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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with chronic kidney disease &#40;CKD&#41; have a high prevalence and incidence of cardiovascular disease &#40;CVD&#41;&#46; The presence of traditional risk factors of vascular disease such as arterial hypertension &#40;HTN&#41;&#44; diabetes mellitus &#40;DM&#41; and dyslipidemia&#44; which are more frequent in CKD&#44; and other factors with the capacity to produce vascular damage closely related to kidney failure&#44; such as chronic inflammation&#44; oxidative stress and vascular calcifications &#40;VC&#41;&#44; among others&#44; contribute to the high cardiovascular morbidity and mortality in CKD&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In CKD&#44; an increase in central &#40;aortic&#41; arterial stiffness can be observed&#44; which summarizes the perpetuation&#44; over time&#44; of all these vasculopathic factors&#46; Increased central arterial stiffness has repercussions on central hemodynamics with effects on cardiac structure and function and on perfusion of organs such as brain and kidney&#46; In fact&#44; in subjects with CKD&#44; increased aortic stiffness has been shown to be a predictor of mortality&#44; cardiovascular events and progression of renal function deterioration&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The VCs observed in CKD extend through different vascular territories and their number and intensity increase with the degree of renal failure&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Two pathological processes lie beneath the CVs&#46; First&#44; calcification of the intima&#44; which is also frequent in the population without kidney disease&#44; and&#44; second&#44; calcification of the media layer of the vascular wall&#44; which is more frequent in CKD&#44; advanced age and DM&#46; These processes&#44; which frequently coexist&#44; have different impacts on cardiovascular events&#46; Calcification of the intima would be associated with occlusive arterial disease due to atherosclerosis&#44; whereas calcification of the media layer would lead to increased arterial stiffness&#44; and consequently&#44; changes in central hemodynamics with repercussions on cardiac structure and function &#40;cardiac hypertrophy and heart failure&#41; and changes in the perfusion of target organs such as the kidney&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although imaging methods are useful in detecting VCs&#44; it is possible that the combined use of imaging techniques&#44; circulating biomarkers<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and arterial function tests such as arterial stiffness may aid in the diagnosis of VCs&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Given the possible impact of CVs&#44; and other factors associated with CKD&#44; on aortic stiffness&#44; the purpose of this study was to analyze&#44; in subjects with stage 3&#8211;4 CKD&#44; the degree of association of CVs in two territories&#44; abdominal aorta and coronary arteries&#44; with aortic stiffness as determined by carotid-femoral pulse velocity &#40;Vp&#41;<span class="elsevierStyleInf">c-f</span>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">We studied 87 patients with stable CKD stage 3&#8211;4 &#40;estimated glomerular filtration rate &#40;eGFR&#41;&#58; 15&#8722;60 ml&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#41;&#44; that were evaluated and followed as out patients in the nephrology clinic of the university hospital&#46; Patients with and without DM were included&#46; Patients had to have stable renal function and no changes in medication &#40;antihypertensive&#44; antidiabetic&#44; phosphorus binders and vitamin D&#41; in the last 3 months&#46; Subjects with atrial fibrillation&#44; immunosuppressive therapy&#44; oncological processes or cardiovascular events in the last 6 months were excluded&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Biochemical parameters including creatinine&#44; lipids&#44; phosphocalcic metabolism parameters &#91;calcium&#44; phosphorus&#44; parathormone &#40;PTH&#41; and 25-hydroxycholecalciferol &#40;25-OHVit&#46;D&#41;&#93;&#44; ultrasensitive C-reactive protein &#40;hsCRP&#41;&#44; uric acid&#44; hemogram&#44; and&#44; in subjects with DM&#44; glycosylated hemoglobin&#44; were determined in blood&#46; The eGFR was calculated using the CKD-EPI <span class="elsevierStyleItalic">&#40;chronic kidney disease&#44; epidemiology&#41;</span> formula&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In all patients&#44; the albumin&#47;creatinine ratio was determined in the first morning urine&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">It was recorded those cardiovascular events that required hospital admission &#40;ischemic heart disease&#44; stroke&#44; heart failure&#41; and the presence of peripheral artery disease diagnosed by clinical signs and symptoms or an ankle-brachial index of less than 0&#46;9&#46; Smoking was investigated by considering as smokers those who were active or had quit smoking versus those that never smoked&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Aortic arterial stiffness and aortic and coronary calcifications were studied within 21 days after of the determination of laboratory parameters&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">All patients gave their consent after being informed and the study met all the ethical criteria of the institution where it was performed&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study of central hemodynamics and aortic arterial stiffness</span><p id="par0055" class="elsevierStylePara elsevierViewall">After the measurement of weight and heigth and resting in the supine position for 15 min&#44; brachial arterial pressure &#40;bBP&#41; was measured &#40;mean of 3 determinations&#41; using an Omron M3 IT &#40;Omron electr&#243;nica Iberia&#44; S&#46;A&#46;U&#46;&#44; Madrid&#41;&#46; The study of central arterial pressure &#40;cBP&#41; and carotid-femoral pulse velocity &#40;Vp<span class="elsevierStyleInf">c-f</span>&#41; was performed by applanation tonometry using a SphygmoCor device &#40;AtCor Medical&#44; Sydney&#44; Australia&#41; according to the methodology previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Briefly&#44; from the pulse wave obtained by tonometry over the radial artery and using a generalized transfer function&#44; central systolic arterial pressure &#40;cSAP&#41;&#44; central diastolic arterial pressure &#40;cDAP&#41;&#44; central mean arterial pressure &#40;cMAP&#41; and central pulse pressure &#40;cPP&#41; were obtained&#46; For the determination of Vp<span class="elsevierStyleInf">c-f</span> the pulse wave was obtained sequentially over the common carotid artery and the femoral artery&#44; calculating the travel time between the two points from the difference between the R wave of the simultaneous electrocardiographic recording and the onset of the pulse wave at the respective arterial sites&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The Vp index<span class="elsevierStyleInf">c-f</span> &#40;iVp<span class="elsevierStyleInf">c-f</span>&#41;&#44; was obtained from the values of Vp<span class="elsevierStyleInf">c-f</span> including other variables that influence Vp<span class="elsevierStyleInf">c-f</span> such as age&#44; sex&#44; blood pressure and heart rate&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The tonometry for the determination of central hemodynamics and Vp<span class="elsevierStyleInf">c-f</span> was always performed by the same investigator who was unaware of the values of VC&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Following the recommendations of the European Society of Hypertension and the evidence that Vp values<span class="elsevierStyleInf">c&#8211;f</span> &#8805;12 m&#47;s have negative prognostic impact in subjects with advanced CKD&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> patients were subdivided into 2 groups&#58; with Vp <span class="elsevierStyleInf">c&#8211;f</span> values &#8805;12 m&#47;s and &#60;12 m&#47;s&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study of vascular calcifications</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Abdominal aortic calcifications &#40;AAC&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">A lateral X-ray of the lumbar spine was performed to evaluate AAC&#46; The reading and scoring of the degree of calcification &#40;iKauppila&#41; was always done by the same investigator following the methodology described&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> This investigator was unaware of the laboratory and arterial function data&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Coronary calcifications &#40;CC&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Due to the requirement that all the parameters studied &#40;abdominal and coronary calcifications&#44; aortic stiffness and laboratory variables&#41; be performed within a relatively short period of time&#44; only 40 patients had the multislice computed tomography &#40;CT&#41; scan without contrast performed to assess the presence of CC&#46; A 64-detector multidetector CT&#44; General Electric &#40;Boston&#44; Massachusetts&#44; USA&#41;&#44; was used&#46; The Agatston method was used to quantify coronary calcium&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The presence of coronary calcium is defined as an area at the coronary level with a threshold of more than 130 Hounsfield units &#40;HU&#41;&#46; A score is calculated for each lesion by multiplying the area by a cofactor that depends on the maximum HU value of each lesion&#46; The final calcification score is obtained by adding the left coronary&#44; anterior descending&#44; circumflex&#44; and right coronary scores and it is expressed as the Agatston index &#40;iAgatston&#41;&#46; The investigator who performed the heart CT was unaware of the laboratory results and the data of arterial function&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Given that a value greater than 400UH<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> is considered severe calcification with a high predictive capacity for coronary events&#44; this value was adopted as the threshold for establishing 2 categories of CC&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0085" class="elsevierStylePara elsevierViewall">Categorical variables are expressed as absolute and relative frequencies&#46; Continuous variables are expressed as mean &#177; standard deviation &#40;x &#177; SD&#41; if distribution was normal or as median and interquartile range &#40;IQR&#41; if the distribution was not normal&#46; In case that the variable values had a highly skewed distribution&#44; such as iKauppila&#44; iAgatston&#44; and urine albumin&#47;creatinine ratio&#44; they were converted to their natural logarithms&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The Shapiro-Wilk test was used to establish the normality of the distribution of the variables&#46; The comparison of qualitative variables was done using the &#967;<span class="elsevierStyleSup">2</span> test&#46; Normally distributed quantitative variables were compared using Student&#39;s <span class="elsevierStyleItalic">t</span>-test and the Mann Whitney test in the case of non-normal distribution&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Since 13&#37; of patients had an iKauppila value of zero&#44; the aortic calcification score was divided into quartiles &#40;&#8804;1&#59; 2&#8211;6&#59; 7&#8211;11&#59; &#8805;12&#41;&#59; comparison of Vp<span class="elsevierStyleInf">c-f</span> values between quartiles&#44; was performed using analysis of variance &#40;ANOVA&#41; with Scheff&#233;&#39;s test for post hoc multiple comparisons&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The effect of some covariates on VC in certain groups was evaluated by analysis of covariance &#40;ANCOVA&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The relationship between variables was analyzed using Pearson&#39;s or Spearman&#39;s correlation coefficient depending on their distribution of the values&#46; The independent relationship between variables was investigated using multiple linear regression by selecting potential covariates that previously demonstrated significant correlation&#46; Stepwise logistic regression was used to evaluate the independent effects and predictive value of various variables on the presence of aortic and coronary CV&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">ROC <span class="elsevierStyleItalic">&#40;receiver operating characteristic&#41;</span> curves were used to establish the value of iVp<span class="elsevierStyleInf">c-f</span> with the highest sensitivity and lowest number of false positives &#40;1-specificity&#41; in the prediction of the presence of AAC and CC&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A value of p &#60; 0&#46;05 was considered significant&#46; All statistical analyses were performed with the statistical program IBM SPSS version 25 for Windows&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0120" class="elsevierStylePara elsevierViewall">We studied 87 patients&#44; with a median age of 66 &#40;14&#41; years&#46; A 65&#46;5&#37; were men&#44; with CKD stage 3 &#40;56&#37;&#41; and 4 &#40;44&#37;&#41;&#46; Forty-six percent of all patients had DM&#46; Considering the whole group&#44; the value of Vp<span class="elsevierStyleInf">c-f</span> was 11&#46;3 &#177; 2&#46;6 m&#47;s and that of iVp<span class="elsevierStyleInf">c-f</span> 10&#46;6 &#177; 1 m&#47;s&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The study of AAC was performed in 83 patients and that of CC in 40&#46; Two of the latter were excluded from the final analysis due to technical deficiencies of the heart CT&#46; A 77&#37; of patients had AAC and 87&#37; had CC&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the clinical and laboratory data in patients with Vp<span class="elsevierStyleInf">c-f</span> &#8805; 12 m&#47;s and with Vp<span class="elsevierStyleInf">c-f</span> &#60; 12 m&#47;s&#46; In the group with Vp<span class="elsevierStyleInf">c-f</span> &#8805; 12 m&#47;s there were higher number of men&#44; more DM and smoking&#46; Age was significantly higher in this group&#46; The percentage of patients with CVD was quantitatively&#44; but not significantly&#44; higher in the group with Vp<span class="elsevierStyleInf">c-f</span> &#8805; 12 m&#47;s&#44; in which there were also greater numbers of subjects treated with statins and antiaggregants&#46; The eGFR was higher in the group with Vp<span class="elsevierStyleInf">c-f</span> &#8805; 12 &#91;34 &#177; 10 vs&#46; 29 &#177; 9 m&#47;s&#44; p &#61; 0&#46;03&#93;&#46; However&#44; when only those without DM were considered or adjustment was made for the presence of DM&#44; the difference in GFR between the groups disappeared&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">PASb&#44; PASc&#44; PPb and PPc and iVp<span class="elsevierStyleInf">c-f</span> were significantly higher in the group with Vp<span class="elsevierStyleInf">c-f</span> &#8805; 12 m&#47;s &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">The AAC and CC score was significantly higher in the group with Vp<span class="elsevierStyleInf">c-f</span> &#8805; 12 m&#47;s &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The iVp<span class="elsevierStyleInf">c-f</span> increased progressively with iKauppila quartiles &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Patients with an iAgatston &#62; 400 UH score had a greater iVp<span class="elsevierStyleInf">c-f</span> than those with a score &#8804; 400 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the correlations between iVp<span class="elsevierStyleInf">c-f</span>&#44; iKauppila and iAgatston with other variables&#46; There was a significant direct correlation between iVp<span class="elsevierStyleInf">c&#8211;f</span> and iKauppila&#44; iAgatston&#44; smoking&#44; BMI &#40;body mass index&#41;&#44; presence of DM and cardiovascular disease&#44; and an inverse correlation with c-HDL&#46; The iKauppila and iAgatston had a direct and significantl correlation&#44; and both correlated directly with arterial pulsatility parameters &#40;PPb and PPc&#41;&#46; The degree of AAC &#40;iKauppila&#41; correlated directly with age&#44; smoking&#44; BMI and presence of DM&#46; No significant correlation was observed between iVp<span class="elsevierStyleInf">c-f</span> and CC with phosphocalcic metabolism parameters&#44; inflammatory parameters or uric acid values&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Compared