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            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Secci&#243;n de Nefrolog&#237;a&#44; Hospital General de Segovia&#44; Segovia&#44; Spain"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "&#191;Mejora la funci&#243;n renal tras la paratiroidectom&#237;a en el hiperparatirodismo primario&#63;"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Primary hyperparathyroidism &#40;PHPT&#41; is a common mineral metabolism disorder caused by the excessive secretion of parathyroid hormone &#40;PTH&#41; by one or more parathyroid glands&#46; Autonomic secretion of PTH acts on its target organs &#40;bone and kidney&#41; and increases the concentrations of calcium in the extracellular space&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are two eras in the history of PHPT&#46; The first was when the condition was discovered&#44; with florid signs and symptoms of renal lithiasis&#44; bone disease and frank hypercalcaemia&#46; The second era began about 40 years ago after the introduction of autoanalysers&#44; when PHPT could be detected at the stage of mild hypercalcaemia&#44; without the classic clinical characteristics&#46; We may now be entering a third era&#44; in which patients have serum concentrations of total and ionised calcium within normal ranges&#44; but persistently elevated PTH levels&#44; known as normocalcaemic PHPT&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the era of symptomatic PHPT&#44; patients often had renal lithiasis and stone-related complications&#44; such as urinary tract infections&#44; hydronephrosis and impaired renal function&#46; Nowadays&#44; these problems are rare&#44; as most PHPT are asymptomatic&#59; in terms of the kidneys&#44; they may present with hypercalciuria&#44; renal microlithiasis and slightly impaired renal function&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The kidney is a classic target organ of PTH&#44; and the relationship between severe PHPT and kidney damage was first described many years ago&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#8211;7</span></a> Moreover&#44; in PHPT the progressive deterioration of renal function secondarily elevates PTH levels&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a> It has traditionally been assumed that resolving PHPT through surgery could preserve renal function in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">4</span></a> A decreased glomerular filtration rate &#40;&#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; remains in the guidelines as a criterion for parathyroidectomy &#40;PTX&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; the influence that PTX has on any changes in renal function is open to debate&#46; Most of the retrospective studies which have looked at this problem have found no improvement in renal function after PTX&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">11&#8211;16</span></a> Moreover&#44; randomised controlled trials carried out mainly in patients with mild asymptomatic PHPT have not shown PTX to have any effect on renal function&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">17&#8211;20</span></a> Other studies have shown PTX to have a negative effect on renal function&#44;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">21</span></a> particularly in patients with creatinine clearance &#62;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">22</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Although it cannot be denied that surgical cure of PHPT prevents further deterioration of renal function&#44; an important question is whether or not PTX in patients with renal failure is capable of slowing down the decrease in the glomerular filtration rate&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">4&#44;22</span></a> The aim of our study was to analyse a large series of patients with treated PHPT and identify changes in renal function after PTX&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Design and patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">We reviewed the records of all patients diagnosed with PHPT who underwent PTX at our centre from 1998 to 2016 who had over a year of postoperative follow-up&#46; This was an observational&#44; retrospective study&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We collected epidemiological data &#40;age&#44; gender&#41; and the medical history of each patient &#40;time since onset of PHPT&#44; presence of renal lithiasis&#44; hypertension&#44; associated symptoms and biochemical parameters&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Definitions</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hypercalcaemia</span>&#58; serum calcium higher than 11&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;serum calcium &#62;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dl above the upper limit of normal&#41;&#46; The measurement of blood calcium was corrected for albumin&#58; corrected calcium &#40;mg&#47;dl&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#40;4&#46;0<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>serum albumin &#91;g&#47;dl&#93;&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;8<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>total Ca &#40;mg&#47;dl&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Symptomatic PHPT</span>&#58; patients who presented symptoms in relation to recurrent renal lithiasis