array:21 [
  "pii" => "X2013251408004198"
  "issn" => "20132514"
  "doi" => " "
  "estado" => "S300"
  "fechaPublicacion" => "2008-12-01"
  "documento" => "article"
  "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
  "subdocumento" => "fla"
  "cita" => "Nefrologia (English Version). 2008;28:593-6"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 6561
    "formatos" => array:3 [
      "EPUB" => 255
      "HTML" => 5531
      "PDF" => 775
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:17 [
      "pii" => "X0211699508004190"
      "issn" => "02116995"
      "doi" => " "
      "estado" => "S300"
      "fechaPublicacion" => "2008-12-01"
      "documento" => "article"
      "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
      "subdocumento" => "fla"
      "cita" => "Nefrologia. 2008;28:593-6"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 33383
        "formatos" => array:3 [
          "EPUB" => 291
          "HTML" => 31786
          "PDF" => 1306
        ]
      ]
      "es" => array:11 [
        "idiomaDefecto" => true
        "titulo" => "Manejo de la hemorragia perioperatoria en el paciente renal"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "593"
            "paginaFinal" => "596"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Management of perioperative bleeding in renal patients"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "MANUEL HERAS BENITO, ROSA SANCHEZ HERNANDEZ, MARIA JOSE FERNANDEZ-REYES, ANA ISABEL DIEZ LOBO"
            "autores" => array:4 [
              0 => array:2 [
                "nombre" => "MANUEL"
                "apellidos" => "HERAS BENITO"
              ]
              1 => array:2 [
                "nombre" => "ROSA"
                "apellidos" => "SANCHEZ HERNANDEZ"
              ]
              2 => array:2 [
                "nombre" => "MARIA JOSE"
                "apellidos" => "FERNANDEZ-REYES"
              ]
              3 => array:2 [
                "nombre" => "ANA ISABEL"
                "apellidos" => "DIEZ LOBO"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "X2013251408004198"
          "doi" => " "
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408004198?idApp=UINPBA000064"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508004190?idApp=UINPBA000064"
      "url" => "/02116995/0000002800000006/v0_201502091415/X0211699508004190/v0_201502091415/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:17 [
    "pii" => "X201325140800427X"
    "issn" => "20132514"
    "doi" => " "
    "estado" => "S300"
    "fechaPublicacion" => "2008-12-01"
    "documento" => "article"
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Nefrologia (English Version). 2008;28:597-606"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 3174
      "formatos" => array:3 [
        "EPUB" => 215
        "HTML" => 2507
        "PDF" => 452
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "titulo" => "Preliminary results of the Spanish Society of Nephrology multicenter study of quality performance measures: hemodialysis outcomes can be improved"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "es"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "597"
          "paginaFinal" => "606"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Resultados del proyecto de mejora de la calidad de la asistencia en hemodiálisis: estudio multicéntrico de indicadores de calidad de la Sociedad Española de Nefrología (SEN)"
        ]
      ]
      "contieneResumen" => array:2 [
        "es" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => " Grupo de Gestión de Calidad de la SEN, Jose Mª Alcázar, Mª Dolores Arenas, Fernando Álvarez-Ude, Rafael Virto, Esther Rubio, Francisco Maduell, Pilar Fernández-Crespo, Manuel Angoso de Guzmán, Ramón Delgado, Carmen Santamaría, Manuel A. Alonso, Sara Anaya, Antoni Bordils, Andrés Antolín, Emilio Gonzalez-Parra, Isabel Pérez, Álvaro Molina Ordás, Mercedes Fernández, Pablo Molina, Pilar Sánchez, Francesc Barbosa, Luisa Palomares Solla, José Lacueva, Guillarmina Barril, José Mª Pastor, Carmen Gámez Matías, Pablo Mateos Hernández, Miguel Fulquet Nicolas, Francisco Ríos, Pablo Rebollo, Eduardo Parra"
