:2 [ "nombre" => "Elena" "apellidos" => "Román" ] 11 => array:2 [ "nombre" => "Roser" "apellidos" => "Torra" ] 12 => array:2 [ "nombre" => "Francisco" "apellidos" => "Valdés" ] 13 => array:2 [ "nombre" => "Ramón" "apellidos" => "Vilalta" ] 14 => array:2 [ "nombre" => "Santiago" "apellidos" => "Rodríguez de Córdoba" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0211699515001356" "doi" => "10.1016/j.nefro.2015.07.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699515001356?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251415000991?idApp=UINPBA000064" "url" => "/20132514/0000003500000005/v2_201602120114/S2013251415000991/v2_201602120114/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Haemodialysis session: The perfect storm for vascular calcification" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "448" "paginaFinal" => "456" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Miguel Seras, Ángel Luis Martín de Francisco, Celestino Piñera, Simón Gundin, Marta García-Unzueta, Maria Kislikova, Zoila Albines, Mara Serrano, Manuel Arias" "autores" => array:9 [ 0 => array:3 [ "nombre" => "Miguel" "apellidos" => "Seras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Ángel Luis" "apellidos" => "Martín de Francisco" "email" => array:1 [ 0 => "angelmartindefrancisco@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Celestino" "apellidos" => "Piñera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Simón" "apellidos" => "Gundin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Marta" "apellidos" => "García-Unzueta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Maria" "apellidos" => "Kislikova" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Zoila" "apellidos" => "Albines" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Mara" "apellidos" => "Serrano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "Manuel" "apellidos" => "Arias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Análisis Clínicos, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sesión de hemodiálisis: la tormenta perfecta para la calcificación vascular" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1518 "Ancho" => 1370 "Tamanyo" => 129936 ] ] "descripcion" => array:1 [ "en" => "Temporal changes in plasma bicarbonate (mM) during haemodialysis sessions. Patients are grouped according to baseline calcium and calcium bath used. Baseline and final values of bicarbonate were independent of the calcium bath used and the baseline calcaemia: there were no significant differences between groups. 50% of patients ended the session with baseline bicarbonate levels >30mM." ] ] ] "textoCompleto" => "IntroductionVascular calcification (VC), a process inherent to ageing, is influenced by multiple classical cardiovascular risk factors, such as arterial hypertension, diabetes mellitus, obesity, and dyslipidaemia, amongst others.<a class="elsevierStyleCrossRef" href="#bib0245">1</a> In the general population, VC takes place in the intimal arterial layer,<a class="elsevierStyleCrossRef" href="#bib0250">2</a> affecting mainly central arteries (the aorta and its branches) and is linked to systemic atherosclerosis.<a class="elsevierStyleCrossRef" href="#bib0255">3</a>Cardiovascular events are the primary cause of morbidity and mortality in patients with chronic kidney disease (CKD).<a class="elsevierStyleCrossRef" href="#bib0260">4</a> In these patients, 2 patterns of VC have been described: predominantly intimal, and predominantly medial. However, there is much debate regarding the differences between intimal calcification and medial calcification. There is no definitive evidence to suggest that calcification isolated to the media is distinct from the calcification that comes from the natural history of atherosclerosis; nor is there definitive evidence to the contrary.<a class="elsevierStyleCrossRefs" href="#bib0265">5,6</a> What is certain is that it is closely related to the mixture of metabolic and biological abnormalities that accompany CKD,<a class="elsevierStyleCrossRefs" href="#bib0275">7,8</a> notably CDK-mineral and bone disorders. This entity implies abnormalities in the metabolism of calcium, phosphorus,<a class="elsevierStyleCrossRef" href="#bib0285">9</a> vitamin D,<a class="elsevierStyleCrossRefs" href="#bib0290">10,11</a> FGF23-Klotho, and parathyroid hormone (PTH).<a class="elsevierStyleCrossRef" href="#bib0300">12</a> To those we must add biological abnormalities such as dysfunctional production of calcification inhibitors by smooth muscle cells, and chronic inflammation.<a class="elsevierStyleCrossRef" href="#bib0305">13</a> Together, these factors induce physiochemical changes in the smooth muscle cells of the arterial wall, promoting their transformation into osteoblasts,<a class="elsevierStyleCrossRef" href="#bib0310">14</a> and hydroxyapatite deposition. Classically, the [Ca]×[P] product has been used to determine VC risk in renal patients.<a class="elsevierStyleCrossRef" href="#bib0315">15</a> However, some in vitro studies have demonstrated that with a stable [Ca]×[P] product, it is the individual concentration of each element that determines the development of VC.<a class="elsevierStyleCrossRef" href="#bib0320">16</a>Until now, all therapeutic efforts have been directed at controlling these metabolic abnormalities (essentially phosphate binders,<a class="elsevierStyleCrossRef" href="#bib0325">17</a> vitamin D derivatives,<a class="elsevierStyleCrossRef" href="#bib0330">18</a> and calimimetics<a class="elsevierStyleCrossRef" href="#bib0335">19</a>) and the classical risk factors, with varying and contradictory results. Although some of these treatments can slow progression, none have been demonstrated to reverse VC.<a class="elsevierStyleCrossRefs" href="#bib0340">20,21</a>In comparison with patients in the early stages of CKD, patients treated with haemodialysis (HD) have higher cardiovascular morbidity and mortality,<a class="elsevierStyleCrossRef" href="#bib0350">22</a> along with more marked abnormalities in bone metabolism and a greater degree of VC.<a class="elsevierStyleCrossRefs" href="#bib0355">23,24</a> As well as all the previously stated mechanisms, the biochemical changes produced during HD could play an important role in such marked development of VC.<a class="elsevierStyleCrossRef" href="#bib0365">25</a> In fact, in vitro studies using rat aortas have shown that changes in calcium and phosphorus concentrations and alkalinisation are precipitating factors for VC.<a class="elsevierStyleCrossRefs" href="#bib0320">16,26</a> It is also known that acidosis protects against VC,<a class="elsevierStyleCrossRef" href="#bib0375">27</a> therefore a high pH could have the unfavourable opposite effect.AimsThe aim of this study was to analyse the biochemical changes in the parameters of mineral metabolism and acid–base balance that take place during HD.Materials and methodsStudy designWe prospectively studied the changes in mineral metabolism and acid–base metabolism that occurred during haemodialysis sessions. We selected 26 stable patients with CKD who attended HD 3 times per week at our hospital centre. Mean patient age was 73.15 years±12.56 years, and 57.69% were men. Time on HD was 1871 days (standard deviation [SD] 2516.82 days; range, 45–12325 days). During the sessions it was not permitted to administer medication that would interfere with mineral metabolism or acid–base balance. All patients gave informed consent to participate in the study.Thirteen patients (50%) were randomly allocated to receive dialysis with a calcium bath concentration of 1.25mM; the other 13 patients received dialysis with a calcium bath concentration was 1.5mM. The dialysis fluid in both groups had the same concentrations of bicarbonate, 35mM; magnesium, 0.5mM; potassium, 1.5mM; and sodium, 140mM.All patients were conventionally dialysed over 4h with high flow Helixona® (Fx CorDiax 80®, Fresenius Medical Care, AG, Bad Homburg, Germany) with an ultrafiltration coefficient of 64mL/h/mmHg or with Evodial® (HeprAN Gambro) with ultrafiltration coefficient of 50mL/h/mmHg.Biochemical parameters studiedBlood samples were taken at the start of the session and subsequently at 15, 30, 60, and 120min, and at 4h, coinciding with the end of the session, to evaluate the changes produced in the variables of mineral metabolism and acid–base metabolism over the course of the HD session.Blood pH and ionised calcium normalised for pH (Ca++) were measured using direct potentiometry with an ion-selective electrode (ABL80 FLEX auto-analyser). Creatinine, urea, phosphorus, magnesium, and bicarbonate were measured using colourimetry (ADVIA 2400 auto-analyser. Siemens). Intact PTH levels in the baseline sample and final sample were measured using immunoassay (IDS-iSYS auto-analyser).The calcium–phosphorus product is expressed in mg2/dL2. The values obtained for ionised calcium in mM were converted to mg/dL according to the molecular weight of calcium (Ca++ 1mM=4mg/dL).Statistical analysisResults are expressed as mean and SD and 95% confidence interval. Statistical analysis was performed using Student's t test for independent data and a chi-square test.ResultsThe 26 patients were classified according to their baseline calcium level, into hypocalcaemic and normocalcaemic, using the normal lower limit of Ca++ in out laboratory as a reference (range, 1.16–1.3mM). The normal limits of phosphataemia used were 2.5–4.5mg/dL. The main characteristics of the sample can be seen in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, with patients grouped according to calcium bath used and baseline calcaemia. There were no significant differences between the groups regarding sex, age, days on HD, ultrafiltration, calcium bath used, or type of vascular access.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the baseline and final values of the different parameters, grouped by calcium bath used and baseline calcium level. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the overall increase of each parameter assessed, which corresponds to the difference between the mean final and mean baseline values. All results are expressed as mean and SD.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>In <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1–5</a>, the temporal changes in patient plasma calcium (mM), phosphorus (mg/dL), Ca×P product (mg2/dL2), bicarbonate (mM), and pH can be seen graphically, grouped by baseline calcium (above/below 1.16mM) and calcium bath (1.25 or 1.5mM). Below, we describe individually the changes in each of the parameters analysed.