or bone manifestations &#40;bone or joint pain or fractures&#41; or general symptoms attributable to PHPT &#40;gastrointestinal or neuromuscular&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hypertension</span>&#58; patients who were receiving blood pressure-lowering treatment&#44; regardless of the blood pressure values recorded&#44; were considered hypertensive&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">PHPT-related bone disease</span>&#58; Bone mineral density was measured by dual-energy X-ray absorptiometry &#40;DEXA&#41; in the lumbar spine &#40;L2&#8211;L4&#41; and femur&#46; A patient was considered to have bone involvement when DEXA showed a decrease in bone mineral density &#40;T score<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;5<span class="elsevierStyleHsp" style=""></span>SD in the spine or femur&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The surgical indication for PTX was identified in asymptomatic patients according to international guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">9</span></a> A patient might have more than one indication&#44; so a hierarchical order was established for the criteria&#58; renal lithiasis&#44; bone involvement&#44; hypercalcaemia&#44; age &#60;50 and decrease in glomerular filtration rate &#40;&#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Localisation</span><p id="par0070" class="elsevierStylePara elsevierViewall">We also collected the results of our patients&#8217; imaging techniques&#44; including parathyroid ultrasound&#44; computed tomography of neck and chest with intravenous contrast&#44; with tomographic slices every 5<span class="elsevierStyleHsp" style=""></span>mm&#44; and pre-operative parathyroid scintigraphy with Tc99m-Sestamibi at a dose of 25<span class="elsevierStyleHsp" style=""></span>mCi using a planar gamma camera&#46; Scintigraphy records were made at 10<span class="elsevierStyleHsp" style=""></span>min and at 2<span class="elsevierStyleHsp" style=""></span>h post-injection&#44; using parallel-hole pin-hole collimator&#46; Persistence of the tracer in the recorded images at 2<span class="elsevierStyleHsp" style=""></span>h was considered pathological&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Surgical procedure</span><p id="par0075" class="elsevierStylePara elsevierViewall">A simple adenomectomy was performed for the single adenomas&#46; In patients with multiple-gland involvement&#44; cases of repeat surgery for persistent PHPT or when there was concomitant thyroid pathology or a negative localisation study&#44; we used the traditional approach of a full neck exploration&#46; During surgery&#44; intact PTH &#40;iPTH&#41; was monitored and a decrease of more than 50&#37; from the pre-operative value was considered satisfactory&#46; In the cases of hyperplasia&#44; a subtotal PTX was performed or reimplantation in the forearm&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Analytical determination methods</span><p id="par0080" class="elsevierStylePara elsevierViewall">Analytical determinations were performed by HPLC autoanalyser &#40;ADAMS A1c analyser&#44; HA-8160&#44; by Menarini&#41; and iPTH by chemiluminescence &#40;Roche diagnostics GmbH&#44; Mannheim&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The glomerular filtration rate was estimated according to the CKD-EPI equation&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">23</span></a> which includes serum creatinine&#44; age&#44; gender and race as variables&#46; Serum creatinine was measured using a compensated kinetic Jaff&#233; method &#40;Roche Diagnostics&#41; traceable to the IDMS reference method&#46; Urinary calcium was measured in a 24<span class="elsevierStyleHsp" style=""></span>h urine sample and the urinary Ca&#47;creatinine ratio calculated&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The normal laboratory ranges considered were&#58; calcium 8&#46;2&#8211;10&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#59; phosphorus 2&#46;3&#8211;4&#46;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#59; plasma creatinine in males 0&#46;7&#8211;1&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and in females 0&#46;5&#8211;0&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#59; and iPTH 15&#46;0&#8211;51&#46;0<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#46; In urine&#44; urinary calcium &#60;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day and the Ca&#47;creatinine ratio &#60;0&#46;20&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The analytical tests were performed at baseline prior to surgery&#44; one week after PTX &#40;PTX-1 week&#41; and 12 months after &#40;PTX-12 months&#41;&#46; No significant changes were found in serum creatinine from the time of diagnosis of PHPT until the baseline determination&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Statistical analysis</span><p id="par0100" class="elsevierStylePara elsevierViewall">The statistical analysis used the SPSS 20 software program &#40;IBM SPSS Statistics<span class="elsevierStyleSup">&#174;</span> 20&#41;&#46; The Kolmogorov&#8211;Smirnov test was used to analyse the normal distribution of variables&#46; The categorical variables were expressed as frequencies &#40;&#37;&#41; and the continuous variables as means and standard deviation where they had normal distribution&#44; or medians &#40;p25&#8211;p75&#41; otherwise&#46; The Chi-square test was used to assess the