to patients without diabetes&#44; those with DM had higher values of iVp<span class="elsevierStyleInf">c&#8211;f</span> &#91;10&#46;8 &#40;1&#46;1&#41; vs&#46; 10&#46;3 &#40;1&#46;5&#41; m&#47;s&#59; p &#61; 0&#46;001&#93; and also greater values of log iKauppila &#91;2 &#40;1&#41; vs&#46; 0&#46;69 &#40;2&#41;&#59; p &#61; 0&#46;009&#93;&#46; Since patients with DM were older and had higher BMI&#44; adjustment was made for these variables &#40;ANCOVA&#41; showing that significant differences persisted in iVp<span class="elsevierStyleInf">c-f</span> and iKauppila&#46; For any value of MAP&#44; subjects with DM had a higher Vp<span class="elsevierStyleInf">c-f</span> than non-diabetics &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">In the multiple regression analysis&#44; the presence of DM and urinary albumin excretion were significantly associated with the value of iVp<span class="elsevierStyleInf">c-f</span>&#46; When iKauppila was introduced in the model&#44; the participation of DM was attenuated &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">The iVp<span class="elsevierStyleInf">c-f</span>&#44; the presence of DM and smoking were the only variables significantly associated with the intensity of AAC as determined by iKauppila &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>A&#41;&#46; When in the logistic regression the existence or not of AAC was considered as a dependent variable&#44; only iVp<span class="elsevierStyleInf">c-f</span> was illustrative of its presence &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>B&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">The overall prevalence of CC was 87&#37; &#40;77&#37; in the group without DM and 92&#37; in the group with DM&#41;&#46; The intensity of CC was also higher in patients with diabetes&#59; a iAgatston &#62; 400 UH was observed in 52&#37; of patients with DM and in only 38&#37; of non-DM&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The magnitude of AAC was the only variable independently associated with the intensity of CC &#40;&#946; &#61; 3&#46;12&#44; p &#61; 0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>A&#41;&#46; The presence of CAA identified patients with CC with a sensitivity of 73&#37;&#44; a specificity of 100&#37;&#44; a positive predictive value of 100&#37;&#44; and a negative predictive value of 38&#37; &#40;X<span class="elsevierStyleSup">2</span> for CC present&#47;absent vs&#46; CAA present&#47;absent&#58; p &#61; 0&#46;002&#41;&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">The iVp<span class="elsevierStyleInf">c-f</span> entered the logistic regression model as a predictor of the presence of CC &#40;OR&#58; 3&#46;35&#44; 95&#37; CI&#58; 1&#46;04&#8211;10&#46;2&#59; p &#61; 0&#46;04&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>B&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In the ROC curves&#44; the area under the curve for AAC and CC was 0&#46;82 &#40;95&#37; CI&#58; 0&#46;71&#8211;0&#46;93&#44; p &#61; 0&#46;001&#41; and 0&#46;81 &#40;95&#37; CI&#58; 0&#46;67&#8211;0&#46;96&#44; p &#61; 0&#46;02&#41;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> A and B&#41;&#46; An iVp <span class="elsevierStyleInf">c-f</span> value &#8805; 10&#46;25 m&#47;s predicted the presence of AAC with a sensitivity of 80&#37; and a specificity of 65&#37;&#46; An iVp <span class="elsevierStyleInf">c-f</span> value &#8805; 10&#44;12 m&#47;s predicted the presence of CC with a sensitivity of 76&#37; and a specificity of 80&#37;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0190" class="elsevierStylePara elsevierViewall">Our study demonstrates that in subjects with CKD stage 3 and 4 there is an increase in aortic arterial stiffness&#44; independent of the values of BP and age&#44; when associated with the presence of DM&#44; and a high prevalence of AAC and CC that frequently coexist&#46; There is&#44; moreover&#44; a close and reciprocal relationship between aortic stiffness and the presence of VC&#46; AAC is associated with increased central stiffness and&#44; in turn&#44; increased aortic stiffness is related to the presence of both AAC and CC&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Several studies have demonstrated an increase in aortic stiffness assessed by Vp<span class="elsevierStyleInf">c-f</span> in CKD&#44; evoking the participation of traditional vascular risk factors&#44; which are more frequent in CKD&#44; and risk factors characteristic of CKD&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4&#44;17</span></a> However&#44; few publications&#44; have analyzed the Vp<span class="elsevierStyleInf">c-f</span> in CKD after adjustment for factors that can modify it&#46; It is especially important to consider BP&#44; since the relationship between BP and arterial stiffness is exponential&#46; As BP increases&#44; the load supported by the vascular wall is transferred from the elastic fibers to the stiffer collagen fibers&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> In our work we investigated the value of Vp<span class="elsevierStyleInf">c-f</span> adjusted for BP&#44; age&#44; sex and heart rate &#40;iVp<span class="elsevierStyleInf">c-f</span>&#41;&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">It has been described a significant negative association between renal function and aortic stiffness&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In our work there was no such correlation and&#44; in addition&#44; we observed an unexpected GFR value&#44; quantitatively unimportant&#44; but significantly higher in the group with Vp<span class="elsevierStyleInf">c-f</span> &#62; 12 m&#47;s&#46; It is possible that these findings are attributable to the narrow range of GFR of the population studied and to the effect of DM in which hyperfiltration may obscure the association between FG and arterial stiffness&#46; In fact&#44; the difference in GFR between the two groups classified according to Vp<span class="elsevierStyleInf">c-f</span> disappeared when the presence of DM was considered&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Arterial wall stiffness is determined by several mechanisms that affect the intimal&#44; medial and adventitial layers of the vascular wall and include endothelial dysfunction&#44; a decrease in the elastin&#47;collagen ratio&#44; reactive oxygen species-induced inflammation&#44; vascular smooth muscle cell stiffness and calcification&#46; There are phenotypic changes of vascular smooth muscle cells &#40;VSMCs&#41; related to mechanotransduction &#40;interaction between extracellular matrix and VSMCs&#41;&#44; oxidative stress and metabolic and epigenetic factors&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> There is a multicellular interaction&#44; mediated by various molecules&#44; of endothelial cells&#44; inflammatory cells&#44; fibroblasts&#44; pericytes and progenitor cells with VSMCs&#46; All these mechanisms participate in the increased aortic stiffness that accompanies normal arterial aging and the vascular aging that occurs early in CKD and DM&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;18</span></a> As expected and as we also show in our study&#44; the increase in arterial stiffness is greater when both conditions coexist&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In fact&#44; although we found a significant correlation between iVp<span class="elsevierStyleInf">c-f</span> and other vascular risk factors and markers&#44; only DM&#44; albuminuria and CAA show an independent association with iVp<span class="elsevierStyleInf">c-f</span>&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Potential mechanisms for increased aortic stiffness in DM include the accumulation of advanced glycation products in vascular wall collagen making it resistant to enzymatic degradation<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and the alterations in nitric oxide &#40;NO&#41; synthesis&#44; superoxide production and endothelial dysfunction observed in insulin resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">In our study the association of DM and iVp<span class="elsevierStyleInf">c-f</span> was attenuated when AAC iKauppila was introduced into the model&#46; It is possible that the independent effect of DM on aortic stiffness is obscured to some extent by the known association of DM with CV&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> calcification involving inflammatory mechanisms&#44; and alterations in the concentration of calcification promoter and inhibitor proteins that are of greater intensity when DM and CKD coexist&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">The association between albuminuria and the magnitude of aortic stiffness has been previously described&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;27</span></a> A stiff aorta prevents attenuation of arterial pulsatility allowing its transmission to organs of low resistance such as the kidney&#44; promoting albuminuria&#46; The presence of albuminuria in the high-normal range has been described as an early marker of increased aortic stiffness&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">The presence of VCs are frequent in multiple territories in CKD&#44; their prevalence increases with the stage of CKD&#46; In our study&#44; the prevalence of AAC detected by radiology in subjects with stage 3&#8211;4 CKD was 77&#37;&#46; This prevalence is similar to that found in other works using computed tomography such as that of S&#248;rensen et al&#46; &#40;77&#46;3&#37; in stage 3 and 82&#46;3&#37; in stage 4&#41;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and in the IMPROVE-CKD study &#40;81&#37; in stages 3b and 4&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The only previous publication on the association between arterial calcifications and aortic stiffness that included subjects with stage 3&#8211;4 CKD<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> found that as observed in our study the intensity of AAC was independently associated with aortic stiffness&#46; It has been shown in experimental animals that degradation of the elastic fibers of the arterial wall &#40;as observed in aging&#44; HTN&#44; DM and CKD&#41; facilitates calcium deposits in the tunica media&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> In turn&#44; calcification of the tunica media induces additional destruction of elastin<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> causing further stiffness of the arteries&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Our study shows that in addition to DM and iVp<span class="elsevierStyleInf">c-f</span>&#44; smoking was also independently associated with iKauppila values&#46; Smoking generates vascular structural and functional damage&#46; It causes endothelial damage&#44; increased superoxide production and decreased availability of NO&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> In both active smokers and ex-smokers&#44; it is observed an increase in the rates of atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> In a population-based study in which Vp<span class="elsevierStyleInf">c-f</span> was associated with thoracoabdominal aortic calcification&#44; the degree of the latter was positively linked to age&#44; BP&#44; DM and degree of smoking&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> In addition to its effects on atherogenesis&#44; smoking may promote VC by other mechanisms&#46; Smoking was one of the independent determinants of reduced fetuin-A values in subjects with renal transplantation and VC&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> In addition&#44; in vitro studies have shown that nicotine induces VSMC calcification by promoting the expression of osteogenic genes &#40;<span class="elsevierStyleItalic">Runt-related transcription factor</span> 2 &#40;Runx2&#41;&#44; osterix &#40;Osx&#41;&#44; osteopontin &#40;OPN&#41;&#41; an effect that is due to increased Nox5 &#40;nicotinamide dinucleotide phosphate oxidase&#41; activity&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">The close relationship between AAC and aortic stiffness is reinforced by the finding in our study of a reciprocal relationship between them&#46; The amount of AAC was linked to increased aortic stiffness and&#44; in turn&#44; the magnitude of aortic stiffness adjusted for age&#44; BP&#44; and gender was independently associated with the degree of AAC and was the only predictor variable for the presence of AAC&#46; In fact&#44; on the ROC curve the iVp<span class="elsevierStyleInf">c-f</span> &#40;&#8805;10&#44;15 m&#47;s&#41; had a high positive predictive value&#46; Two studies that included subjects with CKD at various stages<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> and patients with CKD on hemodialysis<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> have also proven an independent association between Vp<span class="elsevierStyleInf">c-f</span> and AAC&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">In our study&#44; 87&#37; of patients presented some degree of CC&#46; A recent meta analysis reported a prevalence of CC in CKD predialysis and dialysis patients of 60&#37; &#40;24&#8211;90&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> In two other publications that&#44; like ours&#44; included patients with stage 3&#8211;4 CKD&#44; the prevalence of CC was 60&#8211;68&#37; &#40;74&#37; in the subgroup with DM&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;40</span></a> In these studies the age of patients was lower than in our patients and in one of the studies subjects with coronary artery disease were excluded&#46; These two facts may explain the lower prevalence of CC in these studies&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">In autopsy studies in subjects with CKD and coronary artery disease&#44; compared to subjects without CKD&#44; there is a predominance of intimal calcification in the coronary arteries&#46; In renal patients there is a higher percentage with calcification of the intima&#44; which is also of greater intensity&#46; In CKD&#44; stages 4 and 5&#44; only 18&#37; of subjects had calcification of the media of the coronary arteries in segments with and without calcification of the intima&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> However&#44; in other vascular territories such as the aorta&#44; it has been shown that in early stages of CKD&#44; compared to subjects without CKD&#44; there is calcification of the media &#40;which is associated with increased aortic stiffness&#41; and in more advanced stages&#44; there is an additional increase of thickness and calcification of the intima&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Calcification of the intima is an entity distinct from calcification of the media but&#44; nevertheless&#44; it shares pathogenic mechanisms&#46; Intima calcification is a phenomenon secondary to inflammation associated with atherosclerosis&#46; Microcalcification of the atheroma plaque occurs following the release of matrix vesicles&#44; apoptotic bodies&#44; and necrotic debris derived from macrophages and VSMCs&#44; which serve as a nucleus for calcification&#46; In contrast to calcification of the media layer&#44; in the intima calcification the osteochondrogenic transformation of VSMCs is a secondary phenomenon to the primary inflammatory process occurring in the atheroma plaque&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Although it has been shown that in CKD the distribution of calcification in the intima versus the media is not the same in the different vascular territories &#40;e&#46;g&#44; in coronary arteries and elastic arteries the calcification of atherosclerotic plaques of the intima is more prominent than in the muscular arteries of the upper extremity in which calcification of the media predominates with relative resistance to atherosclerosis&#41;&#44; in CKD the coexistence of calcifications of the intima and media in the same or different vascular territories is common&#46; This fact may be based on the existence of various types of cells&#44; in addition to VSMC&#44; which under different stimuli have the capacity for osteoblastic transformation &#40;endothelial cells&#44; pericytes&#44; myofibroblasts&#44; progenitor cells&#41;&#44; cells that communicate with each other through exosomes and various molecular signals &#91;&#40;BMP &#40;bone morphogenetic protein&#41;&#44; OPG&#47;RANK&#47;RANKL &#40;osteoprotegerin&#47;nuclear factor kB receptor activator&#47; RANK ligand&#41;&#44; Wnt&#47;&#946; catenin and AGE &#40;advanced