          "autores" => array:32 [
            0 => array:1 [
              "apellidos" => "Grupo de Gestión de Calidad de la SEN"
            ]
            1 => array:2 [
              "nombre" => "Jose Mª"
              "apellidos" => "Alcázar"
            ]
            2 => array:2 [
              "nombre" => "Mª Dolores"
              "apellidos" => "Arenas"
            ]
            3 => array:2 [
              "nombre" => "Fernando"
              "apellidos" => "Álvarez-Ude"
            ]
            4 => array:2 [
              "nombre" => "Rafael"
              "apellidos" => "Virto"
            ]
            5 => array:2 [
              "nombre" => "Esther"
              "apellidos" => "Rubio"
            ]
            6 => array:2 [
              "nombre" => "Francisco"
              "apellidos" => "Maduell"
            ]
            7 => array:2 [
              "nombre" => "Pilar"
              "apellidos" => "Fernández-Crespo"
            ]
            8 => array:2 [
              "nombre" => "Manuel"
              "apellidos" => "Angoso de Guzmán"
            ]
            9 => array:2 [
              "nombre" => "Ramón"
              "apellidos" => "Delgado"
            ]
            10 => array:2 [
              "nombre" => "Carmen"
              "apellidos" => "Santamaría"
            ]
            11 => array:2 [
              "nombre" => "Manuel"
              "apellidos" => "A. Alonso"
            ]
            12 => array:2 [
              "nombre" => "Sara"
              "apellidos" => "Anaya"
            ]
            13 => array:2 [
              "nombre" => "Antoni"
              "apellidos" => "Bordils"
            ]
            14 => array:2 [
              "nombre" => "Andrés"
              "apellidos" => "Antolín"
            ]
            15 => array:2 [
              "nombre" => "Emilio"
              "apellidos" => "Gonzalez-Parra"
            ]
            16 => array:2 [
              "nombre" => "Isabel"
              "apellidos" => "Pérez"
            ]
            17 => array:2 [
              "nombre" => "Álvaro"
              "apellidos" => "Molina Ordás"
            ]
            18 => array:2 [
              "nombre" => "Mercedes"
              "apellidos" => "Fernández"
            ]
            19 => array:2 [
              "nombre" => "Pablo"
              "apellidos" => "Molina"
            ]
            20 => array:2 [
              "nombre" => "Pilar"
              "apellidos" => "Sánchez"
            ]
            21 => array:2 [
              "nombre" => "Francesc"
              "apellidos" => "Barbosa"
            ]
            22 => array:2 [
              "nombre" => "Luisa"
              "apellidos" => "Palomares Solla"
            ]
            23 => array:2 [
              "nombre" => "José"
              "apellidos" => "Lacueva"
            ]
            24 => array:2 [
              "nombre" => "Guillarmina"
              "apellidos" => "Barril"
            ]
            25 => array:2 [
              "nombre" => "José Mª"
              "apellidos" => "Pastor"
            ]
            26 => array:2 [
              "nombre" => "Carmen"
              "apellidos" => "Gámez Matías"
            ]
            27 => array:2 [
              "nombre" => "Pablo"
              "apellidos" => "Mateos Hernández"
            ]
            28 => array:2 [
              "nombre" => "Miguel"
              "apellidos" => "Fulquet Nicolas"
            ]
            29 => array:2 [
              "nombre" => "Francisco"
              "apellidos" => "Ríos"
            ]
            30 => array:2 [
              "nombre" => "Pablo"
              "apellidos" => "Rebollo"
            ]
            31 => array:2 [
              "nombre" => "Eduardo"
              "apellidos" => "Parra"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "X0211699508004272"
        "doi" => " "
