Letter to the Editor
Efficacy of systematic catheter locks solution of taurolidine/heparin versus taurolidine/urokinase in end-stage renal insufficiency stage 5D
Eficacia de los sellados sistemáticos de catéter con taurolidina/heparina versus taurolidina/uroquinasa en pacientes con insuficiencia renal crónica estadio 5D
Néstor Fontseréa,
, Alex Sorianob, Gaspar Mestresc, Patricia Bermudezd, Federico Zarcod, Valentín Lozanoa, Lida Rodasa, Jose Brosetaa, Marta Ariasa, Francisco Maduella
Corresponding author
a Unidad Funcional de Acceso Vascular, Servicio de Nefrología, Hospital Clínico de Barcelona, Barcelona, Spain
b Unidad Funcional de Acceso Vascular, Servicio de Enfermedades Infecciosas, Hospital Clínico de Barcelona, Barcelona, Spain
c Unidad Funcional de Acceso Vascular, Servicio de Cirugía Vascular, Hospital Clínico de Barcelona, Barcelona, Spain
d Unidad Funcional de Acceso Vascular, Servicio de Radiología Vascular Intervencionista, Hospital Clínico de Barcelona, Barcelona, Spain
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class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Gaspar" "apellidos" => "Mestres" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Patricia" "apellidos" => "Bermudez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "Federico" "apellidos" => "Zarco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "Valentín" "apellidos" => "Lozano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Lida" "apellidos" => "Rodas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Jose" "apellidos" => "Broseta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "Marta" "apellidos" => "Arias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 9 => array:3 [ "nombre" => "Francisco" "apellidos" => "Maduell" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad Funcional de Acceso Vascular, Servicio de Nefrología, Hospital Clínico de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad Funcional de Acceso Vascular, Servicio de Enfermedades Infecciosas, Hospital Clínico de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad Funcional de Acceso Vascular, Servicio de Cirugía Vascular, Hospital Clínico de Barcelona, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad Funcional de Acceso Vascular, Servicio de Radiología Vascular Intervencionista, Hospital Clínico de Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Eficacia de los sellados sistemáticos de catéter con taurolidina/heparina versus taurolidina/uroquinasa en pacientes con insuficiencia renal crónica estadio 5D" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1218 "Ancho" => 1503 "Tamanyo" => 79112 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Survival curves (Kaplan-Meier) analysing primary patency (PP) in each of the tunnelled catheter lock subgroups (T-Hep vs T-U).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Different studies have shown how patients in a haemodialysis programme with native arteriovenous fistulas (nAVF) have a higher patency rate and fewer associated vascular complications.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However, even though nAVF are the best type of vascular access, according to the latest data from the Registro de Enfermos Renales de Cataluña (RMRC) [Catalonia Registry of Patients with Kidney Disease],<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> year on year the rate of use has been reducing (59.8%) and only 39.9% of those who started haemodialysis in 2018 did so with this type of vascular access. Use of the venous catheter as access is therefore an increasing reality related to the older average age of our patients and the coexistence with different cardiopulmonary comorbidity factors (low cardiac output and severe pulmonary hypertension).</p><p id="par0010" class="elsevierStylePara elsevierViewall">The main complications associated with central venous catheters are mechanical dysfunction (fibrin sheath and thrombosis) and endovascular infection. Catheter-related bloodstream infection (CRBSI) is considered the leading cause of hospital admission, at times leading to severe septic complications and requiring removal of the catheter, with the consequent increase in related morbidity and mortality rates.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Different authors have described that catheters become colonised by microorganisms, which produce a mucopolysaccharide matrix (biofilm) over the surface of the catheter, and this plays a significant role in the development of CRBSI, as it protects the microorganisms from the immune system and different antimicrobial agents.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Currently, advances in the prevention of CRBSI have placed particular emphasis on the use of catheter lock solutions deposited in the lumen of the catheter after each dialysis session aiming to maintain the device patent; this has been shown to be an effective way of preventing infection, possibly by reducing biofilm formation.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Our group concluded based on previous studies that locking the catheter lumen with an antiseptic solution with taurolidine-heparin significantly reduces not only the rate of bacteraemia and the inflammatory response, but also the formation of adherent biological material.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Recent studies show the superiority of lock solutions with taurolidine in its different combinations compared to the use of 4% citrate alone (lower rate of CRBSI and dysfunction), particularly with the use of the preparation containing urokinase.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> However, currently there is little scientific evidence on whether or not there are significant differences between the different formulations containing taurolidine (heparin vs urokinase) and whether the therapeutic change is cost-effective.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The main aim of this research was to analyse whether the systematic lock of the catheter with taurolidine-urokinase (T-U: 4% taurolidine-citrate and 25,000 IU urokinase) during the long interdialytic period produces fewer complications as compared to the conventional regimen of taurolidine-heparin (T-Hep: 4% taurolidine-citrate and 500 IU heparin) in each haemodialysis session.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We conducted an observational, retrospective cohort analysis (2013–2018) in 57 prevalent patients with CKD stage 5D (23 T-Hep and 34 T-U), with a mean age of 66.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.5 years (35–93) and 61.4% male. No significant differences were found between subgroups in terms of socio-demographic variables, biochemical parameters or haemodialysis adequacy. During the follow-up period, a total of 25 replacements were performed due to dysfunction, 16 in the T-Hep group and nine in the T-U group; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.003. A total of two bacteraemia episodes were identified during the follow-up period, one in each group (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>NS).