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Iron deficiency in patients with congestive heart failure: A medical practice that requires greater attention
Estudio de la deficiencia de hierro en pacientes con insuficiencia cardiaca congestiva: una práctica clínica que precisa mayor atención
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For those recipients who were not treated with vitamin D, 25OHD<span class="elsevierStyleInf">3</span> by CKD-T stage serum levels (b) and correlation of log transformed 25OHD<span class="elsevierStyleInf">3</span> with log transformed PTH levels are shown as a function of gender (slope was steeper in women; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.01). For all recipients, the correlation between the log transformed 25OHD<span class="elsevierStyleInf">3</span> and log transformed 1,25(OH)<span class="elsevierStyleInf">2</span>D<span class="elsevierStyleInf">3</span> is shown (<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−0.35; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) (d). 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Más allá del fracaso renal agudo" ] ] "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" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1502 "Ancho" => 978 "Tamanyo" => 415104 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Renal biopsy findings in chronic phosphate nephropathy. (a) Case of chronic phosphate nephropathy with abundant intraluminal and intracellular calcifications in distal tubules accompanied by tubular atrophy and fibrosis (hematoxylin and eosin) and (b) a positive histochemical reaction with the von Kossa stain confirms that the tubular concretions are composed of calcium phosphate.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Gema Fernández-Juárez, Leticia Parejo, Javier Villacorta, Ana Tato, Ramiro Cazar, Carmen Guerrero, Isabel Martinez Marin, Javier Ocaña, Angel Mendez-Abreu, Katia López, Enrique Gruss, Eduardo Gallego" "autores" => array:12 [ 0 => array:2 [ "nombre" => "Gema" "apellidos" => "Fernández-Juárez" ] 1 => array:2 [ "nombre" => "Leticia" "apellidos" => "Parejo" ] 2 => array:2 [ "nombre" => "Javier" "apellidos" => "Villacorta" ] 3 => array:2 [ "nombre" => "Ana" "apellidos" => "Tato" ] 4 => array:2 [ "nombre" => "Ramiro" "apellidos" => "Cazar" ] 5 => array:2 [ "nombre" => "Carmen" "apellidos" => "Guerrero" ] 6 => array:2 [ "nombre" => "Isabel Martinez" "apellidos" => "Marin" ] 7 => array:2 [ "nombre" => "Javier" "apellidos" => "Ocaña" ] 8 => array:2 [ "nombre" => "Angel" "apellidos" => "Mendez-Abreu" ] 9 => array:2 [ "nombre" => "Katia" "apellidos" => "López" ] 10 => array:2 [ "nombre" => "Enrique" "apellidos" => "Gruss" ] 11 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Gallego" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0211699516000400" "doi" => "10.1016/j.nefro.2016.02.010" "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/S0211699516000400?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S201325141630027X?idApp=UINPBA000064" "url" => 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class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Mayte" "apellidos" => "García Unzueta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 7 => array:3 [ "nombre" => "Manuel" "apellidos" => "Arias Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Análisis Clínicos, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio de la deficiencia de hierro en pacientes con insuficiencia cardiaca congestiva: una práctica clínica que precisa mayor atención" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Congestive heart failure (CHF) is associated with marked deterioration in health-related quality of life (HRQoL). Patients report symptoms such as dyspnoea during exercise, limited capacity for physical work, tiredness, susceptibility to develop stress and reduced mental and cognitive performance.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1,2</span></a> Its prevalence is 1–2% in the general population, and may exceed 10% in individuals over 80 years of age.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A common feature of CHF is iron deficiency, resulting from exhaustion of iron stores, a deficient intestinal absorption of iron and reduced bioavailability.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4,5</span></a> Various randomised prospective studies have demonstrated that in patients with CHF and iron deficiency with or without anaemia, iron repletion improves symptoms, physical performance and quality of life.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> The FAIR-HF<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> study shows the importance of diagnosing and treating iron deficiency in patients with CHF. A post hoc of the FAIR-HF study found significant improvement in patients after iron therapy. The clinical benefit was similar in anaemic and non-anaemic patients, in terms of patients’ overall self-perception, NYHA class, HRQoL and exercise capacity.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">It is widely known that anaemia is a common comorbidity in patients with CHF<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a>; it is an independent prognostic marker of mortality, hospital admissions and poor quality of life.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10,11</span></a> Correction of anaemia to normal or near-normal values has been associated with an improvement in HRQoL, exercise capacity and symptoms of CHF.