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508004272?idApp=UINPBA000064"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X201325140800427X?idApp=UINPBA000064"
    "url" => "/20132514/0000002800000006/v0_201502091634/X201325140800427X/v0_201502091634/en/main.assets"
  ]
  "itemAnterior" => array:17 [
    "pii" => "X2013251408004202"
    "issn" => "20132514"
    "doi" => " "
    "estado" => "S300"
    "fechaPublicacion" => "2008-12-01"
    "documento" => "article"
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Nefrologia (English Version). 2008;28:587-92"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 4012
      "formatos" => array:3 [
        "EPUB" => 257
        "HTML" => 3155
        "PDF" => 600
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "titulo" => "The facilitator in acute kidney injury: TWEAK"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "es"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "587"
          "paginaFinal" => "592"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "TWEAK, el facilitador del daño renal agudo"
        ]
      ]
      "contieneResumen" => array:2 [
        "es" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Ana Belén Sanz, María Dolores Sánchez-Nino, M. Concepción Izquierdo, Juan Antonio Moreno, Alvaro C. Ucero, Alberto Benito-Martín, Beatríz Santamaria, Carolina Burgos, Jesús Egido, Alberto Ortíz, Marta Ruíz-Ortega, Luis Miguel Blanco-Colio, Adrián Ramos, Sergio Berzal, Eliécer Coto"
          "autores" => array:15 [
            0 => array:2 [
              "nombre" => "Ana Belén"
              "apellidos" => "Sanz"
            ]
            1 => array:2 [
              "nombre" => "María Dolores"
              "apellidos" => "Sánchez-Nino"
            ]
            2 => array:2 [
              "nombre" => "M. Concepción"
              "apellidos" => "Izquierdo"
            ]
            3 => array:2 [
              "nombre" => "Juan Antonio"
              "apellidos" => "Moreno"
            ]
            4 => array:2 [
              "nombre" => "Alvaro"
              "apellidos" => "C. Ucero"
            ]
            5 => array:2 [
              "nombre" => "Alberto"
              "apellidos" => "Benito-Martín"
            ]
            6 => array:2 [
              "nombre" => "Beatríz"
              "apellidos" => "Santamaria"
            ]
            7 => array:2 [
              "nombre" => "Carolina"
              "apellidos" => "Burgos"
            ]
            8 => array:2 [
              "nombre" => "Jesús"
              "apellidos" => "Egido"
            ]
            9 => array:2 [
              "nombre" => "Alberto"
              "apellidos" => "Ortíz"
            ]
            10 => array:2 [
              "nombre" => "Marta"
              "apellidos" => "Ruíz-Ortega"
            ]
            11 => array:2 [
              "nombre" => "Luis Miguel"
              "apellidos" => "Blanco-Colio"
            ]
            12 => array:2 [
              "nombre" => "Adrián"
              "apellidos" => "Ramos"
            ]
            13 => array:2 [
              "nombre" => "Sergio"
              "apellidos" => "Berzal"
            ]
            14 => array:2 [
              "nombre" => "Eliécer"
              "apellidos" => "Coto"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "X0211699508004205"
        "doi" => " "
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508004205?idApp=UINPBA000064"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408004202?idApp=UINPBA000064"
    "url" => "/20132514/0000002800000006/v0_201502091634/X2013251408004202/v0_201502091634/en/main.assets"
  ]
  "en" => array:13 [
    "idiomaDefecto" => true
    "titulo" => "Management of perioperative bleeding in renal patients"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "593"
        "paginaFinal" => "596"
      ]
    ]
    "autores" => array:1 [
      0 => array:3 [
        "autoresLista" => "MANUEL HERAS BENITO, ROSA SANCHEZ HERNANDEZ, MARIA JOSE FERNANDEZ-REYES, ANA ISABEL DIEZ LOBO"
        "autores" => array:4 [
          0 => array:4 [
            "nombre" => "MANUEL"