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia>Ionised calciumIndependently of the baseline calcium level or calcium bath used, in both groups there was an increase in calcaemia on finishing dialysis (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Over the course of the session there was a progressive, uniform increase in calcium (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), which was significantly higher in the group of patients dialysed with a 1.5mM Ca++ bath than in the 1.25mM group (0.23±0.08 vs 0.08±0.09, P<.001) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). In the 1.5mM group, 100% of patients finished dialysis with plasma calcium values >1.3mM, independently of the baseline calcaemia, whereas in the 1.25mM group this only happened in 15% (P<.001). The overall calcium increase was significantly higher in patients with a baseline calcium <1.16mM than in those with baseline calcium >1.16mM (0.2±0.11 vs 0.11±0.11, P=.03) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Lastly, calcium increase and mean final serum calcium levels were independent of the vascular access used, and of baseline phosphataemia: there were no statistically significant differences between those groups.PhosphorusThere were no statistically significant differences in baseline phosphorus levels or final phosphorus levels between groups according to the baseline calcium or the calcium bath used (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). During the session, there was a progressive decrease in phosphorus, which was more marked in the first hours of dialysis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). There were no significant differences between groups in the overall phosphorus decrease (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). As previously mentioned, the final serum calcium levels and the calcium increase were independent of baseline phosphorus levels: there were no significant differences between groups (normal range 2.5–4.5mg/dL).Ca×P productThe baseline calcium phosphorus product was independent of the baseline calcium and calcium bath used: there were no significant differences between groups (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Over the session, there was a fall in the Ca++×P, which was more marked in the first hour (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Patients dialysed with a 1.25mM Ca++ bath had significantly lower final Ca++×P products than those dialysed with a 1.5mM Ca++ bath (10.1±3.84 vs 13.99±4.41, P=.02). Furthermore, in the 1.25mM group, the overall decrease in the Ca++×P product was significantly greater than in the 1.5mM group (13.79±7.09 vs 8.74±4.17, P=.04) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).Bicarbonate and pHThe baseline and final values of bicarbonate and pH were independent of the baseline calcium and calcium bath used; there were no significant differences between groups (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Over the session, bicarbonate increased progressively (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The pH decreased initially in the first 30min, with subsequent alkalinisation (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Overall, 50% of patients ended the session with bicarbonate levels >30mM and 23% with pH >7.5. The overall increase in bicarbonate and the alkalinisation were similar between groups, independently of the baseline calcium or the calcium bath used (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).MagnesiumThe baseline and final values of magnesium were independent of the baseline calcium and calcium bath used; there were no significant differences between groups (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Over the session, there was a homogenous decrease in all groups, with no significant differences between groups (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).Intact parathyroid hormoneThe baseline and final levels of intact parathyroid hormone (iPTH) were lower in patients dialysed with a 1.5mM calcium bath than with a 1.25mM bath (baseline iPHT 574±379.75 vs 321.15±244.46; P=.05) (final iPHT: 496.23±400.61 vs 223.62±236.18; P=.05) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). However, there were no differences in the changes in PTH in relation to the calcium bath used or the baseline calcaemia (<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>).DiscussionIn this study we analysed the changes produced in calcium, phosphorus, magnesium, pH, and bicarbonate, during HD sessions. The induction of alkalinisation, along with the increase in serum calcium in the presence of hyperphosphataemia in the initial phases of HD constitutes a perfect environment for the development of VC.The physiochemical mechanisms responsible for VC have been studied in vitro. Lomashvili<a class="elsevierStyleCrossRef" href="#bib0320">16</a> demonstrated that the calcification of rat aortas in vitro required increased calcium and phosphorus, but was not related to the calcium–phosphorus product. Also, De Solís et al. observed that calcification was potentiated by alkalinisation in the presence of uraemic serum and even more so with the alkalinisation of the extracellular medium (pH of 7.42–7.53).<a class="elsevierStyleCrossRef" href="#bib0370">26</a> Furthermore, in in vivo studies, aortic calcification was proven to increase significantly in alkalinised animals. This is precisely what occurs during HD and what we have observed in our study. Haemodialysis sessions produce these physiochemical changes, which could be responsible, along with other factors, for the development of VC. It is the “perfect biochemical storm”, with high calcium levels and alkalinisation despite a progressive reduction in the calcium–phosphorus product. In many patients, phosphorus normalisation is not achieved until after 2h of HD, adding another factor as there is hyperphosphataemia in the first hours. What occurs post-dialysis can be considered even more critical, as at 2h there is a phosphorus rebound of up to 40%. To that could be added that the magnesium concentrations used in the dialysis fluid (0.5mM) produce a reduction in serum magnesium values during HD (<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>), which could augment even more this “perfect storm” of calcification during HD sessions. Several studies, both in vitro and in animals, have shown a protective effect of magnesium against VC through multiple mechanisms, and clinical studies also demonstrate evidence of this protective effect of magnesium against VC.<a class="elsevierStyleCrossRefs" href="#bib0380">28,29</a>In our study we used dialysis fluid with a concentration of 35mM of bicarbonate, with plasma bicarbonate increasing from 25.35±3.4mM to 29.91±2.16mM and pH from 7.38±0.06 baseline value to 7.47±0.05 final value, with an increase to above 7.50 in 23% of patients (independently of the calcium bath used). These values are similar to, or even higher than, the degree of alkalinisation that led to increased calcification in rat aortas in vitro.<a class="elsevierStyleCrossRefs" href="#bib0320">16,26</a> One of the most debatable points of this study is: if the calcium–phosphorus product is reduced during dialysis, why does the idea remain that dialysis induces VC. In the studies by Lomashvili, the concentrations of Ca++ and P were changed inversely to maintain a constant [Ca++]×[P] product, and it was observed that VC increased directly as calcium increased, despite a decrease in phosphorus. That is, calcification is not a function of the calcium–phosphorus product, but depends more on the individual concentrations of calcium and phosphorus.If the hypothesis of VC during HD is reasonable, we should progress to how to control the physiochemical factors responsible. Or rather, how to avoid the precipitating factors being present at the same time. The first change would relate to the calcium concentration of the dialysis bath. The changes in serum calcium that occur during dialysis depend on the initial serum calcium concentration, the ultrafiltration volume, and the calcium concentration of the dialysis fluid. Calcium kinetics during HD sessions have already been studied by various authors, using different calcium bath concentrations and different HD tecnhiques<a class="elsevierStyleCrossRefs" href="#bib0390">30,31</a>: serum calcium increased to 1.32 and 1.45mM during HD sessions with dialysis fluid calcium concentrations of 1.25 and 1.5mM, respectively. Conversely, in patients with baseline calcaemia in the normal range, the calcium balance is neutral or negative with dialysis fluid concentrations of 1.25mM.<a class="elsevierStyleCrossRef" href="#bib0400">32</a> However, as in our study, in patients with a low baseline calcium, ionised calcium can increase during dialysis with a 1.25mM concentration. In reality, the KDIGO guidelines suggest a dialysis fluid calcium concentration of between 1.25 and 1.50mM,<a class="elsevierStyleCrossRef" href="#bib0405">33</a> based on the theory that a concentration of 1.25mM means a neutral calcium balance. However, Gotch et al. demonstrated very different results with 2 kinetic models. By analysing calcium transport across the dialyser during dialysis, they observed that each session induced more than 500mg of calcium transport. In the kinetic analysis of intestinal absorption of calcium in 320 patients on HD, the study by Gotch concluded that calcium absorption was strongly dependent on the dose of vitamin D analogues and much less so on ingested calcium. The most important conclusion to relate to our study about possible VC during HD was that 70% of patients who received calcium binders and between 20% and 50% of those who take non-calcium binders required a dialysis fluid calcium concentration lower than 1.25mM to prevent long-term calcium build-up.<a class="elsevierStyleCrossRefs" href="#bib0410">34,35</a> However, it must be considered that the concept of calcium gain might not be correct, because plasma calcium is the result of several factors involved in the homeostasis of calcium. Changes in pH modify ionised Ca++, and alkalosis reduces free Ca++ by increasing the binding of Ca++ to albumin. Furthermore, it must be taken into account that PTH releases calcium from bone. In our study we analysed ionised calcium, and therefore the increase did not depend on calcium bound to albumin. Also, since PTH decreased during HD, it would not be responsible for an increase in release of bone calcium, so, in line with the observations of Gotch,<a class="elsevierStyleCrossRefs" href="#bib0410">34,35</a> there would be calcium transport during dialysis that could favour the calcification process, although the reduction in phosphorus could have a certain protective effect. All of this means that the calcium concentration in dialysis fluid should be individualised<a class="elsevierStyleCrossRef" href="#bib0420">36</a> and, if we want to avoid calcium gain during the dialysis session, we should also consider measures to increase the intestinal absorption of calcium (oral Ca++ or vitamin D) to maintain a neutral balance.During HD there is a decrease in plasma phosphorus as it diffuses across the dialyser. This plasma decrease, in conventional HD, leads to a nadir in approximately the first hour; later the phosphorus level is more stable, as seen in our study.<a class="elsevierStyleCrossRefs" href="#bib0425">37,38</a> This seems to be due to the kinetics of phosphate in response to the extracellular decrease, depending on the predialysis concentration.<a class="elsevierStyleCrossRef" href="#bib0435">39</a> Therefore, during the first hour and a half, we could individually programme dialysis, so as to avoid calcium gain while serum phosphorus has not yet reached its nadir. If we add to that the absence of alkalinisation with dialysis bath bicarbonate concentrations similar to, or slightly higher than, predialysis concentrations, we would avoid the concurrent combination of “alkalinisation+calcium gain+hyperphosphataemia”, which, combined with a decrease in magnesium is the “perfect storm” for VC.The hypothesis that the practice of HD sessions can induce VC is also supported by the fact that patients who end up on dialysis have from 2 to 5 times more coronary artery calcification than matched nonrenal patients. Also, as coronary calcification is closely correlated with the number of years on HD, calcification could well be due to long duration of CKD or long treatments with calcification inducers, such as calcium-based phosphate binders or vitamin D compounds.<a class="elsevierStyleCrossRefs" href="#bib0440">40,41</a>This study has some weaknesses. The most important weakness is that it was assumed that the biochemical changes that occurred in vitro and in vivo were applicable to patients during HD sessions. Of course, there are biological factors that interfere in the prevention of VC that we have not analysed.