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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The number of elderly patients with advanced chronic kidney disease &#40;ACKD&#41;&#44; estimated glomerular filtration rate &#40;eGFR&#41; under 30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; stages 4 and 5 according to the DOQI classifications&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> has increased dramatically&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> In some series&#44; it has doubled during the last 25 years&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a> In our area&#44; according to the 2013 data from the Kidney Transplant Coordination Data System of Andalusia &#40;SICATA&#41;&#44; a database of kidney patients treated with dialysis and transplantation in Andalusia&#44; patients over 70 accounted for 38&#37; of the incident patients and 41&#46;4&#37; of the prevalent patients in dialysis programmes&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> Among the ACKD consultations in our hospital in 2013&#44; adults 70 or older accounted for 58&#37; of incident patients and up to 66&#37; of the prevalent patients&#46; Longer life expectancies and medical advances have contributed to the increased period of time for the development of renal atherosclerosis and diabetes mellitus &#40;DM&#41;&#46; During the past years&#44; these patients died before reaching an advanced stage of CKD&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> It is currently unclear whether in this group of patients renal replacement therapy &#40;RRT&#41; is the best option as compared with conservative treatment&#44; since a large proportion of them present an increased fragility&#44; with high indices of dependence and higher comorbidity&#44; including DM&#44; atherosclerosis in several locations&#44; heart disease&#44; with or without heart failure&#44; difficult vascular access&#44; etc&#46; Therefore RRT may not improve their survival<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">11&#8211;13</span></a> much less their quality of life&#46; In this regard&#44; it should be taken into account how a specific patient is affected by the change in lifestyle from the dialysis technique itself &#40;exchanges in peritoneal dialysis&#44; travel to dialysis centres&#44; following schedules&#44; dependence on other caretakers or family members&#44; etc&#46;&#41; and its complications &#40;decreased function after sessions&#44; high rate of hospitalisations&#44; use of venous catheters and their complications&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Currently&#44; there is a growing interest in evaluating the possibility of a more conservative treatment for elderly ACKD patients&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a> It must be specified that conservative treatment in this patient group should not entail an &#8220;absence of treatment&#8221; or less specialised medical care&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">8&#8211;10</span></a> Conservative treatment implies patient care in ACKD clinics with multidisciplinary approach to provide the best quality of life possible to end-stage kidney disease patients not eligible for dialysis therapy&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our objectives in this study were to discover the long-term progression of elderly incident ACKD &#40;stages 4 and 5&#41; patients in our out patient clinics and to retrospectively compare survival in the group of CKD stage 5 patients who underwent dialysis with those who followed a conservative treatment&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">Retrospective&#44; observational study including all patients 70 or older who began follow-up in the ACKD clinic of the Nephrology Department of the Hospital Universitario Virgen del Roc&#237;o in Seville &#40;hospital area includes 1&#44;400&#44;000 habitants&#41; from January 1&#44; 2007 through December 31&#44; 2008 and whose progress was observed for a 5-year period&#59; the end of observational period was December 31&#44; 2013&#46; The database from our own office was used to identify patients and collect follow-up information&#46; The DAE system &#40;electronic data platform&#41; used by the public health system of Andalusia was also employed to support the electronic medical records along with the SICATA registry&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Kidney function at the first visit to the ACKD clinic was computed as baseline estimated GFR using the MDRD-4 equation&#46; Renal function was also computed when patients entered stage 5 &#40;eGFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&#44; in the case that the patient reached this stage during the follow-up period&#46; The following data were extracted from their medical records&#58; cause of kidney disease&#44; vascular access in the case of patients who started haemodialysis&#44; history of DM&#44; ischaemic heart disease &#40;understood as an ischaemic episode&#41;&#44; Charlson comorbidity index calculation&#44; follow-up period in the clinic before they left&#44; and their reason for leaving &#40;death&#44; dialysis&#44; or end of the observation period on December 31&#44; 2013&#41;&#46; For patients who died&#44; the date and cause were recorded when it occurred in our hospital or at home after a previously known disease process&#46; We were not able to determine the cause of death if patient died in another hospital&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A descriptive analysis was conducted on the different quantitative variables using the