            "apellidos" => "HERAS BENITO"
            "email" => array:1 [
              0 => "manuhebe@hotmail.com"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "ROSA"
            "apellidos" => "SANCHEZ HERNANDEZ"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "MARIA JOSE"
            "apellidos" => "FERNANDEZ-REYES"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "ANA ISABEL"
            "apellidos" => "DIEZ LOBO"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "affb"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "SERVICIO DE NEFROLOGIA HOSPITAL GENERAL DE SEGOVIA SEGOVIA, SEGOVIA, ESPAÑA, "
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "affa"
          ]
          1 => array:3 [
            "entidad" => "SERVICIO DE ANESTESIOLOGIA, HOSPITAL GENERAL DE SEGOVIA SEGOVIA, SEGOVIA, ESPAÑA, "
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "affb"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Manejo de la hemorragia perioperatoria en el paciente renal"
      ]
    ]
    "textoCompleto" => "Patients with chronic kidney disease &#40;CKD&#41; often require surgery &#40;vascular accesses&#44; peripheral vascular disease&#44; <br></br>coronary disease&#44; etc&#46;&#41;&#46; The surgical risk in such patients&#44; in the same way as in the general population&#44; depends on <br></br>the type of surgery involved and on the elective or emergency nature of the operation&#46; However&#44; although the surgical risk is similar to that found in the general population&#44; morbidity-mortality among renal patients is much greater than in the general population&#46;1 <br></br><br></br>Recently&#44; a classification of CKD has been established involving 5 stages according to the degree of glomerular <br></br>filtration &#40;GF&#41;&#46;2 The aim of this classification is to allow the early identification of patients with renal disease&#44; and to <br></br>implement treatment measures destined to slow progression and&#47;or to ensure that patients requiring dialysis can receive such treatment under good conditions&#46; Renal patients that may require surgery and therefore are at a high risk of bleeding comprise individuals with CKD &#40;both in predialysis and among those receiving kidney replacement therapy&#41;&#44; patients with acute renal failure&#44; and renal transplant patients presenting chronic graft nephropathy&#46; <br></br><br></br>The association between bleeding and uremia has been well established for years&#46;3 Although the underlying <br></br>physiopathology is not fully clear&#44; a number of factors are accepted to be involved&#58; platelet dysfunction&#44; anemia <br></br>and drugs that interfere with platelet aggregation and clotting&#46;4 <br></br><br></br>Under physiological conditions&#44; the platelets circulate within the bloodstream in an inactive form&#46; Damage to the vascular wall activates the platelets&#44; with the purpose of generating a provisional thrombus and securing hemostasia&#46; <br></br><br></br>Such platelet activation comprises several phases&#58; Once vascular endothelial damage has occurred&#44; the platelets <br></br>adhere to the subendothelium via von Willebrand factor &#40;fvW&#41;&#46; The adhered platelets are activated&#44; and release the <br></br>contents of their granules&#58; ADP&#44; serotonin&#46; Posteriorly&#44; via platelet surface receptor IIb&#47;IIIa&#44; and through the <br></br>mediation of adhesion proteins &#40;fvW and fibrinogen&#41;&#44; the platelets aggregate among each other and with those already adhered to the subendothelium5&#44;6 &#40;see fig&#46; 1&#41;&#46; <br></br><br></br>Patients with uremia present an acquired platelet defect that accounts for the high risk of bleeding in nephropathic <br></br>patients&#46;7 In addition&#44; other factors such as anemia and drugs &#40;antiplatelet agents&#44; anticoagulants&#44; etc&#46;&#41; contribute to this acquired platelet defect&#46; <br></br><br></br>PLATELET DYSFUNCTION <br></br><br></br>Patients with nephropathy present defects in all the mechanisms implicated