<a class="elsevierStyleCrossRefs" href="#bib0450">42–47</a> Studies would be required, directed at calcification during the process of HD, in addition to the existing studies on the progression of CKD. Another of the weaknesses of our study is the absence of gasometry. There was a decrease in pH at 15min from starting the session that theoretically could have a protective effect against calcification.<a class="elsevierStyleCrossRef" href="#bib0375">27</a> It is a transient effect, which, coinciding with the increase in bicarbonate, logically is related to pCO2. In studies on respiratory function during HD with bicarbonate, similar changes were found that were explained by a pCO2 increase greater than the bicarbonate increase.<a class="elsevierStyleCrossRef" href="#bib0480">48</a> However, as in our study, those authors also observed a progressive alkalinisation during HD sessions.In conclusion, in all the studies on VC in patients with CKD, including international guidelines,<a class="elsevierStyleCrossRef" href="#bib0405">33</a> classical and nonclassical factors were analysed, with special emphasis on the active cellular process that occurs, with osteogenic transformation and formation of hydroxyapatite in connection with abnormal calcification-inhibitory factors. Hyperphosphataemia and especially the role of calcium-based phosphate binders in the development of VC form a multitude of articles that defend the use of noncalcium-based binders. However, there is little more in-depth study of the biochemical phenomena that patients experience 156 times per year during HD sessions and that clearly induce calcification: calcium gain in the presence of hyperphosphataemia at the same time as progressive alkalinisation. Therefore, studies are needed that individualise HD according to the characteristics of each patient, especially their baseline calcium and phosphorus. A delay in calcium gain and alkalinisation until serum phosphorus has gone down to normal values during HD sessions could be the first step in modifying this “perfect storm”.Conflicts of interestThe authors declare no potential conflicts of interest related to the contents of this article." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres604413" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec618569" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres604414" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec618568" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Aims" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Materials and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Biochemical parameters studied" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 7 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Ionised calcium" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Phosphorus" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Ca × P product" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Bicarbonate and pH" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "Magnesium" ] 5 => array:2 [ "identificador" => "sec0065" "titulo" => "Intact parathyroid hormone" ] ] ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-11-19" "fechaAceptado" => "2015-03-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec618569" "palabras" => array:3 [ 0 => "Vascular calcification" 1 => "Chronic kidney disease" 2 => "Haemodialysis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec618568" "palabras" => array:3 [ 0 => "Calcificación vascular" 1 => "Enfermedad renal crónica" 2 => "Hemodiálisis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionVascular calcification (VC) associated to chronic kidney disease (CKD) is a complex phenomenon closely related to mineral bone metabolism disorders. Many are the factors implicated, as the drugs used in the treatment of CKD. Some in vitro studies suggest that electrolyte and acid–base disorders induced by haemodialysis (HD) may play a key role in VC. MethodsWe analysed electrolyte and acid–base disorders that occur during an HD session in 26 patients randomly assigned to 1.25mM or 1.5mM calcium bath. ResultsThere is a calcium load in all the patients, independently of calcium bath concentration or basal serum calcium levels. At the end of the session, 100% of the patients dialysed with 1.5mM calcium bath have calcium serum levels >1.3mM. However, this only occurs in 15% of the patients dialysed with 1.25mM calcium bath. During this calcium load, phosphorus levels persist uncontrolled. Besides, there is a progressive alkalinisation in all the patients. In the end of the session 50% have serum bicarbonate >30mM and 23% pH >7.5. ConclusionsDuring HD sessions occur electrolyte and acid–base disorders that induce VC: calcium load and alkalisation in presence of elevated phosphorus levels. It is necessary to perform studies with kinetic models of calcium load and alkalinisation different from the actual ones." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa calcificación vascular (CV) asociada a la enfermedad renal crónica (ERC) es un fenómeno estrechamente ligado a las alteraciones en el metabolismo mineral óseo. Existen muchos factores implicados, entre ellos los fármacos empleados en el tratamiento de la ERC. Algunos estudios in vitro señalan que las alteraciones electrolíticas y ácido-básicas que tienen lugar durante la sesión de hemodiálisis (HD) pueden jugar un papel clave en el proceso de CV. MétodosAnalizamos las alteraciones electrolíticas y ácido-básicas que tienen lugar durante la sesión de HD en 26 pacientes, empleando de forma aleatorizada concentraciones de calcio en el líquido de diálisis de 1,25 o 1,5mM. ResultadosEn todos los pacientes, independientemente del baño de calcio empleado, se produce una ganancia de calcio. En el grupo de pacientes dializados con baño de calcio 1,5mM, el 100% finaliza la sesión con valores de calcio sérico>1,3mM, mientras que en el de 1,25mM, esto solo ocurre en el 15%. Al inicio de la sesión, esta ganancia de calcio coincide con niveles de fósforo aún no controlado. Además, en todos los pacientes se observa una alcalinización progresiva: el 50% finaliza la sesión con cifras de bicarbonato>30mM y el 23% con pH>7,5. ConclusionesDurante la sesión de HD se producen cambios electrolíticos y ácido-básicos inductores de CV: ganancia de calcio y alcalinización en presencia de fósforo sérico inicialmente elevado. Son necesarios estudios con modelos cinéticos de ganancia de calcio y alcalinización diferentes a los actuales." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Seras M, Martín de Francisco ÁL, Piñera C, Gundin S, García-Unzueta M, Kislikova M, et al. Sesión de hemodiálisis: la tormenta perfecta para la calcificación vascular. Nefrologia. 2015;35:448–456." ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1512 "Ancho" => 1363 "Tamanyo" => 132169 ] ] "descripcion" => array:1 [ "en" => "Temporal changes in plasma ionised calcium (mM) during haemodialysis sessions. Patients are grouped according to baseline ionised calcium and calcium bath used. 100% of patients dialysed with Ca++ bath of 1.5mM ended the session with plasma levels >1.3mM, independently of the baseline calcaemia, whilst only 15% of those with a Ca++ bath of 1.25mM reached that level (P<.001)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1523 "Ancho" => 1399 "Tamanyo" => 134131 ] ] "descripcion" => array:1 [ "en" => "Temporal changes in plasma phosphorus (mg/dL) during haemodialysis sessions. Patients are grouped according to baseline calcium and calcium bath used. Changes in phosphorus were independent of the calcium bath used and the baseline calcaemia: there were no significant differences between groups." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1516 "Ancho" => 1367 "Tamanyo" => 136035 ] ] "descripcion" => array:1 [ "en" => "Temporal changes in plasma Ca++×P product (mg2/dL2) during haemodialysis sessions. Patients are grouped according to baseline calcium and calcium bath used. Those dialysed with Ca++ bath 1.25mM had final Ca++×P products significantly lower than those of the 1.5mM group (10.1±3.84 vs 13.99±4.41; P=.029). In the 1.25mM group, the reduction in the Ca++×P product was significantly greater (−13.79±7.09 vs −8.74±4.17; P=.04)." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1518 "Ancho" => 1370 "Tamanyo" => 129936 ] ] "descripcion" => array:1 [ "en" => "Temporal changes in plasma bicarbonate (mM) during haemodialysis sessions. Patients are grouped according to baseline calcium and calcium bath used. Baseline and final values of bicarbonate were independent of the calcium bath used and the baseline calcaemia: there were no significant differences between groups. 50% of patients ended the session with baseline bicarbonate levels >30mM." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1516 "Ancho" => 1390 "Tamanyo" => 137512 ] ] "descripcion" => array:1 [ "en" => "Temporal changes in plasma pH during haemodialysis sessions. Patients are grouped according to baseline calcium and calcium bath used. The baseline and final values were independent of the calcium bath used and the baseline calcaemia: there were no significant differences between groups. Overall, 23% of patients ended the session with pH >7.5." ] ] 5 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Age, days on haemodialysis, and ultrafiltration are expressed as mean±standard deviation. There were no statistically significant differences between groups for any of the variables. AVF, ateriovenous fistula; CVC, central venous catheter." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Calcium bath</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline calcaemia</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1.25mM \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1.5mM \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><1.16mM \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">>1.16mM \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Women/Men \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6/7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5/8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7/6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4/9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ca++ bath 1.25mM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ca++ bath 1.5mM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70.23±16.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">76.08±6.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72±13.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74.31±12.38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Days on HD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.410.92±3.323.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.331.08±1.233.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.114.23±1.432.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.627.77±3.147.22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">UF, mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.54.58±830.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.002.50±720.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.075.18±543.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.804.46±915.19 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">AVF/CVC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6/7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7/6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4/9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9/4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab989859.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics, grouped by baseline calcaemia." ] ] 6 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "Expressed as mean and standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Calcium bath</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline calcium</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1.25mM \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1.5mM \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><1.16mM \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">>1.16mM \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Calcium (mM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.17±0.