median and the 25th and 75th percentiles&#44; since they did not show a normal distribution&#59; qualitative variables were expressed as the number and percentages&#46; The Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test and chi-squared test were used to analyse the difference between patients with &#60;15<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> who received dialysis and those who did not&#44; and between the patients who died and those alive at the end of the follow-up&#46; The analysis was performed in both the entire group &#40;314 patients&#41; and in stage 5 patients &#40;162 patients&#41;&#46; The Kaplan&#8211;Meier and log-rank methods were used to estimate and compare survival in both groups&#46; The Cox proportional hazards regression was used to investigate the impact of dialysis and other independent variables on survival&#46; First&#44; the correlation between each variable &#40;age&#44; eGFR&#44; history of DM&#44; history of ischaemic heart disease&#44; Charlson index&#44; and dialysis treatment&#41; and survival &#40;dependent variable&#41; was independently analysed in a bivariate regression analysis&#46; Then&#44; the variables that were significant and those considered to have specific clinical significance were included in the Cox regression analysis&#46; The IBM SPSS-19 statistical package was used&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">Initially 348 patients were studied who were 70 or older seen for the first time in the ACKD office successively during the specified follow-up period&#46; During the follow-up&#44; 16 patients recovered kidney function and went&#47;returned to the General Nephrology clinic&#46; Similarly&#44; 18 patients were lost to follow-up&#46; These 348 patients accounted for 61&#37; of all 571 patients of all ages seen for the first time during the inclusion period&#46; The final sample was made up of 314 patients&#59; of these&#44; 242 began their follow-up in stage 4 CKD and 90 &#40;37&#37;&#41; progressed to stage 5&#46; At the time of their first visit &#40;in the case of 72 patients&#41; or during the follow-up &#40;in the case of the 90 patients mentioned above&#41; 162 patients reached stage 5 &#40;eGFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> displays this information schematically&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">None of the patients was discarded&#44; despite the fact that in some cases their eGFR was greater than 30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> as there was a slight transitory improvement&#46; In the case where this improvement lasted&#44; they were sent back to the General Nephrology clinic&#46; The demographic data and other characteristics for both the full group &#40;314 patients&#41; and the subgroup of patients with stage 5 CKD &#40;162&#41; are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the survival in the 2 groups by year of follow-up and the overall survival from the first visit &#40;baseline&#41; until the end of the follow-up period or death&#46; As for the 90 patients who started with an eGFR in stage 4 and progressed to stage 5&#44; survival was considered since the time the eGFR was under 15<span class="elsevierStyleHsp" style=""></span>cc&#47;m&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In the group of 69 patients who underwent dialysis &#40;87&#37; haemodialysis&#44; 13&#37; peritoneal dialysis&#41;&#44; 35 patients &#40;51&#37;&#41; had a vascular access&#44; 18 patients &#40;26&#37;&#44; in 10 cases vascular access was requested&#41; started with a transitory venous catheter&#44; type of access was unknown in 7 patients &#40;10&#37;&#41;&#44; and 9 patients had a peritoneal catheter &#40;13&#37;&#41;&#46; The median time in dialysis was 27 months &#40;9&#8211;51&#41; for the entire group of &#8805;70 y&#46;o&#46;&#44; 30 months &#40;14&#8211;46&#41; for the 46 patients &#8805;75 y&#46;o&#46;&#44; and 14 months &#40;2&#8211;39&#41; for the 15 patients &#8805;80 y&#46;o&#46; For the subgroup of 54 patients 70&#8211;80 y&#46;o&#46;&#44; the median time in dialysis was 30 months &#40;10&#8211;52&#41;&#46; None of the patients received a transplant&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Comparison of deaths vs&#46; surviving patients &#40;full group and stage 5 subgroup&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">The difference between patients who died and alive was analysed&#59; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> displays the results in both the full group and in the subgroup with stage 5 CKD&#46; The most frequent causes of death in the full group &#40;196 deaths&#41; were&#58; cardiovascular disease in 137 patients &#40;70&#37;&#41; and cancer in 24 patients &#40;12&#37;&#41;&#46; Data regarding the cause of death was not available in 15 patients &#40;8&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Comparison of dialysis vs&#46; conservative treatment &#40;subgroup of 162 stage 5 patients&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the demographic data for the group comparing those who received dialysis and those who did not&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The Kaplan&#8211;Meier analysis confirmed that the survival was better in patients that were dialyzed&#58; 69 vs&#46; 93 patients in conservative treatment aged 70 or older &#40;log-rank&#58; 15&#46;4&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; An additional sub-analysis was performed in 120 patients aged 75 or older &#40;median 77&#59; 25&#8211;75th percentile&#58; 74&#8211;81 years&#41; &#40;46 vs&#46; 74 patients without