in platelet or provisional thrombus <br></br>formation&#46;4 <br></br><br></br>Adhesion defects&#58; Although in uremic patients the levels of fvW are normal or slightly elevated&#44; the activity of this factor is diminished8 &#191;thereby complicating platelet adhesion to the subendothelium&#46;9 In addition&#44; it has been seen that uremic patients have increased levels of prostacyclin10 and nitric oxide &#40;NO&#41;11&#191; both of which are potent inhibitors of platelet adhesion&#46; <br></br><br></br>Defects in granule content release&#58; An acquired defect is observed in the platelet granule contents&#44; resulting in <br></br>defective release of ADP&#44; serotonin and thromboxane A2&#46;12&#44;13 Calcium in turn is necessary for platelet activation&#44; <br></br>and these patients present alterations in intracellular calcium mobility&#46; 14 <br></br><br></br>Aggregation defects&#58; Defects have been identified in the activity of the IIb&#47;IIIa surface receptors&#46;15 The accumulation of certain substances such as urea&#44; creatinine&#44; phenols&#44; and guanidosuccinic acid have been related to <br></br>defects in platelet aggregation&#46; The fact that uremic patients subjected to dialysis subsequently showed improved binding of fibrinogen to the IIb&#47;IIIa platelet surface receptor has been attributed to the presence in the plasma of renal patients of an unidentified platelet inhibiting factor&#46;4 <br></br><br></br>ANEMIA <br></br><br></br>One of the main factors contributing to the appearance of anemia in CKD is a deficient production of erythropoietin <br></br>&#40;EPO&#41;&#44; associated to the drop in GF&#46; Other factors such as aluminum toxicity&#44; infections or inflammatory processes can also contribute to the appearance of anemia&#46;16 Rheological studies have shown that the red blood cells travel through the bloodstream in the center of the vascular lumen &#191; radially displacing the platelets&#44; which therefore find it easier to adhere to the endothelium&#46; A reduction in red cell mass implies that the platelets circulate more dispersedly&#44; thereby complicating their adhesion to the vascular wall and formation of the platelet thrombus&#46;17 <br></br><br></br>ANTIPLATELET DRUGS <br></br><br></br>The use of these drugs in renal patients implies a prolongation of bleeding time with respect to the general population&#46;18 Glycoprotein &#40;GP&#41; IIb&#47;IIIa inhibitors prevent binding of the adhesion proteins to the platelet surface receptors&#44; as a result of which platelet aggregation is inhibited&#46;19 Among the GP IIb&#47;IIIa inhibitors&#44; abciximab&#44; a monoclonal antibody with a short half-life &#40;10-30 minutes&#41;&#44; requires no dose adjustment in renal failure&#44; since the platelet-abciximab complex is mainly eliminated via the splenic route&#46; In contrast&#44; other GP IIb&#47;IIIa inhibitors such as tirofiban or eptifibatide require dose adjustments in patients with advanced CKD&#46; <br></br><br></br>ANTICOAGULANT DRUGS <br></br><br></br>Heparin is needed in these patients&#44; due to their important co-morbidity and the risk of thrombotic events&#59; in such individuals&#44; bleeding and thrombosis may coincide&#46; <br></br><br></br>Unfractionated heparin is a heterogeneous mixture of glycosaminoglycans with molecular weights in the range of <br></br>3&#44;000-30&#44;000 Da&#46; Low molecular weight heparin &#40;LMWH&#41; is composed of fragments of unfractionated heparin with a <br></br>molecular weight of about 5&#44;000 Da&#46; Both types of heparin exert their anticoagulant effects by binding to and activating antithrombin III&#44; accelerating interaction between the latter and factor Xa and thrombin &#191;which is inactivated as a result&#46; Unfractionated heparin is generally administered via the intravenous route for systemic anticoagulation&#44; and is monitored by means of the activated partial thromboplastin time &#40;aPTT&#41;&#46; LMWH in turn is generally administered subcutaneously&#46;19 Due to the