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.14±0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.07±0.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.23±0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Final \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.25±0.09<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.37±0.04<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.28±0.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.34±0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Phosphorus (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.05±1.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.04±1.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.08±1.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5±1.87 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Final \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.01±0.68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.55±0.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.31±0.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.25±0.83 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ca++×P (mg2/dL2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.89±9.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.73±7.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.86±6.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.76±9.25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Final \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.10±3.84<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.99±4.41<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.94±4.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.15±4.65 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.38±0.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.38±0.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.37±0.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.39±0.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Final \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.48±0.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.45±0.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.46±0.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.47±0.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Bicarbonate (mM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.88±3.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.82±3.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.59±3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.12±2.97 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Final \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.84±2.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.98±2.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.89±2.66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.92±1.62 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Magnesium (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.43±0.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.32±0.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.38±0.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.38±0.39 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Final \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.97±0.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.04±0.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2±0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.01±0.18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">iPTH (pg/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">574.69±379.75<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">321.15±244.46<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">441±293.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">454.85±390.61 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Final \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">496.23±400.61<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">229.62±236.18<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">296.31±338.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">429.54±361.48 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab989858.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Grouped by calcium bath used, there were statistically significant differences in the values of final calcium (P<.001), final Ca++×P (P=.02), baseline iPTH (P=.05) and final iPTH (P=.05). Grouped by baseline calcaemia, there were no statistically significant differences in any of the variables." ] ] ] "descripcion" => array:1 [ "en" => "Mean baseline and final levels of ionised calcium, phosphorus, Ca++×P product, pH, bicarbonate, magnesium, and PTH." ] ] 7 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "Expressed as mean and standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Calcium bath</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline calcaemia</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1.25mM \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1.5mM \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><1.16mM \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">>1.16mM \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ΔCa++ (mM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.08±0.091 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.23±0.08<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.2±0.11<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.11±0.11<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ΔP (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−3.04±1.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−2.48±1.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−2.78±0.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−2.75±1.59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ΔCa++×P (mg2/dL2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−13.79±7.09<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−8.74±4.17<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−9.92±3.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−12.61±8.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ΔHCO3− (mM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.95±2.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.15±2.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.30±2.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.81±2.41 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ΔpH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.10±0.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07±0.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09±0.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.08±0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ΔMg++ (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.46±0.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.28±0.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.38±0.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.37±0.27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ΔPTH (pg/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−78.46±245.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−91.54±227.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−144.69±244 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−25.31±211.68 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab989857.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Grouped by calcium bath, there were statistically significant differences in the increase in calcium (P<.001) and the decrease in Ca++×P (P=.04)." ] 1 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "b" "nota" => "Grouped by baseline calcaemia, there were statistically significant differences only in the calcium increase (P=.03)." ] ] ] "descripcion" => 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Sesión de hemodiálisis: la tormenta perfecta para la calcificación vascular

Miguel Serasa, Ángel Luis Martín de Franciscoa,

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angelmartindefrancisco@gmail.com

Corresponding author.

, Celestino Piñeraa, Simón Gundinb, Marta García-Unzuetab, Maria Kislikovaa, Zoila Albinesa, Mara Serranoa, Manuel Ariasa

a Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Spain

b Servicio de Análisis Clínicos, Hospital Universitario Marqués de Valdecilla, Santander, Spain

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2 patterns of VC have been described&#58; predominantly intimal&#44; and predominantly medial&#46; However&#44; there is much debate regarding the differences between intimal calcification and medial calcification&#46; There is no definitive evidence to suggest that calcification isolated to the media is distinct from the calcification that comes from the natural history of atherosclerosis&#59; nor is there definitive evidence to the contrary&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">5&#44;6</span></a> What is certain is that it is closely related to the mixture of metabolic and biological abnormalities that accompany CKD&#44;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">7&#44;8</span></a> notably CDK-mineral and bone disorders&#46; This entity implies abnormalities in the metabolism of calcium&#44; phosphorus&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">9</span></a> vitamin D&#44;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">10&#44;11</span></a> FGF23-Klotho&#44; and parathyroid hormone &#40;PTH&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">12</span></a> To those we must add biological abnormalities such as dysfunctional production of calcification inhibitors by smooth muscle cells&#44; and chronic inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">13</span></a> Together&#44; these factors induce physiochemical changes in the smooth muscle cells of the arterial wall&#44; promoting their transformation into osteoblasts&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">14</span></a> and hydroxyapatite deposition&#46; Classically&#44; the &#91;Ca&#93;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>&#91;P&#93; product has been used to determine VC risk in renal patients&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">15</span></a> However&#44; some in vitro studies have demonstrated that with a stable &#91;Ca&#93;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>&#91;P&#93; product&#44; it is the individual concentration of each element that determines the development of VC&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">16</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Until now&#44; all therapeutic efforts have been directed at controlling these metabolic abnormalities &#40;essentially phosphate binders&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">17</span></a> vitamin D derivatives&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">18</span></a> and calimimetics<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">19</span></a>&#41; and the classical risk factors&#44; with varying and contradictory results&#46; Although some of these treatments can slow progression&#44; none have been demonstrated to reverse VC&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In comparison with patients in the early stages of CKD&#44; patients treated with haemodialysis &#40;HD&#41; have higher cardiovascular morbidity and mortality&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">22</span></a> along with more marked abnormalities in bone metabolism and a greater degree of VC&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">23&#44;24</span></a> As well as all the previously stated mechanisms&#44; the biochemical changes produced during HD could play an important role in such marked development of