glycation products&#41; systems&#93;&#44; generating an effective CV development network&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">In our study&#44; the magnitude of AAC &#40;iKauppila&#41; was the only variable independently associated with the intensity of CC &#40;iAgatston&#41; and&#44; in addition&#44; the presence of radiology-demonstrated AACs evidenced a high specificity for the presence of CC&#46; It is possible that the calcifications observed in the abdominal aorta represent joint calcification of the media and intima &#40;atherosclerosis and atherosclerosis&#41; of the vascular wall with increased arterial stiffness and it is also associated coronary intima calcification &#40;atherosclerosis&#41;&#46; In one study performed in subjects with stage 3 CKD &#40;eGFR 50 ml&#47; min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#41; and DM&#44; the prevalence of AAC and CC &#40;detected by CT&#41; was higher than that observed in subjects with DM without CKD&#46; Although the association between calcification of both vascular territories was not evaluated&#44; it was concluded that both types could represent atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> In another publication that included subjects with stage 3&#8211;4 CKD&#44; the degree of CAA detected by CT was independently associated with an iAgatston greater than 400 UH&#44; and the C statistic for predicting the presence of severe CHD increased significantly when the abdominal aortic calcification index was added to other traditional vascular risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">In the present study&#44; the iVp<span class="elsevierStyleInf">c-f</span> predicted the presence of CC&#46; To our knowledge&#44; only 3 studies have evaluated the relationship between aortic stiffness and CC in subjects with CKD&#46; In two of them&#44; performed in hemodialysis patients&#44; a direct correlation was observed between Vp<span class="elsevierStyleInf">c-f</span> and CC&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#44;47</span></a> whereas in another study which also included subjects with less advanced stages of CKD&#44; the association between Vp<span class="elsevierStyleInf">c-f</span> and CC disappeared when age&#44; MAP&#44; DM and AAC&#44; which were associated with Vp<span class="elsevierStyleInf">c-f</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> were incorporated in the multivariate analysis&#46; The iVp<span class="elsevierStyleInf">c-f</span> used in our study incorporated age&#44; sex and MAP and predicted the presence of CC&#44; and the ROC curve showed that an iVp<span class="elsevierStyleInf">c-f</span> value equal to or greater than 10&#46;12 m&#47;s provided acceptable values for discriminating the presence of CC&#46; It is possible that this association is attributable to the repercussions of increased aortic stiffness and secondary hemodynamic alterations &#40;increased pulsatility&#44; among others&#41; on the coronary circulation&#46; Clinical and experimental evidence demonstrates an important role of biomechanical forces in the genesis of coronary atherosclerosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;49</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">In advanced CKD patients it has been demonstrated that an elevated value of dephosphorylated and non-carboxylated matrix Gla protein &#40;dp-ucMGP&#41; &#40;i&#46;e&#46;&#44; without capacity to inhibit calcification&#41; is an independent predictor of increased VC and correlates with the intensity of CC and the degree of calcification of the media in other arteries&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> In addition&#44; in CKD patients&#44; elevated values of dp-ucMPG<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> and calciprotein particles containing phosphorylated fetuin A&#44; the expression of a procalcifying medium&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> are associated with icreased aortic stiffness&#46; In subjects with CKD stage 3&#8211;4&#44; an increase in calcification propensity quantified as the transformation time from primary calciprotein particles to secondary calciprotein particles was independently associated with baseline Vp<span class="elsevierStyleInf">c-f</span> and with its progressive increase during 30 months&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> All these data&#44; together with our findings&#44; make it plausible that a parameter of arterial function such as aortic stiffness associated with a biomarker of vascular calcification allows early identification of VC in patients with CKD&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Our study has limitations&#46; It is a cross-sectional study&#44; so we are not able to determine whether aortic stiffness progresses in parallel with VC&#59; likewise we can not assess the prognostic impact of this marker of arterial function on cardiovascular and renal events&#46; However we can affirm that in CKD stage 3&#8211;4&#44; the greater the degree of vascular calcification&#44; the greater the aortic stiffness&#46; Another limitation is that the determination of CC was performed in a smaller number of patients than that of aortic calcification and the latter was assessed by radiographic methods&#46; Despite this limitation&#44; our results are statistically consistent&#46; Furthermore&#44; there are observational studies demonstrating that VC assessed by radiology method is a valid parameter for prognosis of cardiovascular events that is more reliable than many of the traditional risk factors&#44; and that there is a significant correlation between iKauppila and AAC detected by CT&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;55</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">The strengths of our study are the inclusion of patients with similar renal function &#40;CKD stages 3 and 4&#41;&#44; the analysis of the relationship between aortic stiffness &#40;adjusted for age&#44; sex and blood pressure&#41; and AAC and CC using the technique considered <span class="elsevierStyleItalic">gold</span> standard for the determination of aortic stiffness&#44; and the short time interval between the determination of Vp<span class="elsevierStyleInf">c-f</span> and the evaluation of VC&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">In summary&#44; in patients with CKD stage 3 and 4 there is an increase in aortic stiffness measured by iVp<span class="elsevierStyleInf">c-f</span> when DM is added to CKD&#44; and it frequently coexist with a high prevalence of AAC and CC&#46; This increased aortic stiffness is independently associated with VC in both the abdominal aorta and coronary arteries and it may be a useful marker of the presence of VC&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">The Spanish Society of Nephrology&#44; in the document updating and adapting the KDIGO <span class="elsevierStyleItalic">&#40;Kidney Disease Initiative Global Outcomes&#41;</span> guidelines on alterations in bone-mineral metabolism in CKD&#44; recommends for the detection of VC in stage 3&#8211;4 CKD the performance of a lateral radiograph of the lumbar spine at baseline and every 2&#8211;3 years during the follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> Given the association demonstrated in the present study between aortic stiffness and CAA and CC&#44; it seems reasonable to propose the inclusion of Vp<span class="elsevierStyleInf">c-f</span> as an additional method for the study of VC&#46; It would be interesting in future prospective studies to analyze whether the evaluation of aortic stiffness associated with a circulating biomarker of vascular calcification&#44; with or without imaging markers&#44; allows the diagnosis &#40;or an earlier diagnosis&#41; of CV in CKD&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical considerations</span><p id="par0300" class="elsevierStylePara elsevierViewall">All patients gave informed consent for the execution of the present study&#44; which met all the ethical criteria of the institution where it was performed&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Financing</span><p id="par0305" class="elsevierStylePara elsevierViewall">There has not been any type of financing from any institution&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0310" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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          "titulo" => "Introduction"
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              "titulo" => "Study of central hemodynamics and aortic arterial stiffness"
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              "titulo" => "Study of vascular calcifications"
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                  "identificador" => "sec0030"
                  "titulo" => "Abdominal aortic calcifications &#40;AAC&#41;"
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                  "identificador" => "sec0035"
                  "titulo" => "Coronary calcifications &#40;CC&#41;"
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              "titulo" => "Statistical analysis"
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    "fechaRecibido" => "2023-04-11"
    "fechaAceptado" => "2023-06-03"
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            0 => "Aortic stiffness"
            1 => "Pulse velocity"
            2 => "Chronic kidney disease"
            3 => "Vascular calcifications"
            4 => "Kauppila score"
            5 => "Agatston score"
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            0 => "Rigidez a&#243;rtica"
            1 => "Velocidad de pulso"
            2 => "Enfermedad renal cr&#243;nica"
            3 => "Calcificaciones vasculares"
            4 => "&#205;ndice de Kauppila"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Rationale and objectives</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Increased central &#40;aortic&#41; arterial stiffness has hemodynamic repercussions that affect the incidence of cardiovascular and renal disease&#46; In chronic kidney disease &#40;CKD&#41; there may be an increase in aortic stiffness secondary to multiple metabolic alterations including calcification of the vascular wall &#40;VC&#41;&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">The objective of this study was to analyze the association of central aortic pressures and aortic stiffness with the presence of VC in abdominal aorta &#40;AAC&#41; and coronary arteries&#40;CAC&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">We included 87 pacientes with CKD stage 3 and 4&#46; Using applanation tonometry&#44; central aortic pressures and aortic stiffness were studied&#46; We investigated the association of aortic pulse wave velocity &#40;Pv<span class="elsevierStyleInf">c-f</span>&#41; and Pv<span class="elsevierStyleInf">c-f</span> adjusted for age&#44; blood pressure&#44; sex and heart rate &#40;Pv<span class="elsevierStyleInf">c-f</span> index&#41; with AAC obtained on lumbar lateral radiography and CAC assessed by multidetector computed tomography&#46; AAC and CAC were scored according to Kauppila and Agatston methods&#44; respecti-vely&#46; For the study of the association between Pv<span class="elsevierStyleInf">c-f</span> index&#44; Kauppila score&#44; Agatston score&#44; central aortic pressures&#44; clinical parameters and laboratory data&#44; multiple and logistic regression were used&#46; We investigated the diagnosis performance of the Pv<span class="elsevierStyleInf">c-f</span> index for prediction of VC using receiver-operating characteristic &#40;ROC&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Pv<span class="elsevierStyleInf">c-f</span> and Pv<span class="elsevierStyleInf">c-f</span> index were 11&#46;3 &#177; 2&#46;6 and 10&#46;6 m&#47;s&#44; respectively&#46; The Pv<span class="elsevierStyleInf">c-f</span> index was higher when CKD coexisted with diabetes mellitus &#40;DM&#41;&#46; AAC and CAC were detected in 77&#37; and 87&#37;&#44; respectively&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Albuminuria &#40;&#946; &#61; 0&#46;13&#44; p &#61; 0&#46;005&#41; and Kauppila score &#40;&#946; &#61; 0&#46;36&#44; p &#61; 0&#46;001&#41; were independently associated with Pv<span class="elsevierStyleInf">c-f</span> index&#46; In turn&#44; Pv<span class="elsevierStyleInf">c-f</span> index &#40;&#946; &#61; 0&#46;39&#44; p &#61; 0&#46;001&#41;&#44; DM &#40;&#946; &#61; 0&#46;46&#44; p &#61; 0&#46;01&#41;&#44; and smoking &#40;&#946; &#61; 0&#46;53&#59; p &#61; 0&#46;006&#41; were associated with Kauppila score&#44; but only Pv<span class="elsevierStyleInf">c-f</span> index predicted AAC &#91;OR&#58; 3&#46;33 &#40;95&#37; CI&#58; 1&#46;6&#8722;6&#46;9&#59; p &#61; 0&#46;001&#41;&#93;&#46;</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">The Kauppila score was independently associated with the Agatston score &#40;&#946; &#61; 1&#46;53&#44; p &#61; 0&#46;001&#41;&#46; The presence of AAC identified patients with CAC with a sensitivity of 73&#37;&#44; a specificity of 100&#37;&#44; a positive predictive value of 100&#37; and a negative predictive value of 38&#37;&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">The Vp<span class="elsevierStyleInf">c-f</span> index predicted the presence of CAC &#91;OR&#58; 3&#46;35 &#40;95&#37; CI&#58; 1&#46;04&#8722;10&#46;2&#44; p &#61; 0&#46;04&#41;&#93;&#46; In the ROC curves&#44; using the Vp<span class="elsevierStyleInf">c-f</span> index&#44; the AUC for AAC and CAC was 0&#46;82 &#40;95&#37;CI&#58; 0&#46;71&#8722;0&#46;93&#44; p &#61; 0&#46;001&#41; and 0&#46;81 &#40;95&#37; CI&#58; 0&#46;67&#8211;0&#46;96&#44; p &#61; 0&#46;02&#41;&#44; respectively&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">When stage 3&#8211;4 CKD coexists with DM there is an increase in aortic stiffness determined by the Vp<span class="elsevierStyleInf">c-f</span> index&#46; In stage 3&#8211;4 CKD&#44; AAC and CAC are very prevalent and both often coexist&#46; The Vp<span class="elsevierStyleInf">c-f</span> index is independently associated with AAC and CAC and may be useful in identifying patients with VC in these territories&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Rationale and objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Fundamento y objetivos</span><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">El aumento de la rigidez arterial central &#40;a&#243;rtica&#41; tiene repercusiones hemodin&#225;micas con efectos nocivos cardiovasculares y renales&#46; En la enfermedad renal cr&#243;nica &#40;ERC&#41; puede existir un aumento de la rigidez a&#243;rtica secundaria a m&#250;ltiples alteraciones metab&#243;licas entre ellas la calcificaci&#243;n de la pared vascular &#40;CV&#41;&#46;</p><p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio fue analizar la asociaci&#243;n de la rigidez a&#243;rtica y de la hemodin&#225;mica central con la presencia de CV en dos territorios&#44; aorta abdominal &#40;CAA&#41; y arterias coronarias &#40;CC&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 87 pacientes con ERC estadio 3 y 4&#46; Usando tonometr&#237;a de aplanamiento se estudiaron la hemodin&#225;mica central y la rigidez a&#243;rtica&#46; Esta se determin&#243; mediante la velocidad de pulso car&#243;tida-femoral &#40;Vp<span class="elsevierStyleInf">c-f</span>&#41;&#46; A partir de la Vp<span class="elsevierStyleInf">c-f</span> se calcul&#243; el &#237;ndice de la VP<span class="elsevierStyleInf">c-f</span> &#40;iVp<span class="elsevierStyleInf">c-f</span>&#41; que considera otras variables que influyen en la Vp<span class="elsevierStyleInf">c-f</span> como edad&#44; presi&#243;n arterial&#44; sexo y frecuencia cardiaca&#46;</p><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">La presencia de CAA se valor&#243; mediante radiogr&#225;f&#237;a lateral de columna lumbar calcul&#225;ndose el &#237;ndice de Kauppila &#40;iKauppila&#41; y las CC mediante tomograf&#237;a computarizada multidetecci&#243;n por el m&#233;todo de Agatston calcul&#225;ndose su &#237;ndice &#40;iAgatston&#41;&#46;</p><p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">Para el estudio de la asociaci&#243;n entre iVp<span class="elsevierStyleInf">c-f</span>&#44; iKauppila&#44; iAgatston&#44; presi&#243;n a&#243;rtica central&#44; par&#225;metros cl&#237;nicos y datos de laboratorio se usaron la regresi&#243;n m&#250;ltiple y la regresi&#243;n log&#237;stica&#46; La capacidad discrimitativa del iVp<span class="elsevierStyleBold"><span class="elsevierStyleInf">c&#8211;f</span></span> para evaluar la presencia de CAA y CC