fundamentally renal clearance of LMWH&#44; recent editorials and reviews recommend unfractionated heparin anticoagulation in patients with serum creatinine levels of over 2 mg&#47;dl&#44; or with creatinine clearance &#60; 30 ml&#47;min&#46;20&#44;21 In those cases where the use of LMWH is decided in renal patients&#44; <br></br>it is advisable to reduce the dose 50&#37;&#44; and to administer a single daily dose&#44; with monitorization of anti-Xa factor&#46;19 <br></br><br></br>OTHER DRUGS <br></br><br></br>Beta-lactam antibiotics &#40;penicillins&#44; cephalosporins&#44; etc&#46;&#41; also have been related to prolonged bleeding time as a <br></br>result of alterations in the platelet membrane&#46; 22 In turn&#44; nonsteroidal antiinflammatory drugs &#40;NSAIDs&#41; cause platelet dysfunction through reversible cyclooxygenase &#40;COX&#41; inhibition&#46;23 <br></br><br></br>CLINICAL MANIFESTATIONS <br></br><br></br>Patients with kidney disease are more susceptible to bleeding in the context of surgery or invasive procedures&#46;17 Gastrointestinal bleeding has been described as the most common bleeding complication in patients subjected to dialysis &#40;esophagitis&#44; gastritis&#44; duodenitis&#44; etc&#46;&#41;&#46;4 Cerebrovascular hemorrhage in turn is more common than in the general population&#46; A Japanese study reported an incidence of 637 cases per 100&#44;000 inhabitants and year &#191; this representing a 5-fold greater incidence than in the general population&#44;24 with a greater presence in younger patients&#44; and a poorer prognosis than in the general population&#46; Retroperitoneal hematomas &#40;spontaneous or secondary to venous catheter placement&#41; also deserve mention in patients with kidney disease&#46;17 <br></br><br></br>DIAGNOSTIC TESTS <br></br><br></br>There is currently no effective screening test for platelet dysfunction&#46; Neither bleeding time nor PFA-100 &#40;platelet function analyzer&#44; a prototype of a new generation of analyzers designed to screen platelet function defects&#41; is sufficiently sensitive to detect platelet defects in asymptomatic individuals&#46; Bleeding time is dependent upon the type of incision made&#44; the characteristics of the skin&#44; and patient cooperation &#191;while PFA-100 can yield prolonged readings in patients with low hematocrit values and normal platelet function&#46; In a study of 148 patients with known platelet alterations&#44; bleeding time sensitivity was found to be 36&#37;&#44; versus 30&#37; for PFA-100&#46; The combined sensitivity was 48&#37;&#46;25 <br></br><br></br>PREVENTION AND PERIOPERATIVE TREATMENT OF UREMIC BLEEDING <br></br><br></br>Considering that a range of factors intervene in the physiopathology of uremic bleeding&#44; each of them must be <br></br>addressed when preventive and treatment measures are contemplated&#46; For increased simplicity&#44; these measures <br></br>can be classified as general and specific&#58; <br></br><br></br>a&#41; General measures&#58; <br></br><br></br>1&#46; Eliminate uremic toxins&#58; The toxins accumulated in the context of uremia contribute to platelet dysfunction&#46; Their <br></br>treatment by means of kidney replacement therapy contributes to improve platelet function and shorten bleeding <br></br>time&#46;4 Both hemodialysis and peritoneal dialysis are equally effective in clearing toxins&#44; and thus in preventing perioperative bleeding&#46; In the case of patients with advanced CKD who require programmed surgery&#44; dialysis may be started before surgery is performed&#46; In the case of patients enrolled in a hemodialysis program&#44; dialysis is to be performed before the operation&#46;1&#44;26 In order to prevent bleeding&#44; hemodialysis is to be performed without heparin&#44; and with frequent flushing of the system&#46; If hemodialysis has been performed with heparin&#44; it is advisable to wait a prudent period of time before moving the patient to the operating room&#46;17 <br></br><br></br>2&#46; Correction of anemia&#58; The use of human