VC&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">25</span></a> In fact&#44; in vitro studies using rat aortas have shown that changes in calcium and phosphorus concentrations and alkalinisation are precipitating factors for VC&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">16&#44;26</span></a> It is also known that acidosis protects against VC&#44;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">27</span></a> therefore a high pH could have the unfavourable opposite effect&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Aims</span><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study was to analyse the biochemical changes in the parameters of mineral metabolism and acid&#8211;base balance that take place during HD&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Materials and methods</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design</span><p id="par0030" class="elsevierStylePara elsevierViewall">We prospectively studied the changes in mineral metabolism and acid&#8211;base metabolism that occurred during haemodialysis sessions&#46; We selected 26 stable patients with CKD who attended HD 3 times per week at our hospital centre&#46; Mean patient age was 73&#46;15 years<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;56 years&#44; and 57&#46;69&#37; were men&#46; Time on HD was 1871 days &#40;standard deviation &#91;SD&#93; 2516&#46;82 days&#59; range&#44; 45&#8211;12<span class="elsevierStyleHsp" style=""></span>325 days&#41;&#46; During the sessions it was not permitted to administer medication that would interfere with mineral metabolism or acid&#8211;base balance&#46; All patients gave informed consent to participate in the study&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Thirteen patients &#40;50&#37;&#41; were randomly allocated to receive dialysis with a calcium bath concentration of 1&#46;25<span class="elsevierStyleHsp" style=""></span>mM&#59; the other 13 patients received dialysis with a calcium bath concentration was 1&#46;5<span class="elsevierStyleHsp" style=""></span>mM&#46; The dialysis fluid in both groups had the same concentrations of bicarbonate&#44; 35<span class="elsevierStyleHsp" style=""></span>mM&#59; magnesium&#44; 0&#46;5<span class="elsevierStyleHsp" style=""></span>mM&#59; potassium&#44; 1&#46;5<span class="elsevierStyleHsp" style=""></span>mM&#59; and sodium&#44; 140<span class="elsevierStyleHsp" style=""></span>mM&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">All patients were conventionally dialysed over 4<span class="elsevierStyleHsp" style=""></span>h with high flow Helixona<span class="elsevierStyleSup">&#174;</span> &#40;<span class="elsevierStyleItalic">Fx CorDiax 80</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">&#174;</span></span><span class="elsevierStyleItalic">&#44; Fresenius Medical Care&#44; AG&#44; Bad Homburg&#44; Germany</span>&#41; with an ultrafiltration coefficient of 64<span class="elsevierStyleHsp" style=""></span>mL&#47;h&#47;mmHg or with Evodial<span class="elsevierStyleSup">&#174;</span> &#40;<span class="elsevierStyleItalic">HeprAN Gambro</span>&#41; with ultrafiltration coefficient of 50<span class="elsevierStyleHsp" style=""></span>mL&#47;h&#47;mmHg&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Biochemical parameters studied</span><p id="par0045" class="elsevierStylePara elsevierViewall">Blood samples were taken at the start of the session and subsequently at 15&#44; 30&#44; 60&#44; and 120<span class="elsevierStyleHsp" style=""></span>min&#44; and at 4<span class="elsevierStyleHsp" style=""></span>h&#44; coinciding with the end of the session&#44; to evaluate the changes produced in the variables of mineral metabolism and acid&#8211;base metabolism over the course of the HD session&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Blood pH and ionised calcium normalised for pH &#40;Ca<span class="elsevierStyleSup">&#43;&#43;</span>&#41; were measured using direct potentiometry with an ion-selective electrode &#40;ABL80 FLEX auto-analyser&#41;&#46; Creatinine&#44; urea&#44; phosphorus&#44; magnesium&#44; and bicarbonate were measured using colourimetry &#40;ADVIA 2400 auto-analyser&#46; Siemens&#41;&#46; Intact PTH levels in the baseline sample and final sample were measured using immunoassay &#40;IDS-iSYS auto-analyser&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The calcium&#8211;phosphorus product is expressed in mg<span class="elsevierStyleSup">2</span>&#47;dL<span class="elsevierStyleSup">2</span>&#46; The values obtained for ionised calcium in mM were converted to mg&#47;dL according to the molecular weight of calcium &#40;Ca<span class="elsevierStyleSup">&#43;&#43;</span> 1<span class="elsevierStyleHsp" style=""></span>mM<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Results are expressed as mean and SD and 95&#37; confidence interval&#46; Statistical analysis was performed using Student&#39;s <span class="elsevierStyleItalic">t</span> test for independent data and a chi-square test&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">The 26 patients were classified according to their baseline calcium level&#44; into hypocalcaemic and normocalcaemic&#44; using the normal lower limit of Ca<span class="elsevierStyleSup">&#43;&#43;</span> in out laboratory as a reference &#40;range&#44; 1&#46;16&#8211;1&#46;3<span class="elsevierStyleHsp" style=""></span>mM&#41;&#46; The normal limits of phosphataemia used were 2&#46;5&#8211;4&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; The main characteristics of the sample can be seen in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; with patients grouped according to calcium bath used and baseline calcaemia&#46; There were no significant differences between the groups regarding sex&#44; age&#44; days on HD&#44; ultrafiltration&#44; calcium bath used&#44; or type of vascular access&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the baseline and final values of the different parameters&#44; grouped by calcium bath used and baseline calcium level&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the overall increase of each parameter assessed&#44; which corresponds to the difference between the mean final and mean baseline values&#46; All results are expressed as mean and SD&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">In <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;5</a>&#44; the temporal changes in patient plasma calcium &#40;mM&#41;&#44; phosphorus &#40;mg&#47;dL&#41;&#44; Ca<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>P product &#40;mg<span class="elsevierStyleSup">2</span>&#47;dL<span class="elsevierStyleSup">2</span>&#41;&#44; bicarbonate &#40;mM&#41;&#44; and pH can be seen graphically&#44; grouped by baseline calcium &#40;above&#47;below 1&#46;16<span class="elsevierStyleHsp" style=""></span>mM&#41; and calcium bath &#40;1&#46;25 or 1&#46;5<span class="elsevierStyleHsp" style=""></span>mM&#41;&#46; Below&#44; we describe individually the changes in each of the parameters analysed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ionised calcium</span><p id="par0080" class="elsevierStylePara elsevierViewall">Independently of the baseline calcium level or calcium bath used&#44; in both groups there was an increase in calcaemia on finishing dialysis &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Over the course of the session there was a progressive&#44; uniform increase in calcium &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; which was significantly higher in the group of patients dialysed with a 1&#46;5<span class="elsevierStyleHsp" style=""></span>mM Ca<span class="elsevierStyleSup">&#43;&#43;</span> bath than in the 1&#46;25<span class="elsevierStyleHsp" style=""></span>mM group &#40;0&#46;23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;08 vs 0&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;09&#44; <span class="elsevierStyleItalic">P<span class="elsevierStyleHsp" style=""></span></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; In the 1&#46;5<span class="elsevierStyleHsp" style=""></span>mM group&#44; 100&#37; of patients finished dialysis with plasma calcium values &#62;1&#46;3<span class="elsevierStyleHsp" style=""></span>mM&#44; independently of the baseline calcaemia&#44; whereas in the 1&#46;25<span class="elsevierStyleHsp" style=""></span>mM group this only happened in 15&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The overall calcium increase was significantly higher in patients with a baseline calcium &#60;1&#46;16<span class="elsevierStyleHsp" style=""></span>mM than in those with baseline calcium &#62;1&#46;16<span class="elsevierStyleHsp" style=""></span>mM &#40;0&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;11 vs 0&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;11&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;03&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Lastly&#44; calcium increase and mean final serum calcium levels were independent of the vascular access used&#44; and of baseline phosphataemia&#58; there were no statistically significant differences between those groups&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Phosphorus</span><p id="par0085" class="elsevierStylePara elsevierViewall">There were no statistically significant differences in baseline phosphorus levels or final phosphorus levels between groups according to the baseline calcium or the calcium bath used &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; During the session&#44; there was a progressive decrease in phosphorus&#44; which was more marked in the first hours of dialysis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; There were no significant differences between groups in the overall phosphorus decrease &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; As previously mentioned&#44; the final serum calcium levels and the calcium increase were independent of baseline phosphorus levels&#58; there were no significant differences between groups &#40;normal range 2&#46;5&#8211;4&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ca<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>P product</span><p id="par0090" class="elsevierStylePara elsevierViewall">The baseline calcium phosphorus product was independent of the baseline calcium and calcium bath used&#58; there were no significant differences between groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Over the session&#44; there was a fall in the Ca<span class="elsevierStyleSup">&#43;&#43;</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>P&#44; which was more marked in the first hour &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Patients dialysed with a 1&#46;25<span class="elsevierStyleHsp" style=""></span>mM Ca<span class="elsevierStyleSup">&#43;&#43;</span> bath had significantly lower final Ca<span class="elsevierStyleSup">&#43;&#43;</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>P products than those dialysed with a 1&#46;5<span class="elsevierStyleHsp" style=""></span>mM Ca<span class="elsevierStyleSup">&#43;&#43;</span> bath &#40;10&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;84 vs 13&#46;99<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;41&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#46; Furthermore&#44; in the 1&#46;25<span class="elsevierStyleHsp" style=""></span>mM group&#44; the overall decrease in the Ca<span class="elsevierStyleSup">&#43;&#43;</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>P product was significantly greater than in the 1&#46;5<span class="elsevierStyleHsp" style=""></span>mM group &#40;13&#46;79<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;09 vs 8&#46;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;17&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Bicarbonate and pH</span><p