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Congestive Heart Failure and CKD may share the cause (e.g. hypertension), comorbidities (e.g. malnutrition) and risk factors (e.g. advanced age). Therefore, it is not rare to observe these two diseases together in what is known as cardio-renal syndrome.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">12–14</span></a> In addition, if both entities occur together with anaemia, it is known as cardio-renal anaemia syndrome which represents a major independent risk factor for CHF.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">15,16</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design and objectives</span><p id="par0025" class="elsevierStylePara elsevierViewall">A retrospective observational study conducted in 824 patients diagnosed on admission with CHF at Hospital Universitario Marqués de Valdecilla in Santander (Spain) between 1 January 2012 and 11 June 2013.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The primary objective of the study was to determine how many of these CHF patients underwent laboratory testing for iron status evaluation (ferritin and transferrin saturation index [TSI]). The secondary objectives were to determine the percentage of patients with iron deficiency, with or without anaemia, and to quantify the degree of renal impairment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The number of determinations of serum iron (ferritin or TSI), and haemoglobin (Hb), as well as calculations of glomerular filtration rate (GFR). It should be kept in mind that a single patient corresponded to one hospitalisation with one or more rehospitalisation; none of one, more than one laboratory determinations could be generated in each hospitalisation. Patients’ iron parameters were considered to have been investigated when they had undergone one determination of ferritin or TSI. Additional determination during their hospital stay, were not included in the analysis.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Concomitant comorbidities, degree of CHF and stability of CHF were not analysed.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Anaemia was defined as Hb level <13<span class="elsevierStyleHsp" style=""></span>g/dl in men and <12<span class="elsevierStyleHsp" style=""></span>g/dl in women. Iron deficiency was considered if ferritin levels <100<span class="elsevierStyleHsp" style=""></span>μg/ml, or serum ferritin between 100 and 300<span class="elsevierStyleHsp" style=""></span>μg/ml plus a TSI <20%. GFR was calcululated using the MDRD equation. Patients were divided according to GFR into grades 3–5 and >60<span class="elsevierStyleHsp" style=""></span>ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>, as recommended by the KDIGO guidelines. A GFR <60<span class="elsevierStyleHsp" style=""></span>ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> was considered to be kidney failure.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using the SPSS v. 15.0 programme (SPSS Inc., Chicago, United States). Quantitative variables with a normal distribution were expressed as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation, and those without normal distribution were expressed as median and interquartile range. Qualitative variables were expressed as relative frequencies. Normality was confirmed with the Kolmogorov–Smirnov test, and homogeneity of variance was confirmed with the Levene test. Comparison of means between 2 groups was performed depending on the variable's distribution, with Student's <span class="elsevierStyleItalic">t</span> test for independent groups or its non-parametric equivalent (the Mann–Whitney <span class="elsevierStyleItalic">U</span> test). Comparison between groups for qualitative variables was performed with the <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span> test. A <span class="elsevierStyleItalic">p</span> value<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 was considered to be statistically significant.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">A total of 824 patients were analysed. Of them, 39% (324) were evaluated for iron parameters. No significant differences were observed with respect to age (81.3 [73.5–86.7] vs 81.9 [75.8–86.7] years), although significant differences were observed with respect to gender (57 vs 88% men; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.007). Values of GFR (57.3 [43.1–60.0] vs 46.1 [34.1–60] ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>) and Hb (12.4 [43.1–60.0] vs 10.8 [9.7–12.0] g/dl) were significantly lower in the group of patients tested for iron (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). The percentage of patients with anaemia (56 vs 81%), kidney failure (55 vs 73%) or both comorbidities at the same time (35 vs 63%) was significantly greater in the group of patients tested for iron (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Among the 324 patients evaluated for iron parameters, 164 patients (51%) showed iron deficiency. No significant differences were observed with respect to age or gender between those without iron deficiency and those with iron deficiency. Ferritin was evaluated in 291 patients (90%), 127 (44%) of whom had a level <100<span class="elsevierStyleHsp" style=""></span>μg/l. TSI was estimated in 254 patients (78%), 192 (76%) of whom had a level <20%. Iron parameters for the two groups—ferritin (325 [172.0–632.0] vs 69.5 [35.5–100.5] μg/l) and TSI (18% [11.5–26.0] vs 11% [7.0–14.3])—showed significant differences (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). GFR also reflected significant differences (42.0 [30.7–57.6] vs 51.7 [36.8–60] ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001), as did the percentage of patients with CKD (79 vs 66%; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.013). By contrast, Hb did not reflect significant differences between the two groups (11.