recombinant EPO and derived analogs helps improve anemia associated <br></br>with chronic renal failure&#46;16&#44;27 Its use requires the availability of adequate iron deposits&#59; in this sense&#44; the administration of oral or intravenous iron may prove necessary&#46;1 With these measures it is possible to correct anemia associated to CKD&#44; and shorten bleeding time&#46; A period of 2-6 weeks may be needed from the time of administration of EPO to the obtainment of an adequate response in hematocrit level&#46; The use of such agents therefore should be started early&#44; before the patient is moved to the operating room&#46;27 Blood transfusions are not recommended on a chronic basis&#44; since immunization may result in patients who in future may require a kidney transplant&#46;28 Blood transfusions are indicated in cases of acute bleeding and emergency surgery&#46;1 <br></br><br></br>3&#46; Withdrawal of medication &#40;antiplatelet and anticoagulant drugs&#41;&#58; The suspension of antiplatelet drugs should <br></br>be individualized according to the type of surgery involved&#44; with due evaluation of the risk&#47;benefit ratio associated <br></br>with suspension &#40;i&#46;e&#46;&#44; thrombosis&#47;bleeding&#41;&#46; 29 In general&#44; antiplatelet medication should be suspended at least 72 <br></br>hours before the operation&#46;1 Likewise&#44; the suspension of oral anticoagulation is advised&#44; with the introduction of <br></br>heparin&#44; and avoiding the use of drugs commonly used in surgical services&#44; such as NSAIDs &#191;which reversibly <br></br>inhibit COX and thus entail an increased bleeding risk&#46;4 <br></br><br></br>b&#41; Specific measures&#58; <br></br><br></br>1&#46; Desmopressin&#58; Desmopressin is a synthetic derivative of vasopressin-ADH&#44; with a comparatively lesser pressor <br></br>effect&#46; Its mechanism of action in the prevention and treatment of uremic bleeding is related to the release of factor <br></br>VIII and fvW multimers from the endothelium&#46; Desmopressin is administered at a dose of 0&#46;3 mg&#47;kg i&#46;v&#46;&#47;s&#46;c in <br></br>15-30 minutes&#46; The time to onset of activity is 30-60 minutes&#44; with a duration of 6-12 hours&#46; As a result&#44; the main <br></br>indication of desmopressin is the prevention and treatment of acute bleeding&#44; and as treatment prior to invasive <br></br>procedures such as biopsies&#46;17&#44;30 In a recent review of recommendations based on evidence for the management <br></br>of uremic bleeding&#44; the use of desmopressin was included with grade I recommendation and evidence A&#44; with <br></br>avoidance of the administration of a second dose &#40;tachyphylaxis&#41;&#46;31 <br></br><br></br>2&#46; Cryoprecipitates&#58; Upon thawing frozen plasma&#44; the supernatant was found to contain fibrinogen&#44; fibronectin&#44; <br></br>factor VII and factor VIII&#46; The use of these cryoprecipitates shortens bleeding time in uremic patients&#46; The <br></br>underlying mechanism of action is based on the provision of these factors&#46; Administration consists of 10 U via the <br></br>intravenous route&#44; and the effect is noted within one hour&#44; with a duration of 12-24 hours&#46; The fact that cryoprecipitates constitute a potential source of infection has limited their use to those cases refractory to desmopressin and with frequent blood transfusions&#46;17&#44;32 <br></br><br></br>3&#46; Estrogens&#58; The observation that patients with von Willebrand disease and hereditary telangiectasia improved <br></br>during pregnancy led to the use of estrogens for the prevention of bleeding&#46; The underlying mechanism of action in the prevention of bleeding is not fully clear&#46; L-arginine &#40;a precursor of nitric oxide&#41; is believed to be inhibited&#44; thereby improving platelet aggregation&#46; Most studies involving estrogens for the prevention of uremic bleeding have used the intravenous route &#40;0&#46;6 mg&#47;kg&#47;day&#41;&#44; though use has also been made of the oral &#40;50 