association between the different types of PHPT and the categorical variables&#46; The Student&#39;s <span class="elsevierStyleItalic">t</span> test was used for parametric continuous variables&#46; In the case of non-parametric continuous variables&#44; the Mann&#8211;Whitney test was used for independent samples or the Wilcoxon test for paired samples&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><p id="par0105" class="elsevierStylePara elsevierViewall">A total of 297 patients with PHPT had a PTX&#46; The incidence of PTX was 39&#47;million population&#47;year&#46; The mean age of the patients was 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46; The female-to-male ratio was 4&#46;1&#58;1&#59; with the males being younger at the time of the PTX&#46; The mean time from diagnosis to surgery was 14&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 months&#46; A total of 126 patients &#40;42&#37;&#41; had hypertension&#46; PHPT was asymptomatic in 194 patients &#40;65&#46;3&#37;&#41;&#46; The other clinical and analytical characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">In terms of localisation diagnosis&#44; sestamibi scintigraphy was the best method for locating the gland involved&#59; this was performed in 289 patients and was diagnostic in 266 &#40;92&#37;&#41;&#46; Ultrasound of the neck was performed in 269 patients and was positive in 189 &#40;70&#37;&#41;&#46; Computed tomography had similar results&#44; being positive in 52 &#40;68&#37;&#41; of the 76 patients who had a CT scan of the neck &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; With scintigraphy&#44; 22 false negatives were found&#46; Of these&#44; the diagnosis was made with ultrasound in 11 and computed tomography in nine&#59; no localisation images were available prior to surgery for two patients&#46; In 34&#46;7&#37; of the patients the indication for PTX was symptomatic PHPT&#46; Of the asymptomatic patients&#44; hypercalcaemia &#40;Ca<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; was the most common cause &#40;27&#37;&#41;&#44; followed by renal lithiasis &#40;13&#37;&#41;&#44; bone involvement &#40;12&#37;&#41; and being under the age of 50 &#40;11&#37;&#41;&#46; In 280 cases &#40;94&#46;3&#37;&#41;&#44; the histology of the surgical specimen was compatible with parathyroid adenoma &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">After PTX&#44; laboratory tests showed a significant decrease in calcium&#44; iPTH and urinary calcium&#44; with an increase in phosphorus from that in the first week&#44; all of which were maintained over time&#46; Serum creatinine increased and the glomerular filtration rate &#40;GFR&#41; decreased in the first week after surgery&#44; with similar values at 12 months post-PTX &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">We divided the patients into two groups according to their baseline GFR &#40;greater or less than 60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#46; The patients with GFR &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min were older &#40;70<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12 vs 59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and more likely to have hypertension &#40;72&#37; vs 39&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; We found that the elevation in creatinine and the decrease in the GFR at 12 months post-PTX were statistically significant in cases with creatinine clearance &#8805;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#59; renal function also deteriorated in patients with GFR &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min one year post-PTX&#44; although this did not reach statistical significance &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">PHPT is a common disorder&#46; The prevalence varies in different analyses depending on the method of detection and the population studied&#46; Population-based screening studies which included the measurement of serum calcium helped define the epidemiology of PHPT&#46; The incidence has changed in the last forty years&#59; in the United States&#44; the annual incidence of PHPT in 1974 was 78<span class="elsevierStyleHsp" style=""></span>cases&#47;million&#47;year and one year later&#44; after routinely measuring serum calcium&#44; it rose to 277<span class="elsevierStyleHsp" style=""></span>cases&#47;million&#47;year&#46; From 1983 to 1992&#44; despite the more widespread and continuous use of the calcium measurement&#44; the incidence decreased to 208<span class="elsevierStyleHsp" style=""></span>cases&#47;million&#47;year&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a> The situation has been similar in Europe&#44; where the incidence is currently estimated at 100&#8211;150<span class="elsevierStyleHsp" style=""></span>cases&#47;million&#47;year&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">25</span></a> In Spain&#44; a recent study estimated an incidence of 99&#46;5<span class="elsevierStyleHsp" style=""></span>cases&#47;million&#47;year&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Few studies have analysed the incidence of PTX in the general population&#44; and they go back to before 2000&#59; in the USA there was an estimated incidence of 44&#47;million&#47;year and in Sweden 50&#8211;100&#47;million&#47;year&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a> while in our series the incidence was 38&#47;million&#47;year&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">PHPT