</p><p id="par0035" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the different rates of primary patency (PP) in each of the study subgroups. The PP in the group locked with T-U was significantly higher, 1105.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>202.9 days (708.1–1503.6) than that of the T-Hep group, 261.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>53 days (157.5–365.4); <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.014. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows an analysis of the mean cost-effectiveness during the follow-up period in each of the study subgroups. As can be seen, the average cost was higher in the group with T-U lock, albeit with a lower cost for angiography/radiological procedures due to dysfunction.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In the search for new lock solutions, an American study recently published concluded that systematic locking with sodium bicarbonate significantly reduces the rate of thrombosis (0.17 episodes/1000 catheter days vs 4.1 episodes/1000 catheter days; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.0001) and endovascular bacteraemia (0.17 episodes/1000 catheter days vs 2.6 episodes/1000 catheter days; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.0004) compared to saline.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> This potential dual beneficial effect of bicarbonate as an antithrombotic and anti-infective agent should therefore be investigated in the future.</p><p id="par0045" class="elsevierStylePara elsevierViewall">According to the results obtained in our study, the use of systematic locking with the combination T-U in the long interdialytic period significantly reduces the number of replacements due to dysfunction, increasing primary patency rates with no additional financial cost. Nevertheless, the present data is preliminar and will need to be correlated with the design of future prospective, randomised studies.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have not received funding for this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1218 "Ancho" => 1503 "Tamanyo" => 79112 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Survival curves (Kaplan-Meier) analysing primary patency (PP) in each of the tunnelled catheter lock subgroups (T-Hep vs T-U).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Unit price \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">T-Hep (N<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>23) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">T-U (N<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>34) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lock<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Є202<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.90 (213−189) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Є400.60<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>13.80 (426−369) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.000<a class="elsevierStyleCrossRef" href="#tblfn0030">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urokinase<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Є2.10<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10.10 (48.90–0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Є2.80<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11.60 (48.90–0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.801 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Admission for bacteraemia<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Є150.90<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>723.90<span class="elsevierStyleHsp" style=""></span>(3,472–0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Є124<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>723<span class="elsevierStyleHsp" style=""></span>(4,216–0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.799 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Replaced due to dysfunction<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Є1000<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1266.30<span class="elsevierStyleHsp" style=""></span>(3,800–0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Є473.50<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1093<span class="elsevierStyleHsp" style=""></span>(3,800–0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.033<a class="elsevierStyleCrossRef" href="#tblfn0030">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total mean cost<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Є1355.10<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1343.30<span class="elsevierStyleHsp" style=""></span>(4,003.80–97.50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Є1001<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1564.20<span class="elsevierStyleHsp" style=""></span>(7,926.10–369.20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.494 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3703351.png" ] ] ] "notaPie" => array:6 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Cost lock/session: T-Hep Є5/vial and T-U Є19.80/vial.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Cost vial of urokinase (100,000 IU): Є248.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Cost day of hospital stay on ward due to infection: Є248.</p>" ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Catheter replacement due to dysfunction: simple replacement Є1400/procedure; and replacement with percutaneous transluminal angioplasty (PTA) over fibrin sheath Є1900/procedure.</p>" ] 4 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "e" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Mean cost/patient adjusted to the time the catheter remained working in each of the study subgroups.</p>" ] 5 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0030"><span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Analysis of the economic costs by tunnelled catheter lock subgroup (T-Hep vs T-U).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Type of vascular access and mortality in U.S. hemodialysis patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R.K. 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| 2024 August | 84 | 95 | 179 |
| 2024 July | 68 | 50 | 118 |
| 2024 June | 72 | 52 | 124 |
| 2024 May | 76 | 49 | 125 |
| 2024 April | 62 | 47 | 109 |
| 2024 March | 33 | 27 | 60 |
| 2024 February | 49 | 42 | 91 |
| 2024 January | 41 | 28 | 69 |
| 2023 December | 33 | 40 | 73 |
| 2023 November | 36 | 35 | 71 |
| 2023 October | 53 | 37 | 90 |
| 2023 September | 58 | 45 | 103 |
| 2023 August | 54 | 23 | 77 |
| 2023 July | 65 | 43 | 108 |
| 2023 June | 70 | 30 | 100 |
| 2023 May | 70 | 65 | 135 |
| 2023 April | 47 | 42 | 89 |
| 2023 March | 81 | 72 | 153 |
| 2023 February | 54 | 49 | 103 |
| 2023 January | 18 | 40 | 58 |
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