se determin&#243; mediante el &#225;rea bajo la curva &#40;ABC&#41; de ROC &#40;<span class="elsevierStyleItalic">receiver-operating characteristic</span>&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">La Vp<span class="elsevierStyleInf">c-f</span> y el iVp<span class="elsevierStyleInf">c-f</span> fueron 11&#44;3 &#177; 2&#44;6 y 10&#44;6 m&#47;s&#44; respectivamente&#46; El iVp<span class="elsevierStyleInf">c-f</span> fue mayor cuando la ERC coexist&#237;a con diabetes mellitus &#40;DM&#41;&#46; Se detectaron CAA y CC en 77&#37; y 87&#37;&#44; respectivamente&#46;</p><p id="spar0150" class="elsevierStyleSimplePara elsevierViewall">La albuminuria &#40;&#946; &#61; 0&#44;13&#44; p &#61; 0&#44;005&#41; y el iKauppila &#40;&#946; &#61; 0&#44;36&#44; p &#61; 0&#44;001&#41; se asociaron de forma independiente con la magnitud del iVp<span class="elsevierStyleInf">c-f</span>&#46; A su vez&#44; el iVp<span class="elsevierStyleInf">c-f</span> &#40;&#946; &#61; 0&#44;39&#44; p &#61; 0&#44;001&#41;&#44; la DM &#40;&#946; &#61; 0&#44;46&#44; p &#61; 0&#44;01&#41; y el tabaquismo &#40;&#946; &#61; 0&#44;53&#59; p &#61; 0&#44;006&#41; se asociaron con la intensidad del iKauppila&#44; pero solo el iVp<span class="elsevierStyleInf">c-f</span> predijo la existencia de CAA &#91;&#40;OR&#58; 3&#44;33 &#40;IC 95&#37;&#58; 1&#44;6-6&#44;9&#59; p &#61; 0&#44;001&#41;&#93;&#46;</p><p id="spar0155" class="elsevierStyleSimplePara elsevierViewall">El iKauppila se asoci&#243; de forma independiente con el iAgatston &#40;&#946; &#61; 1&#44;53&#44; p &#61; 0&#44;001&#41;&#46; La presencia de CAA identific&#243; pacientes con CC con una sensibilidad del 73&#37;&#44; una especificidaddel 100&#37;&#44; un valor predictivo positivo del 100&#37; y un valor predictivo negativo del 38&#37;&#46;</p><p id="spar0160" class="elsevierStyleSimplePara elsevierViewall">El iVp<span class="elsevierStyleInf">c-f</span> predec&#237;a la presencia de CC &#91;OR&#58; 3&#44;35 &#40;IC 95&#37;&#58;1&#44;04-10&#44;2&#44; p &#61; 0&#44;04&#41;&#93;&#46; En las curvasROC&#44; usando el iVp<span class="elsevierStyleInf">c-f</span>&#44; el ABC para las CAA y CC fue 0&#44;82 &#40;IC 95&#37;&#58; 0&#44;71&#8211;0&#44;93&#44; p &#61; 0&#44;001&#41; y 0&#44;81&#40;IC 95&#37;&#58; 0&#44;67-0&#44;96&#44; p &#61; 0&#44;02&#41;&#44; respectivamente&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0165" class="elsevierStyleSimplePara elsevierViewall">Cuando la ERC se asocia con DM hay un aumento de la rigidez a&#243;rtica determinada por el iVp<span class="elsevierStyleInf">c-f</span>&#46; En la ERC estadios 3-4 son muy prevalentes las CAA y CC que&#44; con mucha frecuencia&#44; coexisten&#46; El iVp<span class="elsevierStyleInf">c-f</span> se asocia de forma independiente con las CAA y CC&#44; y puede ser &#250;til para identificar pacientes con CV en estos territorios&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Resultados"
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            "titulo" => "Conclusiones"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Carotid-femoral pulse velocity index values &#40;iVp<span class="elsevierStyleInf">c-f</span>&#41; according to quartiles of the Kauppila index &#40;iKauppila&#41; &#40;A&#41; and the Agatston index &#40;iAgatston&#41; &#40;B&#41;&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">ROC <span class="elsevierStyleItalic">&#40;Receiver operating characteristic&#41;</span> curve analysis for abdominal aortic &#40;A&#41; and coronary &#40;B&#41; calcifications using the iVp<span class="elsevierStyleInf">c-f</span> &#40;carotid-femoral pulse velocity index&#41;&#46; ABC&#58; area under the curve&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">c-HDL&#58; high-density lipoprotein&#59; c-LDL&#58; low-density lipoprotein&#59; CVD&#58; cardiovascular disease&#59; GFR&#58; glomerular filtration rate&#59; CGN&#58; chronic glomerulonephritis&#59; HbA1c&#58; glycosylated hemoglobin&#59; BMI&#58; body mass index&#59; NS&#58; not significant&#59; hs-CRP&#58; ultrasensitive C-reactive protein&#59; PTH&#58; parathormone&#59; IQR&#58; interquartile range&#59; RAS&#58; renin-angiotensin system&#59; <span class="elsevierStyleItalic">x &#177; DE</span>&#58; mean &#177; standard deviation&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">Group 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">Group 2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vp<span class="elsevierStyleInf">c&#8211;f</span> &#8805; 12 &#40;n &#61; 38&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vp<span class="elsevierStyleInf">c&#8211;f</span> &#60; 12 &#40;n &#61; 49&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;02&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">BMI &#40;kg&#47;m</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleItalic">&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">29 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">29 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Smoking &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Diabetes mellitus &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Type of nephropathy &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nephroangiosclerosis&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetic nephropathy&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CGN&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">GFR &#40;ml&#47;min&#47;1&#46;73 m</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleItalic">&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">34 &#177; 10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">29 &#177; 9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;03&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">GFR &#40;ml&#47;min&#47;1&#46;73 m</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleItalic">&#41; &#40;x &#177; SD&#41; &#40;subjects without DM&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27&#46;6 &#177; 6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">28&#46;6 &#177; 9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">log albumin&#47;creatinine urine &#40;mg&#47;g&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46;<span class="elsevierStyleItalic">4 &#177; 1</span>&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;<span class="elsevierStyleItalic">7 &#177; 1</span>&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Calcium &#40;mg&#47;dl&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#46;<span class="elsevierStyleItalic">6 &#177; 0</span>&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#46;<span class="elsevierStyleItalic">6 &#177; 0</span>&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Phosphorus&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;2 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">PTH &#40;pg&#47;ml&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">128 &#40;107&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">123 &#40;83&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">25-OH-Vit&#46;D &#40;ng&#47;ml&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25 &#177; 11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23 &#177; 10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">hsCRP &#40;mg&#47;dl&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;23 &#40;0&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;25 &#40;0&#46;33&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Uric acid &#40;mg&#47;dl&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">7&#46;<span class="elsevierStyleItalic">4 &#177; 1</span>&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;<span class="elsevierStyleItalic">4 &#177; 1</span>&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cholesterol &#40;mg&#47;dl&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \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">167 &#40;50&#41;&nbsp;\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">193 &#40;65&#41;&nbsp;\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">0&#46;02&nbsp;\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"><span class="elsevierStyleItalic">Triglycerides &#40;mg&#47;dl&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\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">163 &#40;74&#41;&nbsp;\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">134 &#40;101&#41;&nbsp;\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">NS&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleItalic">c-LDL &#40;mg&#47;dl&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">97 &#177; 27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">112 &#177; 30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">c-HDL &#40;mg&#47;dl&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \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"><span class="elsevierStyleItalic">HbA1c &#40;&#37;&#41; &#40;in diabetics&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#46;4 &#177; 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>RAS blockage&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Clinical data and laboratory parameters in groups classified according to the carotid-femoral pulse velocity &#40;Vp<span class="elsevierStyleInf">c-f</span>&#41;&#46;</p>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">98 &#177; 11&nbsp;\t\t\t\t\t\t\n
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                  \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">bPP &#40;mmHg&#41; &#40;x &#177; SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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">cPP &#40;mmHg&#41; &#40;x &#177; SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">64 &#177; 17&nbsp;\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">50 &#177; 14&nbsp;\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
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                  \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">Vp<span class="elsevierStyleInf">c-f</span> &#40;m&#47;s&#41; median &#40;<span class="elsevierStyleItalic">IQR</span>&#41;&nbsp;\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">13 &#40;3&#41;&nbsp;\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">9&#46;3 &#40;2&#41;&nbsp;\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">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="\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">iVp<span class="elsevierStyleInf">c-f</span> &#40;m&#47;s&#41; &#40;x &#177; SD&#41;&nbsp;\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">11 &#177; 0&#46;6&nbsp;\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">10 &#177; 0&#46;9&nbsp;\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">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="\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">Agatston index &#40;log&#41; median &#40;<span class="elsevierStyleItalic">IQR</span>&#41;&nbsp;\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">6&#46;1 &#40;1&#46;6&#41;&nbsp;\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">3&#46;9 &#40;6&#41;&nbsp;\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">0&#46;03&nbsp;\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">Median &#40;log&#41; Kauppila Index &#40;log&#41; &#40;IQR&#41;&nbsp;\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">2&#46;3 &#40;0&#46;5&#41;&nbsp;\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">1&#46;2 &#40;2&#41;&nbsp;\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">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hemodynamic parameters&#44; arterial stiffness and vascular calcification in the groups according to carotid-femoral pulse velocity &#40;Vp<span class="elsevierStyleInf">c-f</span>&#41;&#46;</p>"
        ]
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Alb&#47;creat&#58; albumin&#47;creatinine&#59; BMI&#58; body mass index&#59; c-HDL&#58; high-density lipoproteins&#59; DM&#58; diabetes mellitus&#59; CVD&#58; cardiovascular disease&#59; bPP&#58; brachial pulse pressure&#59; cPP&#58; central pulse pressure&#59; Vp<span class="elsevierStyleInf">c-f</span>&#58; femoral carotid pulse velocity&#46;</p>"
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            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">DM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">iAgatston&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">iKauppila&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">c-HDL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">r&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;392&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;231&nbsp;\t\t\t\t\t\t\n
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                  \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">0&#46;375&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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">p&nbsp;\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">0&#46;001&nbsp;\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">0&#46;001&nbsp;\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">0&#46;02&nbsp;\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">0&#46;001&nbsp;\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">0&#46;02&nbsp;\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">0&#46;001&nbsp;\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">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab3704398.png"
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            1 => 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="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \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">Age&nbsp;\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">DM&nbsp;\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">BMI&nbsp;\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">Tobacco&nbsp;\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">Alb&#47;creat&#46;&nbsp;\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">iAgatston&nbsp;\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">bPP&nbsp;\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">cPP&nbsp;\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">CVD&nbsp;\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">iKauppila&nbsp;\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">r&nbsp;\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">0&#46;508&nbsp;\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">0&#46;365&nbsp;\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">0&#46;262&nbsp;\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">0&#46;357&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3704393.png"
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            2 => array:2 [
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                0 => """
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                  \t\t\t\t">0&#46;02&nbsp;\t\t\t\t\t\t\n
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                  """
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Correlation between VP<span class="elsevierStyleInf">c-f</span>&#44; Kauppila and Agatston with other variables&#46;</p>"
        ]
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      6 => array:8 [
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            0 => array:2 [
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                0 => """
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Log alb&#47;creat&#46;&nbsp;\t\t\t\t\t\t\n
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                  """
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                          "etal" => false
                          "autores" => array:3 [
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                            0 => "A&#46; Levin"
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                      "doi" => "10.1046/j.1525-139x.2003.16025.x"
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                        "tituloSerie" => "Semin Dial"
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Association of aortic stiffness with abdominal vascular and coronary calcifications in patients with stage 3 and 4 chronic kidney disease
Asociación de la rigidez aórtica con calcificaciones vasculares abdominales y coronarias en pacientes con enfermedad renal crónica estadios 3 y 4
Juan Carlos Hidalgo Santiagoa, Jary Perelló Martínezb, Javier Vargas Romeroc, José Luis Pallaresc, Alfredo Michan Doñad, Pablo Gómez-Fernándeze,
Corresponding author
pgomezf@senefro.org

Corresponding author.