id="par0095" class="elsevierStylePara elsevierViewall">The baseline and final values of bicarbonate and pH were independent of the baseline calcium and calcium bath used&#59; there were no significant differences between groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Over the session&#44; bicarbonate increased progressively &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The pH decreased initially in the first 30<span class="elsevierStyleHsp" style=""></span>min&#44; with subsequent alkalinisation &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Overall&#44; 50&#37; of patients ended the session with bicarbonate levels &#62;30<span class="elsevierStyleHsp" style=""></span>mM and 23&#37; with pH &#62;7&#46;5&#46; The overall increase in bicarbonate and the alkalinisation were similar between groups&#44; independently of the baseline calcium or the calcium bath used &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Magnesium</span><p id="par0100" class="elsevierStylePara elsevierViewall">The baseline and final values of magnesium were independent of the baseline calcium and calcium bath used&#59; there were no significant differences between groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Over the session&#44; there was a homogenous decrease in all groups&#44; with no significant differences between groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Intact parathyroid hormone</span><p id="par0105" class="elsevierStylePara elsevierViewall">The baseline and final levels of intact parathyroid hormone &#40;iPTH&#41; were lower in patients dialysed with a 1&#46;5<span class="elsevierStyleHsp" style=""></span>mM calcium bath than with a 1&#46;25<span class="elsevierStyleHsp" style=""></span>mM bath &#40;baseline iPHT 574<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>379&#46;75 vs 321&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>244&#46;46&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; &#40;final iPHT&#58; 496&#46;23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>400&#46;61 vs 223&#46;62<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>236&#46;18&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; However&#44; there were no differences in the changes in PTH in relation to the calcium bath used or the baseline calcaemia &#40;<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>&#41;&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">In this study we analysed the changes produced in calcium&#44; phosphorus&#44; magnesium&#44; pH&#44; and bicarbonate&#44; during HD sessions&#46; The induction of alkalinisation&#44; along with the increase in serum calcium in the presence of hyperphosphataemia in the initial phases of HD constitutes a perfect environment for the development of VC&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The physiochemical mechanisms responsible for VC have been studied in vitro&#46; Lomashvili<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">16</span></a> demonstrated that the calcification of rat aortas in vitro required increased calcium and phosphorus&#44; but was not related to the calcium&#8211;phosphorus product&#46; Also&#44; De Sol&#237;s et al&#46; observed that calcification was potentiated by alkalinisation in the presence of uraemic serum and even more so with the alkalinisation of the extracellular medium &#40;pH of 7&#46;42&#8211;7&#46;53&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">26</span></a> Furthermore&#44; in in vivo studies&#44; aortic calcification was proven to increase significantly in alkalinised animals&#46; This is precisely what occurs during HD and what we have observed in our study&#46; Haemodialysis sessions produce these physiochemical changes&#44; which could be responsible&#44; along with other factors&#44; for the development of VC&#46; It is the &#8220;perfect biochemical storm&#8221;&#44; with high calcium levels and alkalinisation despite a progressive reduction in the calcium&#8211;phosphorus product&#46; In many patients&#44; phosphorus normalisation is not achieved until after 2<span class="elsevierStyleHsp" style=""></span>h of HD&#44; adding another factor as there is hyperphosphataemia in the first hours&#46; What occurs post-dialysis can be considered even more critical&#44; as at 2<span class="elsevierStyleHsp" style=""></span>h there is a phosphorus rebound of up to 40&#37;&#46; To that could be added that the magnesium concentrations used in the dialysis fluid &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>mM&#41; produce a reduction in serum magnesium values during HD &#40;<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>&#41;&#44; which could augment even more this &#8220;perfect storm&#8221; of calcification during HD sessions&#46; Several studies&#44; both in vitro and in animals&#44; have shown a protective effect of magnesium against VC through multiple mechanisms&#44; and clinical studies also demonstrate evidence of this protective effect of magnesium against VC&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">28&#44;29</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In our study we used dialysis fluid with a concentration of 35<span class="elsevierStyleHsp" style=""></span>mM of bicarbonate&#44; with plasma bicarbonate increasing from 25&#46;35<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;4<span class="elsevierStyleHsp" style=""></span>mM to 29&#46;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;16<span class="elsevierStyleHsp" style=""></span>mM and pH from 7&#46;38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;06 baseline value to 7&#46;47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;05 final value&#44; with an increase to above 7&#46;50 in 23&#37; of patients &#40;independently of the calcium bath used&#41;&#46; These values are similar to&#44; or even higher than&#44; the degree of alkalinisation that led to increased calcification in rat aortas in vitro&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">16&#44;26</span></a> One of the most debatable points of this study is&#58; if the calcium&#8211;phosphorus product is reduced during dialysis&#44; why does the idea remain that dialysis induces VC&#46; In the studies by Lomashvili&#44; the concentrations of Ca<span class="elsevierStyleSup">&#43;&#43;</span> and P were changed inversely to maintain a constant &#91;Ca<span class="elsevierStyleSup">&#43;&#43;</span>&#93;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>&#91;P&#93; product&#44; and it was observed that VC increased directly as calcium increased&#44; despite a decrease in phosphorus&#46; That is&#44; calcification is not a function of the calcium&#8211;phosphorus product&#44; but depends more on the individual concentrations of calcium and phosphorus&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">If the hypothesis of VC during HD is reasonable&#44; we should progress to how to control the physiochemical factors responsible&#46; Or rather&#44; how to avoid the precipitating factors being present at the same time&#46; The first change would relate to the calcium concentration of the dialysis bath&#46; The changes in serum calcium that occur during dialysis depend on the initial serum calcium concentration&#44; the ultrafiltration volume&#44; and the calcium concentration of the dialysis fluid&#46; Calcium kinetics during HD sessions have already been studied by various authors&#44; using different calcium bath concentrations and different HD tecnhiques<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">30&#44;31</span></a>&#58; serum calcium increased to 1&#46;32 and 1&#46;45<span class="elsevierStyleHsp" style=""></span>mM during HD sessions with dialysis fluid calcium concentrations of 1&#46;25 and 1&#46;5<span class="elsevierStyleHsp" style=""></span>mM&#44; respectively&#46; Conversely&#44; in patients with baseline calcaemia in the normal range&#44; the calcium balance is neutral or negative with dialysis fluid concentrations of 1&#46;25<span class="elsevierStyleHsp" style=""></span>mM&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">32</span></a> However&#44; as in our study&#44; in patients with a low baseline calcium&#44; ionised calcium can increase during dialysis with a 1&#46;25<span class="elsevierStyleHsp" style=""></span>mM concentration&#46; In reality&#44; the KDIGO guidelines suggest a dialysis fluid calcium concentration of between 1&#46;25 and 1&#46;50<span class="elsevierStyleHsp" style=""></span>mM&#44;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">33</span></a> based on the theory that a concentration of 1&#46;25<span class="elsevierStyleHsp" style=""></span>mM means a neutral calcium balance&#46; However&#44; Gotch et al&#46; demonstrated very different results with 2 kinetic models&#46; By analysing calcium transport across the dialyser during dialysis&#44; they observed that each session induced more than 500<span class="elsevierStyleHsp" style=""></span>mg of calcium transport&#46; In the kinetic analysis of intestinal absorption of calcium in 320 patients on HD&#44; the study by Gotch concluded that calcium absorption was strongly dependent on the dose of vitamin D analogues and much less so on ingested calcium&#46; The most important conclusion to relate to our study about possible VC during HD was that 70&#37; of patients who received calcium binders and between 20&#37; and 50&#37; of those who take non-calcium binders required a dialysis fluid calcium concentration lower than 1&#46;25<span class="elsevierStyleHsp" style=""></span>mM to prevent long-term calcium build-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">34&#44;35</span></a> However&#44; it must be considered that the concept of calcium gain might not be correct&#44; because plasma calcium is the result of several factors involved in the homeostasis of calcium&#46; Changes in pH modify ionised Ca<span class="elsevierStyleSup">&#43;&#43;</span>&#44; and alkalosis reduces free Ca<span class="elsevierStyleSup">&#43;&#43;</span> by increasing the binding of Ca<span class="elsevierStyleSup">&#43;&#43;</span> to albumin&#46; Furthermore&#44; it must be taken into account that PTH releases calcium from bone&#46; In our study we analysed ionised calcium&#44; and therefore the increase did not depend on calcium bound to albumin&#46; Also&#44; since PTH decreased during HD&#44; it would not be responsible for an increase in release of bone calcium&#44; so&#44; in line with the observations of Gotch&#44;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">34&#44;35</span></a> there would be calcium transport during dialysis that could favour the calcification process&#44; although the reduction in phosphorus could have a certain protective effect&#46; All of this means that the calcium concentration in dialysis fluid should be individualised<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">36</span></a> and&#44; if we want to avoid calcium gain during the dialysis session&#44; we should also consider measures to increase the intestinal absorption of calcium &#40;oral Ca&#43;&#43; or vitamin D&#41; to maintain a neutral balance&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">During HD there is a decrease in plasma phosphorus as it diffuses across the dialyser&#46; This plasma decrease&#44; in conventional HD&#44; leads to a nadir in approximately the first hour&#59; later the phosphorus level is more stable&#44; as seen in our study&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">37&#44;38</span></a> This seems to be due to the kinetics of phosphate in response to the extracellular decrease&#44; depending on the predialysis concentration&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">39</span></a> Therefore&#44; during the first hour and a half&#44; we could individually programme dialysis&#44; so as to avoid calcium gain