dialysis&#41;&#44; survival being higher in patients receiving dialysis &#40;log-rank&#58; 8&#46;9&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#46; Similarly&#44; the group of 55 patients aged 80 or over was analysed &#40;median 82&#59; 25&#8211;75th percentile&#58; 81&#8211;84 years&#44; 15 vs&#46; 40 without dialysis&#41;&#59; in this group patients receiving dialysis did not show statistical increase in survival as compared with conservative treatment &#40;log-rank&#58; 1&#46;6&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;2&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the survival curves for the 3 patient groups by age&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Cox regression &#40;subgroup of 162 stage 5 patients&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">To determine which variables influence survival in this group over time&#44; a Cox regression analysis was completed&#44; using survival time as the dependent variable&#46; Among the variables initially assessed independently using bivariate regression&#44; we found the following results&#58; follow-up time in the office &#40;HR&#58; 0&#46;95&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; baseline eGFR &#40;MDRD-4&#41; &#40;HR&#58; 0&#46;96&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; age &#40;HR&#58; 1&#46;04&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#44; dialysis &#40;HR&#58; 1&#46;68&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; There was no statistically significant correlation with sex&#44; comorbidity as measured by the Charlson index&#44; history of diabetes&#44; or history of ischaemic heart disease&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The statistically significant variables in the bivariate regression with survival and the non-significant variables that have clinical relevance &#40;ischaemic heart disease and DM&#41; were included to determine the effect that each one has in the Cox regression model&#58; age&#44; kidney function as measured by the MDRD-4 eGFR&#44; dialysis&#44; and time in the office&#46; History of ischaemic heart disease&#44; history of DM&#44; and age were not statistically significant in the multivariate analysis&#46; The resulting hazard ratios indicate that&#44; in our study&#44; dialysis&#44; follow-up time in the office&#44; and baseline kidney function were the most important variables for survival in our group of patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Influence of comorbidity on survival &#40;full group and stage 5 subgroup&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">An additional survival analysis was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; among the group of stage 5 patients with ischaemic heart disease &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>78&#41; to determine whether dialysis still had a favourable effect on survival in this subgroup of patients&#46; The results showed that dialysis did favour survival &#40;36 dialysis vs&#46; 42 without dialysis&#59; log-rank 14&#46;7&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Similarly&#44; the effect of dialysis in the group of patients with DM &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>81&#41; was analysed&#44; demonstrating that patients treated with dialysis had a better survival &#40;34 vs&#46; 47 patients without dialysis&#59; log-rank 26&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Among the patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>80&#41; with a high Charlson index &#40;over 7&#44; the group median&#41;&#44; the difference in survival with dialysis was also significant &#40;log-rank 6&#46;9&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The effect of a history of DM or ischaemic heart disease and a high Charlson index in stage 5 CKD patients was also analysed and no significant differences were found &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; In the entire group &#40;314 patients&#41; this analysis showed that ischaemic heart disease did affect survival &#40;as seen with the Chi-squared test&#44; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; log-rank 4&#46;2&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#46; As for DM&#44; the difference is close to statistical significance &#40;log-rank 3&#46;3&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#41;&#44; and there were no differences in survival for a Charlson index over 8 &#40;group median&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The results from our study in patients with advance age &#40;&#8805;70 years&#41; with stage 5 CKD show that survival was higher in those treated with dialysis than in a conservative treatment&#59; however this advantage is lost in patients &#8805;80 years&#46; In addition to dialysis&#44; survival in stage 5 patients was improved inpatients with a long time of follow up in the outpatient clinic and was not changed in relation to a higher comorbidity as measured by the Charlson index and a history of DM or ischaemic heart disease&#46; Considering all patients &#40;314 patients&#44; stages 4 and 5&#41;&#44; survival was lower in patients with a history of DM and ischaemic heart disease&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">For ethical and technical reasons randomised studies are not possible in this field&#59; several studies&#44; all observational&#44; mostly conducted in the United Kingdom&#44; have observed the clinical outcome of elderly patients included in dialysis programmes&#44; and a few reports have compared clinical outcome in elderly on dialysis vs&#46; conservative treatment&#46; In