a Centro de Salud del SAS San Telmo, Jerez de la Frontera, Spain
b Unidad de Nefrología, Hospital Universitario de Jerez, Jerez de la Frontera, Spain
c Unidad de Radiodiagnóstico, Hospital Universitario de Jerez, Jerez de la Frontera, Spain
d Unidad de medicina Interna, Hospital Universitario de Jerez, Biomedical Research and Innovation Institute of Cadiz (INiBICA), Jerez de la Frontera, Spain
e Unidad de Factores de Riesgo Vascular, Hospital Universitario de Jerez, Jerez de la Frontera, Spain
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Correlation between carotid-femoral pulse velocity index &#40;iVp<span class="elsevierStyleInf">c-f</span>&#41; and mean arterial pressure &#40;MAP&#41; in patients with and without diabetes mellitus &#40;DM&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with chronic kidney disease &#40;CKD&#41; have a high prevalence and incidence of cardiovascular disease &#40;CVD&#41;&#46; The presence of traditional risk factors of vascular disease such as arterial hypertension &#40;HTN&#41;&#44; diabetes mellitus &#40;DM&#41; and dyslipidemia&#44; which are more frequent in CKD&#44; and other factors with the capacity to produce vascular damage closely related to kidney failure&#44; such as chronic inflammation&#44; oxidative stress and vascular calcifications &#40;VC&#41;&#44; among others&#44; contribute to the high cardiovascular morbidity and mortality in CKD&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In CKD&#44; an increase in central &#40;aortic&#41; arterial stiffness can be observed&#44; which summarizes the perpetuation&#44; over time&#44; of all these vasculopathic factors&#46; Increased central arterial stiffness has repercussions on central hemodynamics with effects on cardiac structure and function and on perfusion of organs such as brain and kidney&#46; In fact&#44; in subjects with CKD&#44; increased aortic stiffness has been shown to be a predictor of mortality&#44; cardiovascular events and progression of renal function deterioration&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The VCs observed in CKD extend through different vascular territories and their number and intensity increase with the degree of renal failure&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Two pathological processes lie beneath the CVs&#46; First&#44; calcification of the intima&#44; which is also frequent in the population without kidney disease&#44; and&#44; second&#44; calcification of the media layer of the vascular wall&#44; which is more frequent in CKD&#44; advanced age and DM&#46; These processes&#44; which frequently coexist&#44; have different impacts on cardiovascular events&#46; Calcification of the intima would be associated with occlusive arterial disease due to atherosclerosis&#44; whereas calcification of the media layer would lead to increased arterial stiffness&#44; and consequently&#44; changes in central hemodynamics with repercussions on cardiac structure and function &#40;cardiac hypertrophy and heart failure&#41; and changes in the perfusion of target organs such as the kidney&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although imaging methods are useful in detecting VCs&#44; it is possible that the combined use of imaging techniques&#44; circulating biomarkers<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and arterial function tests such as arterial stiffness may aid in the diagnosis of VCs&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Given the possible impact of CVs&#44; and other factors associated with CKD&#44; on aortic stiffness&#44; the purpose of this study was to analyze&#44; in subjects with stage 3&#8211;4 CKD&#44; the degree of association of CVs in two territories&#44; abdominal aorta and coronary arteries&#44; with aortic stiffness as determined by carotid-femoral pulse velocity &#40;Vp&#41;<span class="elsevierStyleInf">c-f</span>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">We studied 87 patients with stable CKD stage 3&#8211;4 &#40;estimated glomerular filtration rate &#40;eGFR&#41;&#58; 15&#8722;60 ml&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#41;&#44; that were evaluated and followed as out patients in the nephrology clinic of the university hospital&#46; Patients with and without DM were included&#46; Patients had to have stable renal function and no changes in medication &#40;antihypertensive&#44; antidiabetic&#44; phosphorus binders and vitamin D&#41; in the last 3 months&#46; Subjects with atrial fibrillation&#44; immunosuppressive therapy&#44; oncological processes or cardiovascular events in the last 6 months were excluded&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Biochemical parameters including creatinine&#44; lipids&#44; phosphocalcic metabolism parameters &#91;calcium&#44; phosphorus&#44; parathormone &#40;PTH&#41; and 25-hydroxycholecalciferol &#40;25-OHVit&#46;D&#41;&#93;&#44; ultrasensitive C-reactive protein &#40;hsCRP&#41;&#44; uric acid&#44; hemogram&#44; and&#44; in subjects with DM&#44; glycosylated hemoglobin&#44; were determined in blood&#46; The eGFR was calculated using the CKD-EPI <span class="elsevierStyleItalic">&#40;chronic kidney disease&#44; epidemiology&#41;</span> formula&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In all patients&#44; the albumin&#47;creatinine ratio was determined in the first morning urine&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">It was recorded those cardiovascular events that required hospital admission &#40;ischemic heart disease&#44; stroke&#44; heart failure&#41; and the presence of peripheral artery disease diagnosed by clinical signs and symptoms or an ankle-brachial index of less than 0&#46;9&#46; Smoking was investigated by considering as smokers those who were active or had quit smoking versus those that never smoked&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Aortic arterial stiffness and aortic and coronary calcifications were studied within 21 days after of the determination of laboratory parameters&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">All patients gave their consent after being informed and the study met all the ethical criteria of the institution where it was performed&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study of central hemodynamics and aortic arterial stiffness</span><p id="par0055" class="elsevierStylePara elsevierViewall">After the measurement of weight and heigth and resting in the supine position for 15 min&#44; brachial arterial pressure &#40;bBP&#41; was measured &#40;mean of 3 determinations&#41; using an Omron M3 IT &#40;Omron electr&#243;nica Iberia&#44; S&#46;A&#46;U&#46;&#44; Madrid&#41;&#46; The study of central arterial pressure &#40;cBP&#41; and carotid-femoral pulse velocity &#40;Vp<span class="elsevierStyleInf">c-f</span>&#41; was performed by applanation tonometry using a SphygmoCor device &#40;AtCor Medical&#44; Sydney&#44; Australia&#41; according to the methodology previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Briefly&#44; from the pulse wave obtained by tonometry over the radial artery and using a generalized transfer function&#44; central systolic arterial pressure &#40;cSAP&#41;&#44; central diastolic arterial pressure &#40;cDAP&#41;&#44; central mean arterial pressure &#40;cMAP&#41; and central pulse pressure &#40;cPP&#41; were obtained&#46; For the determination of Vp<span class="elsevierStyleInf">c-f</span> the pulse wave was obtained sequentially over the common carotid artery and the femoral artery&#44; calculating the travel time between the two points from the difference between the R wave of the simultaneous electrocardiographic recording and the onset of the pulse wave at the respective arterial sites&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The Vp index<span class="elsevierStyleInf">c-f</span> &#40;iVp<span class="elsevierStyleInf">c-f</span>&#41;&#44; was obtained from the values of Vp<span class="elsevierStyleInf">c-f</span> including other variables that influence Vp<span class="elsevierStyleInf">c-f</span> such as age&#44; sex&#44; blood pressure and heart rate&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The tonometry for the determination of central hemodynamics and Vp<span class="elsevierStyleInf">c-f</span> was always performed by the same investigator who was unaware of the values of VC&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Following the recommendations of the European Society of Hypertension and the evidence that Vp values<span class="elsevierStyleInf">c&#8211;f</span> &#8805;12 m&#47;s have negative prognostic impact in subjects with advanced CKD&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> patients were subdivided into 2 groups&#58; with Vp <span class="elsevierStyleInf">c&#8211;f</span> values &#8805;12 m&#47;s and &#60;12 m&#47;s&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study of vascular calcifications</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Abdominal aortic calcifications &#40;AAC&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">A lateral X-ray of the lumbar spine was performed to evaluate AAC&#46; The reading and scoring of the degree of calcification &#40;iKauppila&#41; was always done by the same investigator following the methodology described&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> This investigator was unaware of the laboratory and arterial function data&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Coronary calcifications &#40;CC&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Due to the requirement that all the parameters studied &#40;abdominal and coronary calcifications&#44; aortic stiffness and laboratory variables&#41; be performed within a relatively short period of time&#44; only 40 patients had the multislice computed tomography &#40;CT&#41; scan without contrast performed to assess the presence of CC&#46; A 64-detector multidetector CT&#44; General Electric &#40;Boston&#44; Massachusetts&#44; USA&#41;&#44; was used&#46; The Agatston method was used to quantify coronary calcium&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The presence of coronary calcium is defined as an area at the coronary level with a threshold of more than 130 Hounsfield units &#40;HU&#41;&#46; A score is calculated for each lesion by multiplying the area by a cofactor that depends on the maximum HU value of each lesion&#46; The final calcification score is obtained by adding the left coronary&#44; anterior descending&#44; circumflex&#44; and right coronary scores and it is expressed as the Agatston index &#40;iAgatston&#41;&#46; The investigator who performed the heart CT was unaware of the laboratory results and the data of arterial function&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Given that a value greater than 400UH<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> is considered severe calcification with a high predictive capacity for coronary events&#44; this value was adopted as the threshold for establishing 2 categories of CC&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0085" class="elsevierStylePara elsevierViewall">Categorical variables are expressed as absolute and relative frequencies&#46; Continuous variables are expressed as mean &#177; standard deviation &#40;x &#177; SD&#41; if distribution was normal or as median and interquartile range &#40;IQR&#41; if the distribution was not normal&#46; In case that the variable values had a highly skewed distribution&#44; such as iKauppila&#44; iAgatston&#44; and urine albumin&#47;creatinine ratio&#44; they were converted to their natural logarithms&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The Shapiro-Wilk test was used to establish the normality of the distribution of the variables&#46; The comparison of qualitative variables was done using the &#967;<span class="elsevierStyleSup">2</span> test&#46; Normally distributed quantitative variables were compared using Student&#39;s <span class="elsevierStyleItalic">t</span>-test and the Mann Whitney test in the case of non-normal distribution&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Since 13&#37; of patients had an iKauppila value of zero&#44; the aortic calcification score was divided into quartiles &#40;&#8804;1&#59; 2&#8211;6&#59; 7&#8211;11&#59; &#8805;12&#41;&#59; comparison of Vp<span class="elsevierStyleInf">c-f</span> values between quartiles&#44; was performed using analysis of variance &#40;ANOVA&#41; with Scheff&#233;&#39;s test for post hoc multiple comparisons&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The effect of some covariates on VC in certain groups was evaluated by analysis of covariance &#40;ANCOVA&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The relationship between variables was analyzed using Pearson&#39;s or Spearman&#39;s correlation coefficient depending on their distribution of the values&#46; The independent relationship between variables was investigated using multiple linear regression by selecting potential covariates that previously demonstrated significant correlation&#46; Stepwise logistic regression was used to evaluate the independent effects and predictive value of various variables on the presence of aortic and coronary CV&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">ROC <span class="elsevierStyleItalic">&#40;receiver operating characteristic&#41;</span> curves were used to establish the value of iVp<span class="elsevierStyleInf">c-f</span> with the highest sensitivity and lowest number of false positives &#40;1-specificity&#41; in the prediction of the presence of AAC and CC&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A value of p &#60; 0&#46;05 was considered significant&#46; All statistical analyses were performed with the statistical program IBM SPSS version 25 for Windows&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0120" class="elsevierStylePara elsevierViewall">We studied 87 patients&#44; with a median age of 66 &#40;14&#41; years&#46; A 65&#46;5&#37; were men&#44; with CKD stage 3 &#40;56&#37;&#41; and 4 &#40;44&#37;&#41;&#46; Forty-six percent of all patients had DM&#46; Considering the whole group&#44; the value of Vp<span class="elsevierStyleInf">c-f</span> was 11&#46;3 &#177; 2&#46;6 m&#47;s and that of iVp<span class="elsevierStyleInf">c-f</span> 10&#46;6 &#177; 1 m&#47;s&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The study of AAC was performed in 83 patients and that of CC in 40&#46; Two of the latter were excluded from the final analysis due to technical deficiencies of the heart CT&#46; A 77&#37; of patients had AAC and 87&#37; had CC&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the clinical and laboratory data in patients with Vp<span class="elsevierStyleInf">c-f</span> &#8805; 12 m&#47;s and with Vp<span class="elsevierStyleInf">c-f</span> &#60; 12 m&#47;s&#46; In the group with Vp<span class="elsevierStyleInf">c-f</span> &#8805; 12 m&#47;s there were higher number of men&#44; more DM and smoking&#46; Age was significantly higher in this group&#46; The percentage of patients with CVD was quantitatively&#44; but not significantly&#44; higher in the group with Vp<span class="elsevierStyleInf">c-f</span> &#8805; 12 m&#47;s&#44; in which there were also greater numbers of subjects treated with statins and antiaggregants&#46; The eGFR was higher in the group with Vp<span class="elsevierStyleInf">c-f</span> &#8805; 12 &#91;34 &#177; 10 vs&#46; 29 &#177; 9 m&#47;s&#44; p &#61; 0&#46;03&#93;&#46; However&#44; when only those without DM were considered or adjustment was made for the presence of DM&#44; the difference in GFR between the groups disappeared&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">PASb&#44; PASc&#44; PPb and PPc and iVp<span class="elsevierStyleInf">c-f</span> were significantly higher in the group with Vp<span class="elsevierStyleInf">c-f</span> &#8805; 12 m&#47;s &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">The AAC and CC score was significantly higher in the group with Vp<span class="elsevierStyleInf">c-f</span> &#8805; 12 m&#47;s &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The iVp<span class="elsevierStyleInf">c-f</span> increased progressively with iKauppila quartiles &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Patients with an iAgatston &#62; 400 UH score had a greater iVp<span class="elsevierStyleInf">c-f</span> than those with a score &#8804; 400 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the correlations between iVp<span class="elsevierStyleInf">c-f</span>&#44; iKauppila and iAgatston with other variables&#46; There was a significant direct correlation between iVp<span class="elsevierStyleInf">c&#8211;f</span> and iKauppila&#44; iAgatston&#44; smoking&#44; BMI &#40;body mass index&#41;&#44; presence of DM and cardiovascular disease&#44; and an inverse correlation with c-HDL&#46; The iKauppila and iAgatston had a direct and significantl correlation&#44; and both correlated directly with arterial pulsatility parameters &#40;PPb and PPc&#41;&#46; The degree of AAC &#40;iKauppila&#41; correlated directly with age&#44; smoking&#44; BMI and presence of DM&#46; No significant correlation was observed between iVp<span class="elsevierStyleInf">c-f</span> and CC with phosphocalcic metabolism parameters&#44; inflammatory parameters or uric acid values&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Compared to patients without diabetes&#44; those with DM had higher values of iVp<span class="elsevierStyleInf">c&#8211;f</span> &#91;10&#46;8 &#40;1&#46;1&#41; vs&#46; 10&#46;3 &#40;1&#46;5&#41; m&#47;s&#59; p &#61; 0&#46;001&#93; and also greater values of log iKauppila &#91;2 &#40;1&#41; vs&#46; 0&#46;69 &#40;2&#41;&#59; p &#61; 0&#46;009&#93;&#46; Since patients with DM were older and had higher BMI&#44; adjustment was made for these variables &#40;ANCOVA&#41; showing that significant differences persisted in iVp<span class="elsevierStyleInf">c-f</span> and iKauppila&#46; For any value of MAP&#44; subjects with DM had a higher Vp<span class="elsevierStyleInf">c-f</span> than non-diabetics &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">In the multiple regression analysis&#44; the presence of DM and urinary albumin excretion were significantly associated with the value of iVp<span class="elsevierStyleInf">c-f</span>&#46; When iKauppila was introduced in the model&#44; the participation of DM was attenuated &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">The iVp<span class="elsevierStyleInf">c-f</span>&#44; the presence of DM and smoking were the only variables significantly associated with the intensity of AAC as determined by iKauppila &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>A&#41;&#46; When in the logistic regression the existence or not of AAC was considered as a dependent variable&#44; only iVp<span class="elsevierStyleInf">c-f</span> was illustrative of its presence &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>B&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">The overall prevalence of CC was 87&#37; &#40;77&#37; in the group without DM and 92&#37; in the group with DM&#41;&#46; The intensity of CC was also higher in patients with diabetes&#59; a iAgatston &#62; 400 UH was observed in 52&#37; of patients with DM and in only 38&#37; of non-DM&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The magnitude of AAC was the only variable independently associated with the intensity of CC &#40;&#946; &#61; 3&#46;12&#44; p &#61; 0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>A&#41;&#46; The presence of CAA identified patients with CC with a sensitivity of 73&#37;&#44; a specificity of 100&#37;&#44; a positive predictive value of 100&#37;&#44; and a negative predictive value of 38&#37; &#40;X<span class="elsevierStyleSup">2</span> for CC present&#47;absent vs&#46; CAA present&#47;absent&#58; p &#61; 0&#46;002&#41;&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">The iVp<span class="elsevierStyleInf">c-f</span> entered the logistic regression model as a predictor of the presence of CC &#40;OR&#58; 3&#46;35&#44; 95&#37; CI&#58; 1&#46;04&#8211;10&#46;2&#59; p &#61; 0&#46;04&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>B&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In the ROC curves&#44; the area under the curve for AAC and CC was 0&#46;82 &#40;95&#37; CI&#58; 0&#46;71&#8211;0&#46;93&#44; p &#61; 0&#46;001&#41; and 0&#46;81 &#40;95&#37; CI&#58; 0&#46;67&#8211;0&#46;96&#44; p &#61; 0&#46;02&#41;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> A and B&#41;&#46; An iVp <span class="elsevierStyleInf">c-f</span> value &#8805; 10&#46;25 m&#47;s predicted the presence of AAC with a sensitivity of 80&#37; and a specificity of 65&#37;&#46; An iVp <span class="elsevierStyleInf">c-f</span> value &#8805; 10&#44;12 m&#47;s predicted the presence of CC with a sensitivity of 76&#37; and a specificity of 80&#37;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0190" class="elsevierStylePara elsevierViewall">Our study demonstrates that in subjects with CKD stage 3 and 4 there is an increase in aortic arterial stiffness&#44; independent of the values of BP and age&#44; when associated with the presence of DM&#44; and a high prevalence of AAC and CC that frequently coexist&#46; There is&#44; moreover&#44; a close and reciprocal relationship between aortic stiffness and the presence of VC&#46; AAC is associated with increased central stiffness and&#44; in turn&#44; increased aortic stiffness is related to the presence of both AAC and CC&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Several studies have demonstrated an increase in aortic stiffness assessed by Vp<span class="elsevierStyleInf">c-f</span> in CKD&#44; evoking the participation of traditional vascular risk factors&#44; which are more frequent in CKD&#44; and risk factors characteristic of CKD&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4&#44;17</span></a> However&#44; few publications&#44; have analyzed the Vp<span class="elsevierStyleInf">c-f</span> in CKD after adjustment for factors that can modify it&#46; It is especially important to consider BP&#44; since the relationship between BP and arterial stiffness is exponential&#46; As BP increases&#44; the load supported by the vascular wall is transferred from the elastic fibers to the stiffer collagen fibers&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> In our work we investigated the value of Vp<span class="elsevierStyleInf">c-f</span> adjusted for BP&#44; age&#44; sex and heart rate &#40;iVp<span class="elsevierStyleInf">c-f</span>&#41;&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">It has been described a significant negative association between renal function and aortic stiffness&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In our work there was no such correlation and&#44; in addition&#44; we observed an unexpected GFR value&#44; quantitatively unimportant&#44; but significantly higher in the group with Vp<span class="elsevierStyleInf">c-f</span> &#62; 12 m&#47;s&#46; It is possible that these findings are attributable to the narrow range of GFR of the population studied and to the effect of DM in which hyperfiltration may obscure the association between FG and arterial stiffness&#46; In fact&#44; the difference in GFR between the two groups classified according to Vp<span class="elsevierStyleInf">c-f</span> disappeared when the presence of DM was considered&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Arterial wall stiffness is determined by several mechanisms that affect the intimal&#44; medial and adventitial layers of the vascular wall and include endothelial dysfunction&#44; a decrease in the elastin&#47;collagen ratio&#44; reactive oxygen species-induced inflammation&#44; vascular smooth muscle cell stiffness and calcification&#46; There are phenotypic changes of vascular smooth muscle cells &#40;VSMCs&#41; related to mechanotransduction &#40;interaction between extracellular matrix and VSMCs&#41;&#44; oxidative stress and metabolic and epigenetic factors&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> There is a multicellular interaction&#44; mediated by various molecules&#44; of endothelial cells&#44; inflammatory cells&#44; fibroblasts&#44; pericytes and progenitor cells with VSMCs&#46; All these mechanisms participate in the increased aortic stiffness that accompanies normal arterial aging and the vascular aging that occurs early in CKD and DM&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;18</span></a> As expected and as we also show in our study&#44; the increase in arterial stiffness is greater when both conditions coexist&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In fact&#44; although we found a significant correlation between iVp<span class="elsevierStyleInf">c-f</span> and other vascular risk factors and markers&#44; only DM&#44; albuminuria and CAA show an independent association with iVp<span class="elsevierStyleInf">c-f</span>&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Potential mechanisms for increased aortic stiffness in DM include the accumulation of advanced glycation products in vascular wall collagen making it resistant to enzymatic degradation<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and the alterations in nitric oxide &#40;NO&#41; synthesis&#44; superoxide production and endothelial dysfunction observed in insulin resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">In our study the association of DM and iVp<span class="elsevierStyleInf">c-f</span> was attenuated when AAC iKauppila was introduced into the model&#46; It is possible that the independent effect of DM on aortic stiffness is obscured to some extent by the known association of DM with CV&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> calcification involving inflammatory mechanisms&#44; and alterations in the concentration of calcification promoter and inhibitor proteins that are of greater intensity when DM and CKD coexist&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">The association between albuminuria and the magnitude of aortic stiffness has been previously described&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;27</span></a> A stiff aorta prevents attenuation of arterial pulsatility allowing its transmission to organs of low resistance such as the kidney&#44; promoting albuminuria&#46; The presence of albuminuria in the high-normal range has been described as an early marker of increased aortic stiffness&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">The presence of VCs are frequent in multiple territories in CKD&#44; their prevalence increases with the stage of CKD&#46; In our study&#44; the prevalence of AAC detected by radiology in subjects with stage 3&#8211;4 CKD was 77&#37;&#46; This prevalence is similar to that found in other works using computed tomography such as that of S&#248;rensen et al&#46; &#40;77&#46;3&#37; in stage 3 and 82&#46;3&#37; in stage 4&#41;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and in the IMPROVE-CKD study &#40;81&#37; in stages 3b and 4&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The only previous publication on the association between arterial calcifications and aortic stiffness that included subjects with stage 3&#8211;4 CKD<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> found that as observed in our study the intensity of AAC was independently associated with aortic stiffness&#46; It has been shown in experimental animals that degradation of the elastic fibers of the arterial wall &#40;as observed in aging&#44; HTN&#44; DM and CKD&#41; facilitates calcium deposits in the tunica media&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> In turn&#44; calcification of the tunica media induces additional destruction of elastin<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> causing further stiffness of the arteries&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Our study shows that in addition to DM and iVp<span class="elsevierStyleInf">c-f</span>&#44; smoking was also independently associated with iKauppila values&#46; Smoking generates vascular structural and functional damage&#46; It causes endothelial damage&#44; increased superoxide production and decreased availability of NO&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> In both active smokers and ex-smokers&#44; it is observed an increase in the rates of atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> In a population-based study in which Vp<span class="elsevierStyleInf">c-f</span> was associated with thoracoabdominal aortic calcification&#44; the degree of the latter was positively linked to age&#44; BP&#44; DM and degree of smoking&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> In addition to its effects on atherogenesis&#44; smoking may promote VC by other mechanisms&#46; Smoking was one of the independent determinants of reduced fetuin-A values in subjects with renal transplantation and VC&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> In addition&#44; in vitro studies have shown that nicotine induces VSMC calcification by promoting the expression of osteogenic genes &#40;<span class="elsevierStyleItalic">Runt-related transcription factor</span> 2 &#40;Runx2&#41;&#44; osterix &#40;Osx&#41;&#44; osteopontin &#40;OPN&#41;&#41; an effect that is due to increased Nox5 &#40;nicotinamide dinucleotide phosphate oxidase&#41; activity&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">The close relationship between AAC and aortic stiffness is reinforced by the finding in our study of a reciprocal relationship between them&#46; The amount of AAC was linked to increased aortic stiffness and&#44; in turn&#44; the magnitude of aortic stiffness adjusted for age&#44; BP&#44; and gender was independently associated with the degree of AAC and was the only predictor variable for the presence of AAC&#46; In fact&#44; on the ROC curve the iVp<span class="elsevierStyleInf">c-f</span> &#40;&#8805;10&#44;15 m&#47;s&#41; had a high positive predictive value&#46; Two studies that included subjects with CKD at various stages<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> and patients with CKD on hemodialysis<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> have also proven an independent association between Vp<span class="elsevierStyleInf">c-f</span> and AAC&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">In our study&#44; 87&#37; of patients presented some degree of CC&#46; A recent meta analysis reported a prevalence of CC in CKD predialysis and dialysis patients of 60&#37; &#40;24&#8211;90&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> In two other publications that&#44; like ours&#44; included patients with stage 3&#8211;4 CKD&#44; the prevalence of CC was 60&#8211;68&#37; &#40;74&#37; in the subgroup with DM&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;40</span></a> In these studies the age of patients was lower than in our patients and in one of the studies subjects with coronary artery disease were excluded&#46; These two facts may explain the lower prevalence of CC in these studies&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">In autopsy studies in subjects with CKD and coronary artery disease&#44; compared to subjects without CKD&#44; there is a predominance of intimal calcification in the coronary arteries&#46; In renal patients there is a higher percentage with calcification of the intima&#44; which is also of greater intensity&#46; In CKD&#44; stages 4 and 5&#44; only 18&#37; of subjects had calcification of the media of the coronary arteries in segments with and without calcification of the intima&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> However&#44; in other vascular territories such as the aorta&#44; it has been shown that in early stages of CKD&#44; compared to subjects without CKD&#44; there is calcification of the media &#40;which is associated with increased aortic stiffness&#41; and in more advanced stages&#44; there is an additional increase of thickness and calcification of the intima&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Calcification of the intima is an entity distinct from calcification of the media but&#44; nevertheless&#44; it shares pathogenic mechanisms&#46; Intima calcification is a phenomenon secondary to inflammation associated with atherosclerosis&#46; Microcalcification of the atheroma plaque occurs following the release of matrix vesicles&#44; apoptotic bodies&#44; and necrotic debris derived from macrophages and VSMCs&#44; which serve as a nucleus for calcification&#46; In contrast to calcification of the media layer&#44; in the intima calcification the osteochondrogenic transformation of VSMCs is a secondary phenomenon to the primary inflammatory process occurring in the atheroma plaque&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Although it has been shown that in CKD the distribution of calcification in the intima versus the media is not the same in the different vascular territories &#40;e&#46;g&#44; in coronary arteries and elastic arteries the calcification of atherosclerotic plaques of the intima is more prominent than in the muscular arteries of the upper extremity in which calcification of the media predominates with relative resistance to atherosclerosis&#41;&#44; in CKD the coexistence of calcifications of the intima and media in the same or different vascular territories is common&#46; This fact may be based on the existence of various types of cells&#44; in addition to VSMC&#44; which under different stimuli have the capacity for osteoblastic transformation &#40;endothelial cells&#44; pericytes&#44; myofibroblasts&#44; progenitor cells&#41;&#44; cells that communicate with each other through exosomes and various molecular signals &#91;&#40;BMP &#40;bone morphogenetic protein&#41;&#44; OPG&#47;RANK&#47;RANKL &#40;osteoprotegerin&#47;nuclear factor kB receptor activator&#47; RANK ligand&#41;&#44; Wnt&#47;&#946; catenin and AGE &#40;advanced glycation products&#41; systems&#93;&#44; generating an effective CV development network&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">In our study&#44; the magnitude of AAC &#40;iKauppila&#41; was the only variable independently associated with the intensity of CC &#40;iAgatston&#41; and&#44; in addition&#44; the presence of radiology-demonstrated AACs evidenced a high specificity for the presence of CC&#46; It is possible that the calcifications observed in the abdominal aorta represent joint calcification of the media and intima &#40;atherosclerosis and atherosclerosis&#41; of the vascular wall with increased arterial stiffness and it is also associated coronary intima calcification &#40;atherosclerosis&#41;&#46; In one study performed in subjects with stage 3 CKD &#40;eGFR 50 ml&#47; min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#41; and DM&#44; the prevalence of AAC and CC &#40;detected by CT&#41; was higher than that observed in subjects with DM without CKD&#46; Although the association between calcification of both vascular territories was not evaluated&#44; it was concluded that both types could represent atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> In another publication that included subjects with stage 3&#8211;4 CKD&#44; the degree of CAA detected by CT was independently associated with an iAgatston greater than 400 UH&#44; and