is more common in women&#46; In our study&#44; women accounted for 80&#46;5&#37; of cases &#40;female-to-male ratio 4&#46;1&#58;1&#41;&#44; slightly higher than that reported in the literature&#44; with estimates of around 75&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">27&#8211;29</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The localisation techniques are parathyroid Tc99m-sestamibi scintigraphy &#40;with or without SPECT&#41; and ultrasound of the neck&#46; Tc99m-sestamibi scintigraphy has sensitivity of 74&#8211;90&#37; according to the different series<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">10&#44;30</span></a>&#59; in our series it was 92&#37;&#46; The profitability of neck ultrasound depends on the examiner&#39;s expertise&#44; and varies from 70&#37; to 87&#37;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">31</span></a>&#59; in our study it was diagnostic in 70&#37; of patients&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The clinical manifestations of PHPT have changed over the years&#44; and 80&#37; of patients in developed countries are now asymptomatic&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">10&#44;32</span></a> Of our patients undergoing PTX&#44; 65&#37; were asymptomatic&#44; but it is important to remember that this was a selected population which met criteria for parathyroid surgery&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">PTX is the definitive treatment and provides a complete cure for PHPT&#46; Blood calcium levels return to normal&#44; the risk of lithiasis decreases and bone mass increases&#44; with a reduction in the fracture risk&#46; The effect on cardiovascular and neurocognitive symptoms is less certain&#46; The cure rate is over 95&#37;&#44; with few complications and low morbidity and mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">33</span></a> Another important aspect is that surgery reduces costs in PHPT&#59; when performed soon after diagnosis it is 2&#46;5 times more cost-effective than after a period of follow-up with medical treatment&#44; and 1&#46;5 times more cost-effective than in patients who only receive medical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">34</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In the last three editions of the consensus on management of asymptomatic PHPT&#44; renal failure &#40;GFR &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41; has been included among the surgical criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">9</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In mild forms of PHPT&#44; observational studies are not very consistent&#44; and there is therefore no definitive evidence that asymptomatic&#47;mild PHPT has a negative impact on renal function&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">18&#44;32&#44;35&#44;36</span></a> The recent&#44; prospective PEARS study compared 1424 patients with PHPT with 7120 controls and found that individuals with PHPT had a 13&#46;83-times higher risk of developing renal failure at ten years than controls&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">36</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Despite the fact that the decrease in GFR is an indication for PTX&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">9</span></a> there are virtually no studies demonstrating a beneficial effect of PTX on renal function&#46; When we searched the literature for evidence that PTX can change the course of renal failure&#44; we found that most retrospective studies showed no change in renal function &#40;whether estimated with serum creatinine&#44; creatinine clearance&#44; or GFR&#41; during follow-up periods ranging from six months to 11 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">11&#44;37&#44;38</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Two recent studies designed to assess the effect of PTX found that renal function became worse after PTX&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">21&#44;22</span></a> The Egan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">21</span></a> study analysed changes in renal function in 62 patients and found that creatinine rose postoperatively &#40;1&#46;09 vs 1&#46;15<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; and GFR decreased from 78 to 73<span class="elsevierStyleHsp" style=""></span>ml&#47;min at 8&#8211;12 weeks&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Tassone et al&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">22</span></a> analysed changes in renal function at six months post-PTX in 109 patients &#40;14 with clearance &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#46; Serum creatinine increased significantly in patients with creatinine clearance &#62;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;0&#46;82 vs 0&#46;87<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#59; serum creatinine also worsened in the 14 patients whose GFR decreased &#40;1&#46;32 vs 1&#46;41<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;5&#41; although this was not statistically significant&#46; Of the published studies&#44; our series includes the largest number of patients&#44; and the results are superimposable&#46; Renal function worsens in all patients from the first week and this situation is maintained one year after surgery&#46; This is particularly alarming in patients who previously had normal