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.9 vs 10.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.6<span class="elsevierStyleHsp" style=""></span>g/dl) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">This study showed that potential iron deficiency is only studied in 39% of patients who are admitted with CHF to our centre, meaning that opportunities for clinical improvement are lost in many patients. This requires a reconsideration of routine clinical practice in patients with CHF.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In our study, the age structure of the population analysed matched that reflected by the Spanish Statistical Office (INE) in its survey on hospital morbidity<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a>. Thus, 1% of patients were 45 years of age or less, and more than 80% of the population analysed was older than 75 year.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Regarding the prevalence of iron deficiency in CHF, methodological differences in the design of several study have yielded to non uniform results ranging from 13.7%, observed by Hug et al.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a>; to intermediate reports in the 36–43% range, like those indicated by Range et al.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> and Macdougall et al.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a>; to 63%, in a study by Comín-Colet et al.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a>. In our work, iron was only evaluated in 39% of the population, with a prevalence of iron deficiency of 51%, a figure greater than the mean reflected in the studies. This may probably be explained by the limited percentage of population analysed and the older age.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The prevalence of anaemia in CHF has been found to be between 4% and 50%,<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">21,22</span></a> depending on the study population and the cut-off values for Hb used to define the lower limit of normal. In a systematic review and meta-analysis, Groenveld et al.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> noted a prevalence of 37%. Extreme prevalences like those noted by Silverberg et al.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> (79%) have undoubtedly been due to methodological differences in study design. In our study, we found an overall prevalence of 66% of anaemic and in the subgroup of 324 patients whose potential iron deficiency had been investigated the prevalence rose to 79% among those who did not have iron deficiency and 84% in those who did have it. In general, our study reflected a greater prevalence than the majority of the studies evaluated. We believe that this may be mainly due to patients’ older age.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Regarding the prevalence of CKD in CHF, the studies analysed have established it in the 30–64% range.<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">25–27</span></a> In our study, the prevalence of CKD was 62% overall and 73% in the subgroup of patients who were evaluated for iron (79% in those without iron deficiency and 66% in those with iron deficiency). These percentages were close to the upper end of or even above the range reflected in the studies analysed. Once again, the explanation for this result may be found in the patients’ older age.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The epidemiology of cardio-renal anaemia syndrome is complicated, since it depends on the prevalence of each of its components, which in turn depend to a large extent on the definitions used and the severity of the disease in the population studied. As a result, there has been considerable variation among the published data: from 3% to 22%.<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">28,29</span></a> Our results indicated a prevalence of cardio-renal anaemia syndrome of 46% relative to the total population. In the subgroup evaluated for iron parameters, the prevalence rose to 63% (68% in those who did not have iron deficiency and 59% in those who did). As mentioned, the methodological differences in study design, including the age of the population, may account for this difference in prevalence between our study and those reviewed.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Weak aspects of our study were its observational nature, the fact that CHF was diagnosed by assigned physicians without uniform criteria, the fact that it did not analyse reason for admission or degree of CHF decompensation and the fact that it did not include treatments for or analysis of causes of iron deficiency. However, it should be noted that the data that we have presented concerned a single centre, although this does not mean that other centres act differently. The uniformity of the data, as they came from a single centre, and the resulting uniformity of the analytical techniques, must be noted as study strengths.</p><p id="par0100" class="elsevierStylePara elsevierViewall">We believe that the results shown may represent a clear area of improvement for the treatment of heart failure.