the C statistic for predicting the presence of severe CHD increased significantly when the abdominal aortic calcification index was added to other traditional vascular risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">In the present study&#44; the iVp<span class="elsevierStyleInf">c-f</span> predicted the presence of CC&#46; To our knowledge&#44; only 3 studies have evaluated the relationship between aortic stiffness and CC in subjects with CKD&#46; In two of them&#44; performed in hemodialysis patients&#44; a direct correlation was observed between Vp<span class="elsevierStyleInf">c-f</span> and CC&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#44;47</span></a> whereas in another study which also included subjects with less advanced stages of CKD&#44; the association between Vp<span class="elsevierStyleInf">c-f</span> and CC disappeared when age&#44; MAP&#44; DM and AAC&#44; which were associated with Vp<span class="elsevierStyleInf">c-f</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> were incorporated in the multivariate analysis&#46; The iVp<span class="elsevierStyleInf">c-f</span> used in our study incorporated age&#44; sex and MAP and predicted the presence of CC&#44; and the ROC curve showed that an iVp<span class="elsevierStyleInf">c-f</span> value equal to or greater than 10&#46;12 m&#47;s provided acceptable values for discriminating the presence of CC&#46; It is possible that this association is attributable to the repercussions of increased aortic stiffness and secondary hemodynamic alterations &#40;increased pulsatility&#44; among others&#41; on the coronary circulation&#46; Clinical and experimental evidence demonstrates an important role of biomechanical forces in the genesis of coronary atherosclerosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;49</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">In advanced CKD patients it has been demonstrated that an elevated value of dephosphorylated and non-carboxylated matrix Gla protein &#40;dp-ucMGP&#41; &#40;i&#46;e&#46;&#44; without capacity to inhibit calcification&#41; is an independent predictor of increased VC and correlates with the intensity of CC and the degree of calcification of the media in other arteries&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> In addition&#44; in CKD patients&#44; elevated values of dp-ucMPG<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> and calciprotein particles containing phosphorylated fetuin A&#44; the expression of a procalcifying medium&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> are associated with icreased aortic stiffness&#46; In subjects with CKD stage 3&#8211;4&#44; an increase in calcification propensity quantified as the transformation time from primary calciprotein particles to secondary calciprotein particles was independently associated with baseline Vp<span class="elsevierStyleInf">c-f</span> and with its progressive increase during 30 months&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> All these data&#44; together with our findings&#44; make it plausible that a parameter of arterial function such as aortic stiffness associated with a biomarker of vascular calcification allows early identification of VC in patients with CKD&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Our study has limitations&#46; It is a cross-sectional study&#44; so we are not able to determine whether aortic stiffness progresses in parallel with VC&#59; likewise we can not assess the prognostic impact of this marker of arterial function on cardiovascular and renal events&#46; However we can affirm that in CKD stage 3&#8211;4&#44; the greater the degree of vascular calcification&#44; the greater the aortic stiffness&#46; Another limitation is that the determination of CC was performed in a smaller number of patients than that of aortic calcification and the latter was assessed by radiographic methods&#46; Despite this limitation&#44; our results are statistically consistent&#46; Furthermore&#44; there are observational studies demonstrating that VC assessed by radiology method is a valid parameter for prognosis of cardiovascular events that is more reliable than many of the traditional risk factors&#44; and that there is a significant correlation between iKauppila and AAC detected by CT&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;55</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">The strengths of our study are the inclusion of patients with similar renal function &#40;CKD stages 3 and 4&#41;&#44; the analysis of the relationship between aortic stiffness &#40;adjusted for age&#44; sex and blood pressure&#41; and AAC and CC using the technique considered <span class="elsevierStyleItalic">gold</span> standard for the determination of aortic stiffness&#44; and the short time interval between the determination of Vp<span class="elsevierStyleInf">c-f</span> and the evaluation of VC&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">In summary&#44; in patients with CKD stage 3 and 4 there is an increase in aortic stiffness measured by iVp<span class="elsevierStyleInf">c-f</span> when DM is added to CKD&#44; and it frequently coexist with a high prevalence of AAC and CC&#46; This increased aortic stiffness is independently associated with VC in both the abdominal aorta and coronary arteries and it may be a useful marker of the presence of VC&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">The Spanish Society of Nephrology&#44; in the document updating and adapting the KDIGO <span class="elsevierStyleItalic">&#40;Kidney Disease Initiative Global Outcomes&#41;</span> guidelines on alterations in bone-mineral metabolism in CKD&#44; recommends for the detection of VC in stage 3&#8211;4 CKD the performance of a lateral radiograph of the lumbar spine at baseline and every 2&#8211;3 years during the follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> Given the association demonstrated in the present study between aortic stiffness and CAA and CC&#44; it seems reasonable to propose the inclusion of Vp<span class="elsevierStyleInf">c-f</span> as an additional method for the study of VC&#46; It would be interesting in future prospective studies to analyze whether the evaluation of aortic stiffness associated with a circulating biomarker of vascular calcification&#44; with or without imaging markers&#44; allows the diagnosis &#40;or an earlier diagnosis&#41; of CV in CKD&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical considerations</span><p id="par0300" class="elsevierStylePara elsevierViewall">All patients gave informed consent for the execution of the present study&#44; which met all the ethical criteria of the institution where it was performed&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Financing</span><p id="par0305" class="elsevierStylePara elsevierViewall">There has not been any type of financing from any institution&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0310" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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          "titulo" => "Introduction"
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              "titulo" => "Study of central hemodynamics and aortic arterial stiffness"
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              "titulo" => "Study of vascular calcifications"
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                  "identificador" => "sec0030"
                  "titulo" => "Abdominal aortic calcifications &#40;AAC&#41;"
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                1 => array:2 [
                  "identificador" => "sec0035"
                  "titulo" => "Coronary calcifications &#40;CC&#41;"
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              "titulo" => "Statistical analysis"
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    "fechaRecibido" => "2023-04-11"
    "fechaAceptado" => "2023-06-03"
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            0 => "Aortic stiffness"
            1 => "Pulse velocity"
            2 => "Chronic kidney disease"
            3 => "Vascular calcifications"
            4 => "Kauppila score"
            5 => "Agatston score"
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            0 => "Rigidez a&#243;rtica"
            1 => "Velocidad de pulso"
            2 => "Enfermedad renal cr&#243;nica"
            3 => "Calcificaciones vasculares"
            4 => "&#205;ndice de Kauppila"
            5 => "&#205;ndice de Agatston"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Rationale and objectives</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Increased central &#40;aortic&#41; arterial stiffness has hemodynamic repercussions that affect the incidence of cardiovascular and renal disease&#46; In chronic kidney disease &#40;CKD&#41; there may be an increase in aortic stiffness secondary to multiple metabolic alterations including calcification of the vascular wall &#40;VC&#41;&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">The objective of this study was to analyze the association of central aortic pressures and aortic stiffness with the presence of VC in abdominal aorta &#40;AAC&#41; and coronary arteries&#40;CAC&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">We included 87 pacientes with CKD stage 3 and 4&#46; Using applanation tonometry&#44; central aortic pressures and aortic stiffness were studied&#46; We investigated the association of aortic pulse wave velocity &#40;Pv<span class="elsevierStyleInf">c-f</span>&#41; and Pv<span class="elsevierStyleInf">c-f</span> adjusted for age&#44; blood pressure&#44; sex and heart rate &#40;Pv<span class="elsevierStyleInf">c-f</span> index&#41; with AAC obtained on lumbar lateral radiography and CAC assessed by multidetector computed tomography&#46; AAC and CAC were scored according to Kauppila and Agatston methods&#44; respecti-vely&#46; For the study of the association between Pv<span class="elsevierStyleInf">c-f</span> index&#44; Kauppila score&#44; Agatston score&#44; central aortic pressures&#44; clinical parameters and laboratory data&#44; multiple and logistic regression were used&#46; We investigated the diagnosis performance of the Pv<span class="elsevierStyleInf">c-f</span> index for prediction of VC using receiver-operating characteristic &#40;ROC&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Pv<span class="elsevierStyleInf">c-f</span> and Pv<span class="elsevierStyleInf">c-f</span> index were 11&#46;3 &#177; 2&#46;6 and 10&#46;6 m&#47;s&#44; respectively&#46; The Pv<span class="elsevierStyleInf">c-f</span> index was higher when CKD coexisted with diabetes mellitus &#40;DM&#41;&#46; AAC and CAC were detected in 77&#37; and 87&#37;&#44; respectively&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Albuminuria &#40;&#946; &#61; 0&#46;13&#44; p &#61; 0&#46;005&#41; and Kauppila score &#40;&#946; &#61; 0&#46;36&#44; p &#61; 0&#46;001&#41; were independently associated with Pv<span class="elsevierStyleInf">c-f</span> index&#46; In turn&#44; Pv<span class="elsevierStyleInf">c-f</span> index &#40;&#946; &#61; 0&#46;39&#44; p &#61; 0&#46;001&#41;&#44; DM &#40;&#946; &#61; 0&#46;46&#44; p &#61; 0&#46;01&#41;&#44; and smoking &#40;&#946; &#61; 0&#46;53&#59; p &#61; 0&#46;006&#41; were associated with Kauppila score&#44; but only Pv<span class="elsevierStyleInf">c-f</span> index predicted AAC &#91;OR&#58; 3&#46;33 &#40;95&#37; CI&#58; 1&#46;6&#8722;6&#46;9&#59; p &#61; 0&#46;001&#41;&#93;&#46;</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">The Kauppila score was independently associated with the Agatston score &#40;&#946; &#61; 1&#46;53&#44; p &#61; 0&#46;001&#41;&#46; The presence of AAC identified patients with CAC with a sensitivity of 73&#37;&#44; a specificity of 100&#37;&#44; a positive predictive value of 100&#37; and a negative predictive value of 38&#37;&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">The Vp<span class="elsevierStyleInf">c-f</span> index predicted the presence of CAC &#91;OR&#58; 3&#46;35 &#40;95&#37; CI&#58; 1&#46;04&#8722;10&#46;2&#44; p &#61; 0&#46;04&#41;&#93;&#46; In the ROC curves&#44; using the Vp<span class="elsevierStyleInf">c-f</span> index&#44; the AUC for AAC and CAC was 0&#46;82 &#40;95&#37;CI&#58; 0&#46;71&#8722;0&#46;93&#44; p &#61; 0&#46;001&#41; and 0&#46;81 &#40;95&#37; CI&#58; 0&#46;67&#8211;0&#46;96&#44; p &#61; 0&#46;02&#41;&#44; respectively&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">When stage 3&#8211;4 CKD coexists with DM there is an increase in aortic stiffness determined by the Vp<span class="elsevierStyleInf">c-f</span> index&#46; In stage 3&#8211;4 CKD&#44; AAC and CAC are very prevalent and both often coexist&#46; The Vp<span class="elsevierStyleInf">c-f</span> index is independently associated with AAC and CAC and may be useful in identifying patients with VC in these territories&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Rationale and objectives"
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          1 => array:2 [
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            "titulo" => "Materials and methods"
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            "identificador" => "abst0015"
            "titulo" => "Results"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Fundamento y objetivos</span><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">El aumento de la rigidez arterial central &#40;a&#243;rtica&#41; tiene repercusiones hemodin&#225;micas con efectos nocivos cardiovasculares y renales&#46; En la enfermedad renal cr&#243;nica &#40;ERC&#41; puede existir un aumento de la rigidez a&#243;rtica secundaria a m&#250;ltiples alteraciones metab&#243;licas entre ellas la calcificaci&#243;n de la pared vascular &#40;CV&#41;&#46;</p><p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio fue analizar la asociaci&#243;n de la rigidez a&#243;rtica y de la hemodin&#225;mica central con la presencia de CV en dos territorios&#44; aorta abdominal &#40;CAA&#41; y arterias coronarias &#40;CC&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 87 pacientes con ERC estadio 3 y 4&#46; Usando tonometr&#237;a de aplanamiento se estudiaron la hemodin&#225;mica central y la rigidez a&#243;rtica&#46; Esta se determin&#243; mediante la velocidad de pulso car&#243;tida-femoral &#40;Vp<span class="elsevierStyleInf">c-f</span>&#41;&#46; A partir de la Vp<span class="elsevierStyleInf">c-f</span> se calcul&#243; el &#237;ndice de la VP<span class="elsevierStyleInf">c-f</span> &#40;iVp<span class="elsevierStyleInf">c-f</span>&#41; que considera otras variables que influyen en la Vp<span class="elsevierStyleInf">c-f</span> como edad&#44; presi&#243;n arterial&#44; sexo y frecuencia cardiaca&#46;</p><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">La presencia de CAA se valor&#243; mediante radiogr&#225;f&#237;a lateral de columna lumbar calcul&#225;ndose el &#237;ndice de Kauppila &#40;iKauppila&#41; y las CC mediante tomograf&#237;a computarizada multidetecci&#243;n por el m&#233;todo de Agatston calcul&#225;ndose su &#237;ndice &#40;iAgatston&#41;&#46;</p><p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">Para el estudio de la asociaci&#243;n entre iVp<span class="elsevierStyleInf">c-f</span>&#44; iKauppila&#44; iAgatston&#44; presi&#243;n a&#243;rtica central&#44; par&#225;metros cl&#237;nicos y datos de laboratorio se usaron la regresi&#243;n m&#250;ltiple y la regresi&#243;n log&#237;stica&#46; La capacidad discrimitativa del iVp<span class="elsevierStyleBold"><span class="elsevierStyleInf">c&#8211;f</span></span> para evaluar la presencia de CAA y CC se determin&#243; mediante el &#225;rea bajo la curva &#40;ABC&#41; de ROC &#40;<span class="elsevierStyleItalic">receiver-operating characteristic</span>&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">La Vp<span class="elsevierStyleInf">c-f</span> y el iVp<span class="elsevierStyleInf">c-f</span> fueron 11&#44;3 &#177; 2&#44;6 y 10&#44;6 m&#47;s&#44; respectivamente&#46; El iVp<span class="elsevierStyleInf">c-f</span> fue mayor cuando la ERC coexist&#237;a con diabetes mellitus &#40;DM&#41;&#46; Se detectaron CAA y CC en 77&#37; y 87&#37;&#44; respectivamente&#46;</p><p id="spar0150" class="elsevierStyleSimplePara elsevierViewall">La albuminuria &#40;&#946; &#61; 0&#44;13&#44; p &#61; 0&#44;005&#41; y el iKauppila &#40;&#946; &#61; 0&#44;36&#44; p &#61; 0&#44;001&#41; se asociaron de forma independiente con la magnitud del iVp<span class="elsevierStyleInf">c-f</span>&#46; A su vez&#44; el iVp<span class="elsevierStyleInf">c-f</span> &#40;&#946; &#61; 0&#44;39&#44; p &#61; 0&#44;001&#41;&#44; la DM &#40;&#946; &#61; 0&#44;46&#44; p &#61; 0&#44;01&#41; y el tabaquismo &#40;&#946; &#61; 0&#44;53&#59; p &#61; 0&#44;006&#41; se asociaron con la intensidad del iKauppila&#44; pero solo el iVp<span class="elsevierStyleInf">c-f</span> predijo la existencia de CAA &#91;&#40;OR&#58; 3&#44;33 &#40;IC 95&#37;&#58; 1&#44;6-6&#44;9&#59; p &#61; 0&#44;001&#41;&#93;&#46;</p><p id="spar0155" class="elsevierStyleSimplePara elsevierViewall">El iKauppila se asoci&#243; de forma independiente con el iAgatston &#40;&#946; &#61; 1&#44;53&#44; p &#61; 0&#44;001&#41;&#46; La presencia de CAA identific&#243; pacientes con CC con una sensibilidad del 73&#37;&#44; una especificidaddel 100&#37;&#44; un valor predictivo positivo del 100&#37; y un valor predictivo negativo del 38&#37;&#46;</p><p id="spar0160" class="elsevierStyleSimplePara elsevierViewall">El iVp<span class="elsevierStyleInf">c-f</span> predec&#237;a la presencia de CC &#91;OR&#58; 3&#44;35 &#40;IC 95&#37;&#58;1&#44;04-10&#44;2&#44; p &#61; 0&#44;04&#41;&#93;&#46; En las curvasROC&#44; usando el iVp<span class="elsevierStyleInf">c-f</span>&#44; el ABC para las CAA y CC fue 0&#44;82 &#40;IC 95&#37;&#58; 0&#44;71&#8211;0&#44;93&#44; p &#61; 0&#44;001&#41; y 0&#44;81&#40;IC 95&#37;&#58; 0&#44;67-0&#44;96&#44; p &#61; 0&#44;02&#41;&#44; respectivamente&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0165" class="elsevierStyleSimplePara elsevierViewall">Cuando la ERC se asocia con DM hay un aumento de la rigidez a&#243;rtica determinada por el iVp<span class="elsevierStyleInf">c-f</span>&#46; En la ERC estadios 3-4 son muy prevalentes las CAA y CC que&#44; con mucha frecuencia&#44; coexisten&#46; El iVp<span class="elsevierStyleInf">c-f</span> se asocia de forma independiente con las CAA y CC&#44; y puede ser &#250;til para identificar pacientes con CV en estos territorios&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Fundamento y objetivos"