renal function&#46; Renal function also worsened in patients with creatinine clearance &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#44; but probably due to the sample size&#44; this did not reach statistical significance&#46; Our patients with renal failure were older and had a higher prevalence of hypertension&#44; so these factors probably do not explain the worsening&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In a study performed in kidney transplant patients&#44; comparing them with a control group with similar characteristics&#44; a significant deterioration in serum creatinine was detected six months after PTX&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">39</span></a> The transplant patients had renal failure &#40;mean clearance of 47<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; and the control group had no elevation of iPTH&#46; The authors attributed this to a haemodynamic effect mediated by the decrease in PTH levels&#44; but what was not explained was that the deterioration continued beyond the first months&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">We included a large number of patients in our study&#44; but due to its retrospective observational nature&#44; we were unable to establish a direct cause-and-effect relationship between renal function and PTX&#46; Another limitation of the study is the CKD-EPI method used in the estimation of GFR which&#44; although it underestimates less than the MDRD in patients with GFR above 60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; is not an exact measurement&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">40</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">We can only hypothesise that in the patients who did not have renal failure had a renal function deteriorated after PTX&#44; this may have been due to factors unrelated to PHPT&#46; One possible mechanism would be that PTH has a pre-glomerular vasodilatory effect&#59; another would be the hypertensive effect of hypercalcaemia&#44; although that would only explain an acute deterioration&#44; not one maintained over time&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a> Yet another proposed mechanism is that PTH increases the tubular secretion of creatinine by increasing permeability in the proximal tubule&#44;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">42</span></a> and the normalisation of PTH would then raise serum creatinine levels&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Although a GFR &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min is a criterion for surgery&#44; we need prospective studies on the changes in renal function in PHPT which compare patients with PTX to a control group &#40;observational&#41; and measure GFR with more accurate methods that do not use creatinine as a marker&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall">PHPT is a common endocrine disorder in older women and is asymptomatic in more than half of patients&#46; PHPT should be ruled out when a patient presents with hypercalcaemia and renal lithiasis&#46; Taking into account all the limitations mentioned above&#44; our data show that surgical cure of PHPT is not accompanied by improvement in renal function&#44; and this effect is evident from the first week and sustained over time&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Primary hyperparathyroidism"
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            2 => "Renal function"
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            0 => "Hiperparatiroidismo primario"
            1 => "Paratiroidectom&#237;a"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Primary hyperparathyroidism &#40;PHPT&#41; is a common endocrine disorder characterised by hypercalcaemia and parathormone increase&#46; Decreased glomerular filtration rate &#40;&#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; continues to be a parathyroidectomy &#40;PTX&#41; criterion in asymptomatic PHPT&#46; The influence of PTX on renal function evolution is the subject of debate&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To analyse the clinical&#44; laboratory and histological characteristics of patients undergoing PHPT&#44; as well as renal function evolution after PTX&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of 297 patients diagnosed with PHPT and referred to surgery in a single centre between 1998 and 2016&#46; Laboratory parameters were determined at baseline&#44; one week and one year after PTX&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The Incidence of PTX was 38<span class="elsevierStyleHsp" style=""></span>cases&#47;million&#47;year&#46; Mean age was 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 years and 80&#46;5&#37; of the patients were female&#46; Approximately 65&#46;3&#37; were asymptomatic&#46; Nephrolithiasis was the most common clinical finding &#40;33&#37;&#41;&#44; followed by bone involvement &#40;29&#46;5&#37;&#41;&#46; PTX indications were&#58; clinical symptoms &#40;34&#46;7&#37;&#41;&#44; hypercalcaemia &#62;11&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;27&#37;&#41;&#44; nephrolithiasis &#40;13&#37;&#41;&#44; low bone mass &#40;12&#37;&#41;&#44; age &#60;50 years &#40;11&#37;&#41; and decreased glomerular filtration rate &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;2&#46;3&#37;&#41;&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">For diagnostic