while serum phosphorus has not yet reached its nadir&#46; If we add to that the absence of alkalinisation with dialysis bath bicarbonate concentrations similar to&#44; or slightly higher than&#44; predialysis concentrations&#44; we would avoid the concurrent combination of &#8220;alkalinisation<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>calcium gain<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>hyperphosphataemia&#8221;&#44; which&#44; combined with a decrease in magnesium is the &#8220;perfect storm&#8221; for VC&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The hypothesis that the practice of HD sessions can induce VC is also supported by the fact that patients who end up on dialysis have from 2 to 5 times more coronary artery calcification than matched nonrenal patients&#46; Also&#44; as coronary calcification is closely correlated with the number of years on HD&#44; calcification could well be due to long duration of CKD or long treatments with calcification inducers&#44; such as calcium-based phosphate binders or vitamin D compounds&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">40&#44;41</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">This study has some weaknesses&#46; The most important weakness is that it was assumed that the biochemical changes that occurred in vitro and in vivo were applicable to patients during HD sessions&#46; Of course&#44; there are biological factors that interfere in the prevention of VC that we have not analysed&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">42&#8211;47</span></a> Studies would be required&#44; directed at calcification during the process of HD&#44; in addition to the existing studies on the progression of CKD&#46; Another of the weaknesses of our study is the absence of gasometry&#46; There was a decrease in pH at 15<span class="elsevierStyleHsp" style=""></span>min from starting the session that theoretically could have a protective effect against calcification&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">27</span></a> It is a transient effect&#44; which&#44; coinciding with the increase in bicarbonate&#44; logically is related to pCO<span class="elsevierStyleInf">2</span>&#46; In studies on respiratory function during HD with bicarbonate&#44; similar changes were found that were explained by a pCO<span class="elsevierStyleInf">2</span> increase greater than the bicarbonate increase&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">48</span></a> However&#44; as in our study&#44; those authors also observed a progressive alkalinisation during HD sessions&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In conclusion&#44; in all the studies on VC in patients with CKD&#44; including international guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">33</span></a> classical and nonclassical factors were analysed&#44; with special emphasis on the active cellular process that occurs&#44; with osteogenic transformation and formation of hydroxyapatite in connection with abnormal calcification-inhibitory factors&#46; Hyperphosphataemia and especially the role of calcium-based phosphate binders in the development of VC form a multitude of articles that defend the use of noncalcium-based binders&#46; However&#44; there is little more in-depth study of the biochemical phenomena that patients experience 156 times per year during HD sessions and that clearly induce calcification&#58; calcium gain in the presence of hyperphosphataemia at the same time as progressive alkalinisation&#46; Therefore&#44; studies are needed that individualise HD according to the characteristics of each patient&#44; especially their baseline calcium and phosphorus&#46; A delay in calcium gain and alkalinisation until serum phosphorus has gone down to normal values during HD sessions could be the first step in modifying this &#8220;perfect storm&#8221;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare no potential conflicts of interest related to the contents of this article&#46;</p></span></span>"
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              "titulo" => "Introducci&#243;n"
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            1 => array:2 [
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          "titulo" => "Results"
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            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Ionised calcium"
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            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Phosphorus"
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              "identificador" => "sec0050"
              "titulo" => "Ca &#215; P product"
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              "identificador" => "sec0055"
              "titulo" => "Bicarbonate and pH"
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              "titulo" => "Magnesium"
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              "identificador" => "sec0065"
              "titulo" => "Intact parathyroid hormone"
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          "titulo" => "Discussion"
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    "fechaRecibido" => "2014-11-19"
    "fechaAceptado" => "2015-03-17"
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          "clase" => "keyword"
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          "palabras" => array:3 [
            0 => "Vascular calcification"
            1 => "Chronic kidney disease"
            2 => "Haemodialysis"
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          "clase" => "keyword"
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          "palabras" => array:3 [
            0 => "Calcificaci&#243;n vascular"
            1 => "Enfermedad renal cr&#243;nica"
            2 => "Hemodi&#225;lisis"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Vascular calcification &#40;VC&#41; associated to chronic kidney disease &#40;CKD&#41; is a complex phenomenon closely related to mineral bone metabolism disorders&#46; Many are the factors implicated&#44; as the drugs used in the treatment of CKD&#46; Some in vitro studies suggest that electrolyte and acid&#8211;base disorders induced by haemodialysis &#40;HD&#41; may play a key role in VC&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We analysed electrolyte and acid&#8211;base disorders that occur during an HD session in 26 patients randomly assigned to 1&#46;25<span class="elsevierStyleHsp" style=""></span>mM or 1&#46;5<span class="elsevierStyleHsp" style=""></span>mM calcium bath&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There is a calcium load in all the patients&#44; independently of calcium bath concentration or basal serum calcium levels&#46; At the end of the session&#44; 100&#37; of the patients dialysed with 1&#46;5<span class="elsevierStyleHsp" style=""></span>mM calcium bath have calcium serum levels &#62;1&#46;3<span class="elsevierStyleHsp" style=""></span>mM&#46; However&#44; this only occurs in 15&#37; of the patients dialysed with 1&#46;25<span class="elsevierStyleHsp" style=""></span>mM calcium bath&#46; During this calcium load&#44; phosphorus levels persist uncontrolled&#46; Besides&#44; there is a progressive alkalinisation in all the patients&#46; In the end of the session 50&#37; have serum bicarbonate &#62;30<span class="elsevierStyleHsp" style=""></span>mM and 23&#37; pH &#62;7&#46;5&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">During HD sessions occur electrolyte and acid&#8211;base disorders that induce VC&#58; calcium load and alkalisation in presence of elevated phosphorus levels&#46; It is necessary to perform studies with kinetic models of calcium load and alkalinisation different from the actual ones&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La calcificaci&#243;n vascular &#40;CV&#41; asociada a la enfermedad renal cr&#243;nica &#40;ERC&#41; es un fen&#243;meno estrechamente ligado a las alteraciones en el metabolismo mineral &#243;seo&#46; Existen muchos factores implicados&#44; entre ellos los f&#225;rmacos empleados en el tratamiento de la ERC&#46; Algunos estudios <span class="elsevierStyleItalic">in vitro</span> se&#241;alan que las alteraciones electrol&#237;ticas y &#225;cido-b&#225;sicas que tienen lugar durante la sesi&#243;n de hemodi&#225;lisis &#40;HD&#41; pueden jugar un papel clave en el proceso de CV&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Analizamos las alteraciones electrol&#237;ticas y &#225;cido-b&#225;sicas que tienen lugar durante la sesi&#243;n de HD en 26 pacientes&#44; empleando de forma aleatorizada concentraciones de calcio en el l&#237;quido de di&#225;lisis de 1&#44;25 o 1&#44;5<span class="elsevierStyleHsp" style=""></span>mM&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En todos los pacientes&#44; independientemente del ba&#241;o de calcio empleado&#44; se produce una ganancia de calcio&#46; En el grupo de pacientes dializados con ba&#241;o de calcio 1&#44;5<span class="elsevierStyleHsp" style=""></span>mM&#44; el 100&#37; finaliza la sesi&#243;n con valores de calcio s&#233;rico<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#44;3<span class="elsevierStyleHsp" style=""></span>mM&#44; mientras que en el de 1&#44;25<span class="elsevierStyleHsp" style=""></span>mM&#44; esto solo ocurre en el 15&#37;&#46; Al inicio de la sesi&#243;n&#44; esta ganancia de calcio coincide con niveles de f&#243;sforo a&#250;n no controlado&#46; Adem&#225;s&#44; en todos los pacientes se observa una alcalinizaci&#243;n progresiva&#58; el 50&#37; finaliza la sesi&#243;n con cifras de bicarbonato<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mM y el 23&#37; con pH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>7&#44;5&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Durante la sesi&#243;n de HD se producen cambios electrol&#237;ticos y &#225;cido-b&#225;sicos inductores de CV&#58; ganancia de calcio y alcalinizaci&#243;n en presencia de f&#243;sforo s&#233;rico inicialmente elevado&#46; Son necesarios estudios con modelos cin&#233;ticos de ganancia de calcio y alcalinizaci&#243;n diferentes a los actuales&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Seras M&#44; Mart&#237;n de Francisco &#193;L&#44; Pi&#241;era C&#44; Gundin S&#44; Garc&#237;a-Unzueta M&#44; Kislikova M&#44; et al&#46; Sesi&#243;n de hemodi&#225;lisis&#58; la tormenta perfecta para la calcificaci&#243;n vascular&#46; Nefrologia&#46; 2015&#59;35&#58;448&#8211;456&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Temporal changes in plasma phosphorus &#40;mg&#47;dL&#41; during haemodialysis sessions&#46; Patients are grouped according to baseline calcium and calcium bath used&#46; Changes in phosphorus were independent of the calcium bath used and the baseline calcaemia&#58; there were no significant differences between groups&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Temporal changes in plasma bicarbonate &#40;mM&#41; during haemodialysis sessions&#46; Patients are grouped according to baseline calcium and calcium bath used&#46; Baseline and final values of bicarbonate were independent of the calcium bath used and the baseline calcaemia&#58; there were no significant differences between groups&#46; 50&#37; of patients ended the session with baseline bicarbonate levels &#62;30<span class="elsevierStyleHsp" style=""></span>mM&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Temporal changes in plasma pH during haemodialysis sessions&#46; Patients are grouped according to baseline calcium and calcium bath used&#46; The baseline and final values were independent of the calcium bath used and the baseline calcaemia&#58; there were no significant differences between groups&#46; Overall&#44; 23&#37; of patients ended the session with pH &#62;7&#46;5&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Age&#44; days on haemodialysis&#44; and ultrafiltration are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46; There were no statistically significant differences between groups for any of the variables&#46; AVF&#44; ateriovenous fistula&#59; CVC&#44; central venous catheter&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Calcium bath</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline calcaemia</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1&#46;25<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1&#46;5<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#60;1&#46;16<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#62;1&#46;16<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#47;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ca<span class="elsevierStyleSup">&#43;&#43;</span> bath 1&#46;5<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age&#44; years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#46;23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">76&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">74&#46;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Days on HD&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;331&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;233&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;114&#46;23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;432&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;627&#46;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;147&#46;22&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;002&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>720&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;075&#46;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>543&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;804&#46;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>915&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">AVF&#47;CVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Expressed as mean and standard deviation&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Calcium bath</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline calcium</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1&#46;25<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1&#46;5<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#60;1&#46;16<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#62;1&#46;16<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Calcium &#40;mM&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;14<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Final&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;09<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;04<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;34<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Phosphorus &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;05<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;04<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Final&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;55<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ca<span class="elsevierStyleSup">&#43;&#43;</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>P &#40;mg<span class="elsevierStyleSup">2</span>&#47;dL<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;73<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;86<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;76<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Final&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;84<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;99<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;41<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;94<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">pH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;39<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Final&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Bicarbonate &#40;mM&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;82<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Final&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;84<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;98<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Magnesium &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;43<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;32<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Final&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;97<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;04<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;01<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">iPTH &#40;pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">574&#46;69<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>379&#46;75<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">321&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>244&#46;46<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">441<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>293&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">454&#46;85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>390&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Final&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">496&#46;23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>400&#46;61<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">229&#46;62<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>236&#46;18<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">296&#46;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>338&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">429&#46;54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>361&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab989858.png"
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            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Grouped by calcium bath used&#44; there were statistically significant differences in the values of final calcium &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; final Ca<span class="elsevierStyleSup">&#43;&#43;</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>P &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#44; baseline iPTH &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; and final iPTH &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46; Grouped by baseline calcaemia&#44; there were no statistically significant differences in any of the variables&#46;</p>"
            ]
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Mean baseline and final levels of ionised calcium&#44; phosphorus&#44; Ca<span class="elsevierStyleSup">&#43;&#43;</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>P product&#44; pH&#44; bicarbonate&#44; magnesium&#44; and PTH&#46;</p>"
        ]
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      7 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Expressed as mean and standard deviation&#46;</p>"
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            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Calcium bath</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline calcaemia</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1&#46;25<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1&#46;5<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#60;1&#46;16<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#62;1&#46;16<span class="elsevierStyleHsp" style=""></span>mM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#916;Ca<span class="elsevierStyleSup">&#43;&#43;</span> &#40;mM&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;09<span class="elsevierStyleSup">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;08<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;11<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;11<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#916;P &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;3&#46;04<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;2&#46;48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;2&#46;78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;2&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#916;Ca<span class="elsevierStyleSup">&#43;&#43;</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>P &#40;mg<span class="elsevierStyleSup">2</span>&#47;dL<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;13&#46;79<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;09<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;8&#46;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;17<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;9&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;12&#46;61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#916;HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> &#40;mM&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;30<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#916;pH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#916;Mg<span class="elsevierStyleSup">&#43;&#43;</span> &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;35&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#916;PTH &#40;pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 20132514
Original language: English

DOI:10.1016/j.nefroe.2015.09.008

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Year/Month	Html	Pdf	Total

2024 November	6	4	10
2024 October	36	40	76
2024 September	51	27	78
2024 August	49	61	110
2024 July	27	29	56
2024 June	72	40	112
2024 May	52	34	86
2024 April	43	34	77
2024 March	60	26	86
2024 February	43	35	78
2024 January	29	25	54
2023 December	32	38	70
2023 November	47	34	81
2023 October	39	36	75
2023 September	34	22	56
2023 August	30	27	57
2023 July	48	23	71
2023 June	32	28	60
2023 May	40	42	82
2023 April	35	19	54
2023 March	52	22	74
2023 February	48	17	65
2023 January	42	22	64
2022 December	81	33	114
2022 November	66	44	110
2022 October	69	52	121
2022 September	46	52	98
2022 August	39	42	81
2022 July	33	47	80
2022 June	31	33	64
2022 May	39	24	63
2022 April	40	46	86
2022 March	66	45	111
2022 February	84	38	122
2022 January	77	42	119
2021 December	79	44	123
2021 November	82	31	113
2021 October	89	47	136
2021 September	52	40	92
2021 August	63	48	111
2021 July	77	37	114
2021 June	45	22	67
2021 May	89	44	133
2021 April	84	46	130
2021 March	58	35	93
2021 February	64	18	82
2021 January	53	16	69
2020 December	52	14	66
2020 November	52	17	69
2020 October	40	14	54
2020 September	30	19	49
2020 August	47	21	68
2020 July	50	13	63
2020 June	34	20	54
2020 May	77	11	88
2020 April	46	18	64
2020 March	57	16	73
2020 February	46	23	69
2020 January	58	20	78
2019 December	56	25	81
2019 November	52	23	75
2019 October	37	10	47
2019 September	53	14	67
2019 August	32	17	49
2019 July	40	19	59
2019 June	39	26	65
2019 May	29	18	47
2019 April	109	27	136
2019 March	40	19	59
2019 February	31	16	47
2019 January	37	34	71
2018 December	375	54	429
2018 November	911	27	938
2018 October	776	26	802
2018 September	256	19	275
2018 August	83	17	100
2018 July	42	20	62
2018 June	35	16	51
2018 May	39	12	51
2018 April	33	12	45
2018 March	40	9	49
2018 February	31	8	39
2018 January	29	5	34
2017 December	32	7	39
2017 November	57	13	70
2017 October	42	8	50
2017 September	57	13	70
2017 August	51	21	72
2017 July	43	7	50
2017 June	52	11	63
2017 May	59	8	67
2017 April	43	9	52
2017 March	31	4	35
2017 February	29	18	47
2017 January	35	13	48
2016 December	92	13	105
2016 November	96	25	121
2016 October	137	9	146
2016 September	166	5	171
2016 August	162	3	165
2016 July	174	6	180
2016 June	162	0	162
2016 May	239	0	239
2016 April	176	0	176
2016 March	162	0	162
2016 February	172	0	172
2016 January	130	0	130
2015 December	116	0	116
2015 November	111	0	111
2015 October	49	0	49

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