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            "titulo" => "Material y m&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Carotid-femoral pulse velocity index values &#40;iVp<span class="elsevierStyleInf">c-f</span>&#41; according to quartiles of the Kauppila index &#40;iKauppila&#41; &#40;A&#41; and the Agatston index &#40;iAgatston&#41; &#40;B&#41;&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Correlation between carotid-femoral pulse velocity index &#40;iVp<span class="elsevierStyleInf">c-f</span>&#41; and mean arterial pressure &#40;MAP&#41; in patients with and without diabetes mellitus &#40;DM&#41;&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">ROC <span class="elsevierStyleItalic">&#40;Receiver operating characteristic&#41;</span> curve analysis for abdominal aortic &#40;A&#41; and coronary &#40;B&#41; calcifications using the iVp<span class="elsevierStyleInf">c-f</span> &#40;carotid-femoral pulse velocity index&#41;&#46; ABC&#58; area under the curve&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">c-HDL&#58; high-density lipoprotein&#59; c-LDL&#58; low-density lipoprotein&#59; CVD&#58; cardiovascular disease&#59; GFR&#58; glomerular filtration rate&#59; CGN&#58; chronic glomerulonephritis&#59; HbA1c&#58; glycosylated hemoglobin&#59; BMI&#58; body mass index&#59; NS&#58; not significant&#59; hs-CRP&#58; ultrasensitive C-reactive protein&#59; PTH&#58; parathormone&#59; IQR&#58; interquartile range&#59; RAS&#58; renin-angiotensin system&#59; <span class="elsevierStyleItalic">x &#177; DE</span>&#58; mean &#177; standard deviation&#46;</p>"
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                  \t\t\t\t" scope="col">Group 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">Group 2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vp<span class="elsevierStyleInf">c&#8211;f</span> &#8805; 12 &#40;n &#61; 38&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vp<span class="elsevierStyleInf">c&#8211;f</span> &#60; 12 &#40;n &#61; 49&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age &#40;years&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;02&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">45&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">BMI &#40;kg&#47;m</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleItalic">&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">29 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">29 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Diabetes mellitus &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Type of nephropathy &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nephroangiosclerosis&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetic nephropathy&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CGN&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">GFR &#40;ml&#47;min&#47;1&#46;73 m</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleItalic">&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">34 &#177; 10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">29 &#177; 9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;03&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">GFR &#40;ml&#47;min&#47;1&#46;73 m</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleItalic">&#41; &#40;x &#177; SD&#41; &#40;subjects without DM&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27&#46;6 &#177; 6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">28&#46;6 &#177; 9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">log albumin&#47;creatinine urine &#40;mg&#47;g&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46;<span class="elsevierStyleItalic">4 &#177; 1</span>&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;<span class="elsevierStyleItalic">7 &#177; 1</span>&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Calcium &#40;mg&#47;dl&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#46;<span class="elsevierStyleItalic">6 &#177; 0</span>&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#46;<span class="elsevierStyleItalic">6 &#177; 0</span>&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Phosphorus&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">PTH &#40;pg&#47;ml&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">128 &#40;107&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">123 &#40;83&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">25-OH-Vit&#46;D &#40;ng&#47;ml&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25 &#177; 11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23 &#177; 10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">hsCRP &#40;mg&#47;dl&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;23 &#40;0&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;25 &#40;0&#46;33&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Uric acid &#40;mg&#47;dl&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;<span class="elsevierStyleItalic">4 &#177; 1</span>&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;<span class="elsevierStyleItalic">4 &#177; 1</span>&#46;3&nbsp;\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">NS&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cholesterol &#40;mg&#47;dl&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\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">167 &#40;50&#41;&nbsp;\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">193 &#40;65&#41;&nbsp;\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">0&#46;02&nbsp;\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"><span class="elsevierStyleItalic">Triglycerides &#40;mg&#47;dl&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\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">163 &#40;74&#41;&nbsp;\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">134 &#40;101&#41;&nbsp;\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">NS&nbsp;\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"><span class="elsevierStyleItalic">c-LDL &#40;mg&#47;dl&#41; &#40;x &#177; SD&#41;</span>&nbsp;\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">97 &#177; 27&nbsp;\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">112 &#177; 30&nbsp;\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">NS&nbsp;\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"><span class="elsevierStyleItalic">c-HDL &#40;mg&#47;dl&#41; &#40;x &#177; SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">44 &#177; 9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">50 &#177; 16&nbsp;\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
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                  \t\t\t\t">0&#46;03&nbsp;\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"><span class="elsevierStyleItalic">HbA1c &#40;&#37;&#41; &#40;in diabetics&#41; &#40;x &#177; SD&#41;</span>&nbsp;\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
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                  \t\t\t\t">7&#46;4 &#177; 1&nbsp;\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
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                  \t\t\t\t">NS&nbsp;\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
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                  \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">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>RAS blockage&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">65&nbsp;\t\t\t\t\t\t\n
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                  \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">NS&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">cSBP &#40;mmHg&#41; &#40;x &#177; SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MAP &#40;mmHg&#41; &#40;x &#177; SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">98 &#177; 11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">bPP &#40;mmHg&#41; &#40;x &#177; SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#177; 16&nbsp;\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">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="\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">cPP &#40;mmHg&#41; &#40;x &#177; SD&#41;&nbsp;\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">64 &#177; 17&nbsp;\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">50 &#177; 14&nbsp;\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">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="\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">Vp<span class="elsevierStyleInf">c-f</span> &#40;m&#47;s&#41; median &#40;<span class="elsevierStyleItalic">IQR</span>&#41;&nbsp;\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">13 &#40;3&#41;&nbsp;\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">9&#46;3 &#40;2&#41;&nbsp;\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">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="\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">iVp<span class="elsevierStyleInf">c-f</span> &#40;m&#47;s&#41; &#40;x &#177; SD&#41;&nbsp;\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">11 &#177; 0&#46;6&nbsp;\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">10 &#177; 0&#46;9&nbsp;\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">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="\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">Agatston index &#40;log&#41; median &#40;<span class="elsevierStyleItalic">IQR</span>&#41;&nbsp;\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">6&#46;1 &#40;1&#46;6&#41;&nbsp;\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">3&#46;9 &#40;6&#41;&nbsp;\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">0&#46;03&nbsp;\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">Median &#40;log&#41; Kauppila Index &#40;log&#41; &#40;IQR&#41;&nbsp;\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">2&#46;3 &#40;0&#46;5&#41;&nbsp;\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">1&#46;2 &#40;2&#41;&nbsp;\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">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3704400.png"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hemodynamic parameters&#44; arterial stiffness and vascular calcification in the groups according to carotid-femoral pulse velocity &#40;Vp<span class="elsevierStyleInf">c-f</span>&#41;&#46;</p>"
        ]
      ]
      5 => array:8 [
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        "etiqueta" => "Table 3"
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          0 => array:3 [
            "identificador" => "at0145"
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Alb&#47;creat&#58; albumin&#47;creatinine&#59; BMI&#58; body mass index&#59; c-HDL&#58; high-density lipoproteins&#59; DM&#58; diabetes mellitus&#59; CVD&#58; cardiovascular disease&#59; bPP&#58; brachial pulse pressure&#59; cPP&#58; central pulse pressure&#59; Vp<span class="elsevierStyleInf">c-f</span>&#58; femoral carotid pulse velocity&#46;</p>"
          "tablatextoimagen" => array:3 [
            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">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \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">DM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \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">Tobacco&nbsp;\t\t\t\t\t\t\n
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                  \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">Alb&#47;creat&#46;&nbsp;\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">iAgatston&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">iKauppila&nbsp;\t\t\t\t\t\t\n
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                  \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">c-HDL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">iVp<span class="elsevierStyleInf">c&#8211;f</span>&nbsp;\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">r&nbsp;\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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;392&nbsp;\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">0&#46;231&nbsp;\t\t\t\t\t\t\n
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                  \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">0&#46;377&nbsp;\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">0&#46;375&nbsp;\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">0&#46;480&nbsp;\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">&#8722;0&#46;422&nbsp;\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">&nbsp;\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">p&nbsp;\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">0&#46;001&nbsp;\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">0&#46;001&nbsp;\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">0&#46;02&nbsp;\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">0&#46;001&nbsp;\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">0&#46;02&nbsp;\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">0&#46;001&nbsp;\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">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3704398.png"
              ]
            ]
            1 => 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">&nbsp;\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">&nbsp;\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">Age&nbsp;\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">DM&nbsp;\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">BMI&nbsp;\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">Tobacco&nbsp;\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">Alb&#47;creat&#46;&nbsp;\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">iAgatston&nbsp;\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">bPP&nbsp;\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">cPP&nbsp;\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">CVD&nbsp;\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">iKauppila&nbsp;\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">r&nbsp;\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">0&#46;508&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;365&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;262&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3704393.png"
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            2 => array:2 [
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                0 => """
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab3704395.png"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Correlation between VP<span class="elsevierStyleInf">c-f</span>&#44; Kauppila and Agatston with other variables&#46;</p>"
        ]
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      6 => array:8 [
        "identificador" => "tbl0020"
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          0 => array:3 [
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">alb&#47;creat&#58; urine albumin&#47;creatinine&#59; DM&#58; diabetes mellitus&#59; iKauppila&#58; Kauppila index&#59; Log&#44; logarithm&#46;</p>"
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            0 => array:2 [
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                0 => """
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Constant&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Log alb&#47;creat&#46;&nbsp;\t\t\t\t\t\t\n
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                  """
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                      "titulo" => "Cardiovascular co-morbidity in chronic kidney disease&#58; current knowledge and future research needs"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "H&#46; Alani"
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                            2 => "N&#46; Tamimi"
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                      "doi" => "10.5527/wjn.v3.i4.156"
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                        "tituloSerie" => "World J Nephrol"
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                        "volumen" => "3"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25374809"
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                      "titulo" => "Clinical epidemiology of cardiovascular disease in chronic kidney disease prior to dialysis"
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                          "autores" => array:1 [
                            0 => "A&#46; Levin"
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Article information
ISSN: 20132514
Original language: English
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Nefrología (English Edition)