localisation&#44; spect-MIBI had a sensitivity of 92&#37; and cervical ultrasound of 70&#37;&#46; A total of 94&#46;3&#37; of PHPT cases were due to a parathyroid adenoma&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">After PTX&#44; normalisation of PHPT-related parameters was observed&#46; We found a significant increase in serum creatinine levels &#40;0&#46;81 vs 0&#46;85<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; from the first week post-PTX until the end of the first year&#46; The renal function was only found to be significant in patients with glomerular filtration rate &#62;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;baseline serum creatinine levels 0&#46;77<span class="elsevierStyleHsp" style=""></span>mg&#47;dl vs serum creatinine levels after one year 0&#46;81<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">PHPT was asymptomatic in most patients who underwent surgery&#46; Hypercalcaemia and nephrolithiasis were the most common indications of parathyroidectomy in asymptomatic patients&#46; MIBI scan was the most useful localisation method&#46; Surgical treatment of PHPT is followed by renal function impairment&#44; which persists after the first week post-PTX&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El hiperparatiroidismo primario &#40;HPTP&#41; es un trastorno endocrino frecuente&#44; caracterizado por hipercalcemia y elevaci&#243;n de la parathormona&#46; La disminuci&#243;n del filtrado glomerular &#40;&#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; se mantiene en la gu&#237;as como un criterio para la realizaci&#243;n de la paratiroidectom&#237;a &#40;PTX&#41; en el HPTP asintom&#225;tico&#46; La influencia que tiene la PTX sobre la evoluci&#243;n de la funci&#243;n renal es controvertida&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Analizar las caracter&#237;sticas cl&#237;nicas&#44; anal&#237;ticas e histol&#243;gicas de los pacientes intervenidos por HPTP&#44; as&#237; como la evoluci&#243;n de la funci&#243;n renal tras la PTX&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Material y m&#233;todos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de 297 pacientes con HPTP remitidos a cirug&#237;a en un &#250;nico centro entre 1998 y 2016&#46; Los par&#225;metros anal&#237;ticos se determinaron en situaci&#243;n basal&#44; a la semana y al a&#241;o de la PTX&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La incidencia de PTX fue de 38 casos&#47;mill&#243;n&#47;a&#241;o&#46; La edad media fue 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 a&#241;os y el 80&#44;5&#37; de los pacientes eran mujeres&#46; El 65&#44;3&#37; estaban asintom&#225;ticos&#46; La nefrolitiasis fue el hallazgo cl&#237;nico m&#225;s frecuente &#40;33&#37;&#41; seguido de la afectaci&#243;n &#243;sea &#40;29&#44;5&#37;&#41;&#46; Las indicaciones de PTX fueron&#58; s&#237;ntomas cl&#237;nicos &#40;34&#44;7&#37;&#41;&#44; hipercalcemia &#62;11&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;27&#37;&#41;&#44; litiasis renal &#40;13&#37;&#41;&#44; baja masa &#243;sea &#40;12&#37;&#41;&#44; edad &#60;50 a&#241;os &#40;11&#37;&#41; y disminuci&#243;n del filtrado &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;2&#44;3&#37;&#41;&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">En el diagn&#243;stico de localizaci&#243;n el spect-MIBI present&#243; una sensibilidad del 92&#37; y la ecograf&#237;a cervical del 70&#37;&#46; El 94&#44;3&#37; de los casos de HPTP eran debidos a un adenoma paratiroideo&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Tras la PTX se objetiv&#243; normalizaci&#243;n de los par&#225;metros relacionados con el HPTP&#46; Objetivamos un incremento significativo de la creatinina s&#233;rica &#40;0&#44;81 vs&#46; 0&#44;85<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; desde la primera semana del postoperatorio y que se mantiene al a&#241;o&#46; Cuando comparamos los pacientes seg&#250;n el filtrado glomerular basal&#44; encontramos que el deterioro de la funci&#243;n renal solamente fue significativo en pacientes con filtrado glomerular &#62;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;creatinina s&#233;rica basal 0&#44;77<span class="elsevierStyleHsp" style=""></span>mg&#47;dl vs&#46; creatinina s&#233;rica al a&#241;o 0&#44;81<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">El HPTP curs&#243; asintom&#225;tico en la mayor&#237;a de los pacientes intervenidos&#46; La hipercalcemia y la nefrolitiasis fueron las indicaciones m&#225;s frecuentes de paratiroidectom&#237;a en los pacientes asintom&#225;ticos&#46; El scan-MIBI fue el m&#233;todo de localizaci&#243;n m&#225;s &#250;til&#46; La curaci&#243;n quir&#250;rgica del HPTP se sigue de un deterioro de la funci&#243;n renal&#44; que se mantiene desde la primera semana de la cirug&#237;a&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Please cite this article as&#58; Garc&#237;a-Mart&#237;n F&#44; Guadalix S&#44; Garc&#237;a-Boyano F&#44; Mel&#243;n Pe&#241;a N&#44; Mart&#237;nez Pueyo JI&#44; Callejas Mart&#237;nez R&#44; et al&#46; &#191;Mejora la funci&#243;n renal tras la paratiroidectom&#237;a en el hiperparatirodismo primario&#63; Nefrologia&#46; 2019&#59;39&#58;160&#8211;167&#46;</p>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">BMD&#58; bone densitometry&#59; CT&#58; computed tomography&#59; DR&#58; distal radius&#59; DXA&#58; dual-energy X-ray absorptiometry&#59; LS&#58; lumbar spine&#59; MRI&#58; magnetic