general&#44; it was shown that patients have better survival on dialysis&#44; although this advantage is lost in patients with medical history of ischaemic heart disease&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a> Comorbidity as measured by the Charlson index<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a> or in patients with several mortality risk factors considered six months after starting dialysis&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a> Similarly&#44; longer survival may not be significant if hospitalisation days or those dedicated to dialysis sessions are subtracted&#44; as shown in the work by Da Silva-Gane&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a> The 404-day difference in survival in patients treated with dialysis is to some extent lost if the 326 days allocated to haemodialysis sessions are subtracted&#46; The case of peritoneal dialysis has different interpretation&#44; since patients do not need to travel&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The results from this study are very similar to those previously published&#46; In the study by Hussain&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a> with a group of patients very similar to ours in which survival in patients over 70 years with eGFR of 15<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> was compared to patients treated conservatively vs&#46; those treated with dialysis&#44; overall survival was improved&#44; although&#44; like in our study&#44; it was lost in those patients older than 80 years and in patients with higher comorbidity&#44; as measured by the Charlson index&#44; among others&#46; The study by Murtagh&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a> like ours&#44; also observed that survival was longer in patients treated with dialysis&#44; especially in patients referred early to ACKD outpatient clinics with a higher eGFR&#46; It is unclear if this advantage in survival comes from the dialysis itself or from correctly screening and care of patients in those visits&#46; However&#44; this benefit was substantially lost in those cases that presented higher comorbidity indices&#44; particularly with the presence of ischaemic heart disease&#46; Conversely&#44; in our study we did not find any differences relating to comorbidity in the stage 5 CKD group &#40;we did observe a difference in our full group of 314 patients in stages 4 and 5&#41;&#44; and in patients with DM and ischaemic heart disease the positive effect of dialysis on survival was still present&#46; One explanation may be the lower number of patients&#44; which lowers the statistical power&#59; also many patients have both DM and ischaemic heart disease&#46; So the sample of patients is homogeneous&#46; There was also no difference in the prevalence of DM and ischaemic heart disease among those who received dialysis and those who did not&#44; but there was a difference in being younger and in the Charlson index of the patients treated with dialysis&#44; which implies that the patients were screened and those who were younger and had a lower comorbidity were included in dialysis which favoured survival in addition to the treatment&#46; This is in line with previous studies which warned about the importance of personalising the treatment &#40;dialysis vs&#46; conservative&#41; in each elderly patients based on their comorbidity&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#8211;10&#44;14&#8211;16</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In our study patients &#40;the full group with stages 4 and 5 CKD as well as in the stage 5 CKD group&#41; that visited our outpatient clinics for long period of time have better survival in both the individual analysis as well as after adjusting for the different variables in the multivariate analysis&#46; Our results are similar to other previously published results&#44; such as the paper by De Nicola&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a> in which patients seen for ACKD were followed for one year&#46; They concluded that patients seen for a longer time had a lower risk of mortality&#46; Previous follow-up in ACKD offices is an important factor in preparing these patients to choose the dialysis modality according to each patient&#39;s situation which may condition the short- and mid-term prognosis in RRT&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">20&#8211;22</span></a> A short period of visits to the office correlated with serious non-CKD-related comorbid processes that caused the early death&#44; unrelated to follow-up in the office&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Another noteworthy point is the slow deterioration in kidney function in our patients despite significant deterioration at baseline&#44; with a median eGFR near 20<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> &#40;after 5 years of follow-up&#58; 27&#37; did not reach stage 5&#59; 35&#37; died before progressing to stage 5&#59; 37&#37; progressed to stage 5&#41;&#46; This evolution has been previously described and it may be justified in part or in many cases by the absence of albuminuria&#44; more common in patients with concomitant low filtration rate and albuminuria&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">23&#44;24</span></a> In any case&#44; current knowledge does not enable us to identify patients with ACKD who will progress and those who will not&#46; In our study&#44; the possibility of dying was similar to that of progressing to stage 5 in patients who started follow-up in stage 4&#46; In other studies&#44; the risk of dying was higher