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0105" class="elsevierStylePara elsevierViewall">Iron deficiency, with or without concomitant anaemia, was found to be significantly associated with HRQoL, NYHA functional class and exercise capacity. Bearing in mind the data from prospective studies that have demonstrated clinical improvement with the administration of iron in patients with iron deficiency, early detection should be given more substantial consideration as a therapeutic target in the treatment of CHF. Our results have merely aimed to show that gap in routine medical practice, with limited laboratory determinations of iron levels in patients with CHF.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no potential conflicts of interest related to the contents of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres828208" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec824439" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres828209" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec824438" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Study design and objectives" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-10-14" "fechaAceptado" => "2015-12-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec824439" "palabras" => array:7 [ 0 => "Congestive heart failure" 1 => "Iron deficiency" 2 => "Health-related quality of life" 3 => "Exercise intolerance" 4 => "Anaemia" 5 => "Renal failure" 6 => "Cardiorenal syndrome" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec824438" "palabras" => array:7 [ 0 => "Insuficiencia cardiaca congestiva" 1 => "Deficiencia de hierro" 2 => "Calidad de vida relacionada con la salud" 3 => "Intolerancia al ejercicio" 4 => "Anaemia" 5 => "Insuficiencia renal" 6 => "Síndrome cardio-renal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Iron deficiency in congestive heart failure (CHF), with or without concomitant anaemia, is associated with health-related quality of life, NYHA functional class, and exercise capacity. Prospective, randomised studies have demonstrated that correcting iron deficiency improves the quality of life and functional status of patients with CHF, including those who do not have anaemia.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to analyse how frequently these iron parameters are tested and thus determine the extent to which this quality improvement tool has been implemented in patients admitted with CHF.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Retrospective observational study of patients from a university hospital diagnosed with CHF on admission between 01/01/2012 and 11/06/2013.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Iron parameters were tested in 39% (324) of the 824 patients analysed. There was no significant difference in age between the patients whose iron was tested and those whose iron was not tested, but the difference in terms of gender was significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.007). Glomerular filtration rate and haemoglobin, were significantly lower in the group of patients whose iron was tested (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). The proportion of patients with anaemia, renal failure or both was significantly higher in the group of patients who had iron tests (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001).</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Of the 324 patients whose iron parameters were tested, 164 (51%) had iron deficiency. There were no differences between patients with and without iron deficiency in terms of age or gender. The iron parameters in both groups, ferritin and transferrin saturation index were significantly lower among the patients with iron deficiency (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). The glomerular filtration rate values were significantly lower in patients with no iron deficiency (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). Significant differences were also observed between those with and without iron deficiency in the proportion of patients with renal failure (79 vs. 66%, respectively, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.013), but not in terms of haemoglobin concentration.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Congestive heart failure is very frequently associated with anaemia, iron deficiency and renal failure. Despite the fact that correcting iron deficiency is known to improve symptoms, testing of iron parameters in patients admitted with CHF is not performed as often as it should be.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducción</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La deficiencia de hierro en la insuficiencia cardiaca crónica (ICC), con o sin anaemia concomitante, se halla asociada a la calidad de vida relacionada con la salud, clase funcional NYHA, y a la capacidad de realización de ejercicio. Estudios prospectivos aleatorizados han demostrado que la corrección de la deficiencia de hierro mejora la calidad de vida y el estadio funcional de estos pacientes con ICC, incluidos aquellos que no presentaban anaemia.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio es analizar la frecuencia de determinaciones de estos parámetros de hierro y, por consiguiente, conocer la implementación de esta herramienta de mejoría de la calidad en pacientes que ingresan por ICC.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Métodos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo sobre pacientes de un hospital universitario, que fueron diagnosticados al ingreso de ICC, entre el 1/1/2012 y el 11/6/2013.