resonance imaging&#59; SD&#58; standard deviation&#59; TH&#58; total hip&#59; VFA&#58; vertebral fracture assessment&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Bilezikian et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">9</span></a></p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criterion&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">Value&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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;50&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">Serum calcium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>mg&#47;dl above the upper limit of normal&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">Bone involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMD &#40;DXA&#41;&#58; T-<span class="elsevierStyleItalic">score</span> LS&#44; TH or DR &#60;&#8722;2&#46;5<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vertebral fracture&#58; plain X-ray&#44; CT&#44; MRI&#44; VFA&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">Kidney involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Glomerular filtration rate &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urine calcium &#62;400<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nephrolithiasis or nephrocalcinosis &#40;plain X-ray&#44; ultrasound&#44; CT&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Criteria for parathyroidectomy in asymptomatic primary hyperparathyroidism&#46;</p>"
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">iPTH&#58; intact parathyroid hormone&#59; SD&#58; standard deviation&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">The laboratory values are expressed as median &#40;p25&#8211;p75&#41; or mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#46;</p>"
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              "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">&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">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>297&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">Range&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 &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#8211;83&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">Female &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">239 &#40;80&#46;5&#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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time since onset &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#8211;98&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">Hypertension &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">126 &#40;42&#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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Symptomatic &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">103 &#40;34&#46;7&#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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal lithiasis &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97 &#40;33&#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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bone involvement &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88 &#40;29&#46;5&#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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serum calcium &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;4 &#40;10&#46;8&#8211;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;1&#8211;17&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">Serum phosphate &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;5 &#40;2&#46;2&#8211;2&#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">1&#46;1&#8211;4&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">iPTH &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">164 &#40;116&#8211;221&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#8211;1104&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">Serum creatinine &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;8 &#40;0&#46;7&#8211;0&#46;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;43&#8211;1&#46;9&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">Glomerular filtration rate &#40;ml&#47;min&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">84&#46;7 &#40;71&#8211;97&#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&#8211;142&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">Urine calcium &#40;mg in 24<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">393<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>168&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#8211;521&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">Urinary Ca&#47;creatinine ratio &#40;mg&#47;mg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;07&#8211;0&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Baseline clinical and analytical characteristics&#46;</p>"