than progressing to end-stage CKD&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">25&#44;26</span></a> It is possible that&#44; had we considered a lower eGFR in our study&#44; such as 8&#8211;10<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> instead of 15<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; the probability of dying would have been clearly higher than that of progressing and considering treatment with dialysis&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The limitations of the present study include the unavailability of additional data that could potentially condition mortality or survival&#44; such as family support&#44; autonomy&#44; quality of life data after starting RRT or conservative treatment&#46; The scarce number of patients in the older subgroups treated with dialysis must also be pointed out&#46; This study was performed in a single centre&#44; and findings might not apply fully to other patient groups&#46; Missing from our study is information on patients who did not receive dialysis&#44; whether they had abandoned the treatment&#44; refused it&#44; or had a medical contraindication&#46; The results&#44; which show higher ages and Charlson index in patients who received dialysis&#44; make this last option more likely&#44; since the patients were clearly screened&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The study was conducted in a single centre&#44; so it has the advantage of being a homogeneous population of patients and that the treatment applied was uniform in all patients according to our current CKD patient handling guidelines&#46; The inclusion period was short&#44; and this favoured a similar treatment for all patients with similar criteria and same drugs available&#46; It is also important that the follow-up time was long&#44; more than 5 years&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Patients of other studies were compared based on the intention to treat or the initial decision on either RRT or conservative treatment&#46; Our study compares outcomes of treatment followed by the patient&#44; which reflects reality and increases its usefulness of our data that can be used as a tool for counselling patients&#46; Patients ask about specific outcomes&#44; so they can decide on modality of treatment&#58; Dialysis or conservative treatment&#46; Treatment with dialysis in many cases involves a worsening of quality of life&#44; and according to our study in some cases did not even extend survival as compared with those who followed a conservative treatment&#59; therefore treatment must always be personalised&#46; Innovative strategies such as home care for elderly ACKD patients who accept or choose conservative treatment for kidney failure in its most advanced phase may improve the quality of life of the patients and their family&#44; as it has been doing in some hospitals in our country&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In conclusion&#44; in our group of elderly patients &#40;&#8805;70 years&#41;&#44; we have observed that dialysis treatment improves survival in screened patients&#44; with lower ages and comorbidity indices&#46; This result was favoured by extended follow-up periods in the ACKD office&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "identificador" => "abst0050"
              "titulo" => "Conclusiones"
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          "identificador" => "xpalclavsec824455"
          "titulo" => "Palabras clave"
        ]
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          "identificador" => "sec0005"
          "titulo" => "Introduction"
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          "identificador" => "sec0015"
          "titulo" => "Results"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Comparison of deaths vs&#46; surviving patients &#40;full group and stage 5 subgroup&#41;"
            ]
            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Comparison of dialysis vs&#46; conservative treatment &#40;subgroup of 162 stage 5 patients&#41;"
            ]
            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Cox regression &#40;subgroup of 162 stage 5 patients&#41;"
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              "identificador" => "sec0035"
              "titulo" => "Influence of comorbidity on survival &#40;full group and stage 5 subgroup&#41;"
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          "identificador" => "sec0040"
          "titulo" => "Discussion"
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          "identificador" => "sec0045"
          "titulo" => "Conflicts of interest"
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        9 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-12-24"
    "fechaAceptado" => "2015-11-10"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec824456"
          "palabras" => array:5 [
            0 => "Advanced chronic kidney disease"
            1 => "Elderly"
            2 => "Survival"
            3 => "Conservative care"
            4 => "Frail patient"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec824455"
          "palabras" => array:5 [
            0 => "Enfermedad renal cr&#243;nica avanzada"
            1 => "Ancianos"
            2 => "Supervivencia"
            3 => "Tratamiento conservador"
            4 => "Paciente fr&#225;gil"
          ]