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El número de pacientes analizados fue de 824, de los que a un 39% (324) les fueron evaluados los parámetros de hierro. Entre los pacientes no evaluados y sí evaluados de hierro, no se observó diferencia significativa en la edad, aunque sí en el género, (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,007). Los valores del filtrado glomerular y de hemoglobina fueron significativamente inferiores en el grupo de pacientes analizados de hierro (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001). La proporción de pacientes con anaemia, insuficiencia renal y de aquellos que presentaban conjuntamente ambas comorbilidades fue significativamente superior en el grupo de pacientes analizados de hierro (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001).</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Entre los 324 pacientes evaluados de parámetros férricos, 164 pacientes (51%) mostraban deficiencia de hierro. Entre los no deficientes y sí deficientes en hierro, no se observaron diferencias significativas en edad, ni en género. Los parámetros férricos de ambos grupos, ferritina e índice de saturación de la transferrina fueron significativamente inferiores entre los deficientes de hierro, (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001). Los valores de filtrado glomerular fueron significativamente inferiores en aquellos que no mostraban deficiencia de hierro, (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001). Se observaron igualmente diferencias significativas en la proporción de pacientes con insuficiencia renal, entre no deficientes y sí deficientes de hierro, (79 vs. 66%; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,013), aunque no en los valores de hemoglobina.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusión</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La ICC se asocia con alta frecuencia a anaemia, deficiencia de hierro e insuficiencia renal. El estudio de los parámetros férricos en los pacientes que ingresan con ICC, pese a que la corrección de la deficiencia de hierro se asocia a mejoría de la sintomatología, no se realiza con la frecuencia necesaria.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Belmar Vega L, De Francisco, ALM, Albines Fiestas Z, Serrano Soto M, Kislikova M, Seras Mozas M, et al. Estudio de la deficiencia de hierro en pacientes con insuficiencia cardiaca congestiva: una práctica clínica que precisa mayor atención. Nefrologia. 2016;36:249–254.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Values in parentheses are interquartile ranges.</p>" "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" 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"><span class="elsevierStyleItalic">N</span> \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">Not tested for iron \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"><span class="elsevierStyleItalic">N</span> \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">Tested for iron \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"><span class="elsevierStyleItalic">p</span> \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">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81.3 (73.5–86.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">324 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81.9 (75.8–86.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Gender (male) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">283 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">152 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.007 \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">GFR (ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">496 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.3 (43.1–60.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">324 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.1 (34.1–60) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.001 \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">Hb (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">498 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.4 (11.1–13.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">324 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.8 (9.7–12.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.001 \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">Anaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">278 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">263 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.001 \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">CKD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">272 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">235 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.001 \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">Cardio-renal anaemia syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">173 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">204 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1393521.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Comparison of parameters between patients not tested for iron and tested for iron.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Values in parentheses are interquartile ranges.</p>" "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" 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"><span class="elsevierStyleItalic">N</span> \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">Non-iron-deficient \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"><span class="elsevierStyleItalic">N</span> \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">Iron-deficient \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"><span class="elsevierStyleItalic">p</span> \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">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81.6 (76.7–85.