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              "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">&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">n</span> &#40;&#37;&#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" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Localisationc diagnosis</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Neck ultrasound&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">189&#47;269 &#40;70&#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"><span class="elsevierStyleHsp" style=""></span>Computed axial tomography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&#47;76 &#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"><span class="elsevierStyleHsp" style=""></span>Scintigraphy &#40;MIBI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">266&#47;289 &#40;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Parathyroidectomy indication</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Clinical symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">103 &#40;34&#46;7&#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"><span class="elsevierStyleHsp" style=""></span>Hypercalcaemia &#40;Ca<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80 &#40;27&#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"><span class="elsevierStyleHsp" style=""></span>Renal lithiasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38 &#40;13&#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"><span class="elsevierStyleHsp" style=""></span>Osteoporosis&#47;osteopenia&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&#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"><span class="elsevierStyleHsp" style=""></span>Age &#60;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;11&#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"><span class="elsevierStyleHsp" style=""></span>Glomerular filtration rate &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&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;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Histology</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Adenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">280 &#40;94&#46;3&#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"><span class="elsevierStyleHsp" style=""></span>Hyperplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;5&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Parathyroidectomy&#58; localisation&#44; indications and histology&#46;</p>"
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          "leyenda" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Cr&#58; creatinine&#59; iPTH&#58; intact parathyroid hormone&#59; ND&#58; not determined&#59; PTX&#58; parathyroidectomy&#59; SD&#58; standard deviation&#46;</p><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">The laboratory values are expressed as median &#40;p25&#8211;p75&#41; and mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#46;</p>"
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            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" 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">Preoperative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1 week post-PTX&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">12 months post-PTX&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">Calcium &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;4 &#40;10&#46;8&#8211;12&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;0 &#40;8&#46;5&#8211;9&#46;5&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;5 &#40;9&#46;2&#8211;9&#46;8&#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">Phosphorus &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;5 &#40;2&#46;2&#8211;2&#46;8&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42 &#40;25&#8211;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45 &#40;33&#8211;59&#41;&nbsp;\t\t\t\t\t\t\n
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                        0 => array:2 [
                          "etal" => false
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                            1 => "L&#46; Bandeira"
                            2 => "A&#46; Khan"
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                          "etal" => false
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                            0 => "M&#46; Mu&#241;oz-Torres"
                            1 => "A&#46; Garc&#237;a-Mart&#237;n"
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                    0 => array:2 [
                      "doi" => "10.1016/j.medcli.2017.07.020"
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                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "2017"
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                    0 => array:2 [
                      "titulo" => "Kidney involvement in patients with primary hyperparathyroidism&#58; an update on clinical and molecular aspects"
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                            0 => "C&#46; Verdelli"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Renal impairment as a surgical indication in primary hyperparathyroidism&#58; do the data support this recommendation&#63;"
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                            0 => "S&#46; Valdemarsson"
                            1 => "B&#46; Linderg&#229;rd"
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                      "titulo" => "A slight decrease in renal function further impairs bone mineral density in primary hyperparathyroidism"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46; Gianotti"
                            1 => "F&#46; Tassone"
                            2 => "F&#46; Cesario"
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                            4 => "P&#46; Razzore"
                            5 => "G&#46; Magro"
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