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    "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">The number of elderly patients with advanced chronic kidney disease &#40;ACKD&#41; has increased in recent years&#44; and the best therapeutic approach has not been determined due to a lack of evidence&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To observe the progression of elderly patients with ACKD &#40;stages 4 and 5&#41; and to compare the survival of stage 5 CKD patients with and without dialysis treatment&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All patients &#8805;70 years who began ACKD follow-up from 01&#47;01&#47;2007 to 31&#47;12&#47;2008 were included&#44; and their progression was observed until 31&#47;12&#47;2013&#46; Demographic data&#44; the Charlson comorbidity index&#44; history of ischaemic heart disease &#40;IHD&#41; and diabetes mellitus &#40;DM&#41; were assessed&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A total of 314 patients &#8805;70 years with stages 4 and 5 CKD were studied&#46; Of these patients&#44; 162 patients had stage 5 CKD at the beginning of follow-up or progressed to stage 5 during the study&#44; and 69 of these patients were treated with dialysis&#46; In the stage 5 group&#44; median age was 77 years &#40;74&#8211;81&#41;&#59; 48&#37; had IHD&#59; 50&#37; had DM&#44; Charlson 7 &#40;6&#8211;9&#41;&#46; Kaplan&#8211;Meier survival analysis&#58; &#8805;70 years &#40;93 vs&#46; 69 patients with dialysis&#44; log rank&#58; 15 <span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#59; patients &#8805;75 years &#40;74 vs&#46; 46 patients with dialysis&#44; log rank&#58; 8&#46;9 <span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#59; patients &#8805;80 &#40;40 vs&#46; 15 patients with dialysis&#41; and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;2&#46; Patients receiving dialysis were younger&#44; with a lower Charlson comorbidity index and shorter follow-up time&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Our study shows that dialysis treatment improves survival&#44; although this benefit is lost in patients &#8805;80 years&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objectives"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Material and methods"
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            "identificador" => "abst0020"
            "titulo" => "Results"
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            "identificador" => "abst0025"
            "titulo" => "Conclusions"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los pacientes de edad avanzada que llegan a enfermedad renal cr&#243;nica avanzada &#40;ERCA&#41; se han incrementado en los &#250;ltimos a&#241;os&#46; No hay evidencia de la mejor actitud terap&#233;utica en estos pacientes&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Observar la evoluci&#243;n de pacientes ancianos en consulta de ERCA &#40;estadios 4 y 5&#41; y comparar la supervivencia de los pacientes con ERC estadio 5 tratados con di&#225;lisis o no&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Material y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; a todos los pacientes con &#8805;70 a&#241;os que iniciaron seguimiento en consulta de ERCA desde el 1-1-2007 hasta el 31-12-2008 y se observ&#243; su evoluci&#243;n hasta el 31-12-2013&#46; Se recogieron datos demogr&#225;ficos&#44; &#237;ndice de comorbilidad de Charlson&#44; antecedentes de cardiopat&#237;a isqu&#233;mica &#40;CI&#41; y diabetes mellitus &#40;DM&#41;&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se estudi&#243; a 314 pacientes con ERC estadios 4 y 5 con &#8805;70 a&#241;os&#44; 162 de los cuales estaban en el momento del inicio del seguimiento o a lo largo del mismo en estadio 5&#59; 69 de estos pacientes recibieron tratamiento con di&#225;lisis&#46; En el grupo estadio 5&#58; mediana de edad de 77 a&#241;os &#40;74-81&#41;&#59; 48&#37; CI&#59; 50&#37; DM&#59; Charlson 7 &#40;6-9&#41;&#46; Supervivencia Kaplan-Meier&#58; &#8805;70 a&#241;os &#40;93 vs&#46; 69 pacientes con di&#225;lisis&#41; log rank&#58; 15 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; con &#8805;75 a&#241;os &#40;74 vs&#46; 46 pacientes con di&#225;lisis&#59; log rank&#58; 8&#44;9&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#44; con &#8805;80 a&#241;os &#40;40 vs&#46; 15 pacientes con di&#225;lisis&#41; y p&#61;0&#44;2&#46; Los pacientes que recibieron tratamiento con di&#225;lisis ten&#237;an menor edad e &#237;ndice de Charlson y el tiempo de seguimiento en consulta era inferior&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">En nuestro estudio el tratamiento con di&#225;lisis mejora la supervivencia&#44; si bien esta ventaja se pierde en los pacientes con &#8805;80 a&#241;os&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mart&#237;nez Echevers Y&#44; Toapanta Gaibor NG&#44; Nava P&#233;rez N&#44; Barbosa Martin F&#44; Montes Delgado R&#44; Guerrero Riscos M&#193;&#46; Supervivencia de pacientes de edad avanzada &#40;&#8805;70 a&#241;os&#41; con enfermedad cr&#243;nica estadios 4-5&#58; di&#225;lisis vs tratamiento conservador&#46; Nefrolog&#237;a&#46; 2016&#59;36&#58;283&#8211;291&#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" 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">Full group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>314&#41;&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">CKD 5 subgroup &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>162&#41;&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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age in years&#44; <span class="elsevierStyleItalic">n</span> &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77 &#40;74&#8211;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77 &#40;74&#8211;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">143 &#40;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes mellitus&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">157 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Charlson index&#44; <span class="elsevierStyleItalic">n</span> &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;7&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;6&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ischaemic heart disease&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">159 &#40;51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78 &#40;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Baseline eGFR &#40;ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;16&#8211;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;12&#8211;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">In-office follow-up &#40;months&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41 &#40;13&#8211;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;6&#8211;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deaths&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">196 &#40;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">110 &#40;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Survival &#40;months&#41;&#44; median &#40;25&#8211;75th percentile&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56 &#40;25&#8211;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53 &#40;29&#8211;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <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">&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">Full group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>314&#41;&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">CKD 5 subgroup &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>162&#41;&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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">261&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">235&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">231&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">169&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">131&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Survival since baseline&#44; months&#44; median &#40;25&#8211;75th percentile&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56 &#40;25&#8211;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53 &#40;29&#8211;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Survival since stage 5&#44; months&#44; median &#40;25&#8211;75th percentile&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">33 &#40;12&#8211;57&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1393559.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Survival by year of follow-up and total&#46;</p>"
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      ]
      7 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:1 [
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            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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Full group</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Grade 5 CKD subgroup</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">No death <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>118&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">Death <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>196&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"><span class="elsevierStyleItalic">p</span>&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">No death <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>52&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">Death <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>110&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"><span class="elsevierStyleItalic">p</span>&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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age in years&#44; median &#40;25&#8211;75th percentile&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77 &#40;73&#8211;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77 &#40;74&#8211;82&#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;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77 &#40;73&#8211;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77 &#40;75&#8211;81&#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;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex &#40;M&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69 &#40;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">102 &#40;52&#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;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29 &#40;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;55&#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;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes mellitus&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51 &#40;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">106 &#40;54&#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;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59 &#40;54&#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;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Charlson index&#44; median &#40;25&#8211;75th percentile&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;7&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;7&#8211;9&#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;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;6&#8211;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;6&#8211;9&#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;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ischaemic