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">164 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82.6 (74.8–88.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Gender (male) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Ferritin (μg/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">127 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">325 (172.0–632.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">164 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.5 (35.5–100.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.001 \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">TSI (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">115 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (11.5–26.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">139 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (7.0–14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.001 \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">GFR (ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.0 (30.7–57.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">164 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.7 (36.8–60) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.001 \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">Hb (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">164 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Anaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">126 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">137 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">CKD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">126 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">109 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.013 \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">Cardio-renal anaemia syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">108 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1393520.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Comparison of parameters between non-iron-deficient and iron-deficient patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 1 | 8 |
| 2024 October | 66 | 31 | 97 |
| 2024 September | 43 | 23 | 66 |
| 2024 August | 73 | 50 | 123 |
| 2024 July | 53 | 24 | 77 |
| 2024 June | 66 | 35 | 101 |
| 2024 May | 55 | 27 | 82 |
| 2024 April | 68 | 41 | 109 |
| 2024 March | 78 | 30 | 108 |
| 2024 February | 41 | 34 | 75 |
| 2024 January | 29 | 25 | 54 |
| 2023 December | 38 | 23 | 61 |
| 2023 November | 49 | 28 | 77 |
| 2023 October | 66 | 39 | 105 |
| 2023 September | 77 | 66 | 143 |
| 2023 August | 82 | 27 | 109 |
| 2023 July | 42 | 39 | 81 |
| 2023 June | 41 | 36 | 77 |
| 2023 May | 65 | 60 | 125 |
| 2023 April | 38 | 17 | 55 |
| 2023 March | 75 | 16 | 91 |
| 2023 February | 57 | 17 | 74 |
| 2023 January | 35 | 15 | 50 |
| 2022 December | 78 | 43 | 121 |
| 2022 November | 83 | 34 | 117 |
| 2022 October | 78 | 56 | 134 |
| 2022 September | 56 | 29 | 85 |
| 2022 August | 43 | 44 | 87 |
| 2022 July | 38 | 51 | 89 |
| 2022 June | 51 | 34 | 85 |
| 2022 May | 49 | 29 | 78 |
| 2022 April | 45 | 38 | 83 |
| 2022 March | 56 | 50 | 106 |
| 2022 February | 50 | 36 | 86 |
| 2022 January | 49 | 33 | 82 |
| 2021 December | 56 | 47 | 103 |
| 2021 November | 47 | 37 | 84 |
| 2021 October | 62 | 29 | 91 |
| 2021 September | 55 | 40 | 95 |
| 2021 August | 99 | 63 | 162 |
| 2021 July | 70 | 47 | 117 |
| 2021 June | 60 | 28 | 88 |
| 2021 May | 59 | 43 | 102 |
| 2021 April | 149 | 111 | 260 |
| 2021 March | 155 | 36 | 191 |
| 2021 February | 90 | 64 | 154 |
| 2021 January | 64 | 26 | 90 |
| 2020 December | 74 | 25 | 99 |
| 2020 November | 76 | 24 | 100 |
| 2020 October | 74 | 28 | 102 |
| 2020 September | 53 | 22 | 75 |
| 2020 August | 66 | 35 | 101 |
| 2020 July | 66 | 17 | 83 |
| 2020 June | 83 | 36 | 119 |
| 2020 May | 83 | 22 | 105 |
| 2020 April | 60 | 17 | 77 |
| 2020 March | 77 | 35 | 112 |
| 2020 February | 79 | 33 | 112 |
| 2020 January | 99 | 33 | 132 |
| 2019 December | 98 | 42 | 140 |
| 2019 November | 92 | 24 | 116 |
| 2019 October | 112 | 18 | 130 |
| 2019 September | 116 | 30 | 146 |
| 2019 August | 85 | 21 | 106 |
| 2019 July | 80 | 21 | 101 |
| 2019 June | 90 | 30 | 120 |
| 2019 May | 66 | 17 | 83 |
| 2019 April | 128 | 51 | 179 |
| 2019 March | 76 | 32 | 108 |
| 2019 February | 52 | 25 | 77 |
| 2019 January | 51 | 25 | 76 |
| 2018 December | 156 | 37 | 193 |
| 2018 November | 302 | 17 | 319 |
| 2018 October | 279 | 25 | 304 |
| 2018 September | 111 | 15 | 126 |
| 2018 August | 54 | 29 | 83 |
| 2018 July | 52 | 15 | 67 |
| 2018 June | 67 | 23 | 90 |
| 2018 May | 121 | 12 | 133 |
| 2018 April | 152 | 15 | 167 |
| 2018 March | 134 | 20 | 154 |
| 2018 February | 189 | 8 | 197 |
| 2018 January | 71 | 10 | 81 |
| 2017 December | 199 | 10 | 209 |
| 2017 November | 68 | 16 | 84 |
| 2017 October | 56 | 14 | 70 |
| 2017 September | 59 | 12 | 71 |
| 2017 August | 102 | 12 | 114 |
| 2017 July | 115 | 28 | 143 |
| 2017 June | 162 | 23 | 185 |
| 2017 May | 129 | 24 | 153 |
| 2017 April | 106 | 34 | 140 |
| 2017 March | 87 | 27 | 114 |
| 2017 February | 69 | 14 | 83 |
| 2017 January | 53 | 17 | 70 |
| 2016 December | 82 | 14 | 96 |
| 2016 November | 101 | 35 | 136 |
| 2016 October | 116 | 40 | 156 |
| 2016 September | 136 | 12 | 148 |
| 2016 August | 151 | 10 | 161 |
| 2016 July | 227 | 18 | 245 |
| 2016 June | 20 | 0 | 20 |
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