heart disease&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52 &#40;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">107 &#40;55&#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;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55 &#40;50&#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;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">eGFR &#40;ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&#44; median &#40;25&#8211;75th percentile&#41;&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;2 &#40;16&#46;8&#8211;26&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;7 &#40;14&#46;1&#8211;5&#46;8&#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;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;6 &#40;14&#46;3&#8211;20&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;1 &#40;12&#46;5&#8211;21&#46;5&#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;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 5 eGFR &#40;ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&#44; median &#40;25&#8211;75th percentile&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">13 &#40;12&#46;2&#8211;14&#46;5&#41;&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;5 &#40;12&#8211;14&#46;3&#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;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">In-office follow-up &#40;months&#41;&#44; median &#40;25&#8211;75th percentile&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66 &#40;60&#8211;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;7&#8211;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61 &#40;35&#8211;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;7&#8211;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">In-office follow-up since stage 5 &#40;months&#41;&#44; median &#40;25&#8211;75th percentile&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">30 &#40;11&#8211;63&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;3&#8211;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Survival since baseline &#40;months&#41;&#44; median &#40;25&#8211;75th percentile&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69 &#40;64&#8211;77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;12&#8211;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70 &#40;65&#8211;77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;15&#8211;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Survival since stage 5 &#40;months&#41;&#44; median &#40;25&#8211;75th percentile&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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="char" valign="top">58 &#40;39&#8211;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;8&#8211;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dialysis&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;20&#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;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;35&#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;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;45&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Definition and classification of stages of chronic kidney disease"
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                            0 => "K&#47;DOQI Clinical Practice Guide Lines for Chronic Kidney Disease&#46; Workgroup"
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                        "tituloSerie" => "Am J Kidney Dis"
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                      "titulo" => "The contribution of chronic kidney disease to the global burden of major non communicable diseases"
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                    0 => array:2 [
                      "doi" => "10.1038/ki.2011.368"
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                        "volumen" => "80"
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                        "paginaFinal" => "1270"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21993585"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence&#44; management&#44; and outcomes of end-stage renal disease in the elderly"
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                          "autores" => array:1 [
                            0 => "M&#46; Kurella Tamura"
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                    0 => array:1 [
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                        "tituloSerie" => "Curr Opin Nephrol Hypertens"
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                            "web" => "Medline"
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                      "titulo" => "Sistema de Informaci&#243;n de la Coordinaci&#243;n Auton&#243;mica de Trasplante renal de Andaluc&#237;a &#40;SICATA&#41;&#46; Datos presentados en el Congreso de la Sociedad Andaluza de Nefrolog&#237;a&#46; Granada"
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                      "titulo" => "Chronic kidney disease and the aging population"
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                      "titulo" => "Mas all&#225; de la supervivencia en di&#225;lisis&#44; necesitamos cambiar el paradigma"
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                    0 => array:2 [
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                        "tituloSerie" => "Semin Dial"
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