mg&#47;day&#41; or transdermal route &#40;50-100 mg twice a week&#41;&#46; The effect appears after 24 hours&#44; with a peak after 5-7 days&#44; and <br></br>persists for two weeks&#46; This slower onset of action causes estrogen to be used mainly for elective and chronic <br></br>preparation prior to surgery&#46;17&#44;29&#44;33 4&#46; Antifibrinolytic agents&#58; The systemic <br></br><br></br>inflammation present in uremia is associated with activation of the fibrinolytic system&#46; As a result&#44; the use of such agents &#40;tranexamic acid&#41; could shorten bleeding time in uremia&#46;34 <br></br><br></br>The management of perioperative bleeding in uremic patients can be summarized as follows&#58; <br></br><br></br>1&#46; Minor surgery&#44; tooth extractions&#44; biopsies and emergency surgery&#58; general measures &#43; desmopressin&#46; <br></br><br></br>2&#46; Programmed major surgery&#58; general measures &#43; conjugated estrogens 5 days before the operation &#43; <br></br>desmopressin one hour before surgery&#46; <br></br><br></br>In conclusion&#58; <br></br><br></br>Patients with chronic kidney disease requiring surgery are at a high risk of bleeding&#44; due to multiple factors &#40;platelet <br></br>dysfunction&#44; anemia&#44; drugs&#44; etc&#46;&#41;&#46; Knowledge of these factors and the adoption of a multifactor approach to deal with each of them will allow safe surgery &#191;reducing the high risk of bleeding in these subjects&#46; <br></br>"
    "pdfFichero" => "P-E-S-A328-EN.pdf"
    "tienePdf" => true
    "PalabrasClave" => array:2 [
      "es" => array:4 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec440419"
          "palabras" => array:1 [
            0 => "Enfermedad Renal Cr&#243;nica"
          ]
        ]
        1 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec440421"
          "palabras" => array:1 [
            0 => "Perioperatoria"
          ]
        ]
        2 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec440423"
          "palabras" => array:1 [
            0 => "Hemorragia"
          ]
        ]
        3 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec440425"
          "palabras" => array:1 [
            0 => "Uremia"
          ]
        ]
      ]
      "en" => array:4 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec440420"
          "palabras" => array:1 [
            0 => "Chronic Kidney Disease"
          ]
        ]
        1 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec440422"
          "palabras" => array:1 [
            0 => "Perioperative"
          ]
        ]
        2 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec440424"
          "palabras" => array:1 [
            0 => "Bleeding"
          ]
        ]
        3 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec440426"
          "palabras" => array:1 [
            0 => "Uremia"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "es" => array:1 [
        "resumen" => "RESUMEN&#58; Los pacientes con enfermedad renal cr&#243;nica &#40;ERC&#41; frecuentemente requieren ser intervenidos quir&#250;rgicamente y tienen alto riesgo de hemorragia perioperatoria&#46; La disfunci&#243;n plaquetaria adquirida por acumulaci&#243;n de toxinas ur&#233;micas &#44; la anemia asociada al descenso del filtrado glomerular &#40;FG&#41; y diversos f&#225;rmacos&#44; son los principales factores implicados en la fisiopatolog&#237;a de la hemorragia en la uremia&#46; El conocimiento y abordaje de todos estos factores&#44; reducir&#225; el riesgo de hemorragia perioperatoria en el paciente con enfermedad renal&#46; "
      ]
      "en" => array:1 [
        "resumen" => "SUMMARY&#58; Patients with chronic kidney disease &#40;ERC&#41; frequently need to be surgically treated and are at high risk of perioperative bleeding&#46; The platelet dysfunction acquired by accumulation of uremic toxins&#44; anemia associated with the decline of glomerular filtration &#40;FG&#41; and various drugs&#44; are the main factors involved in the pathophysiology of bleeding in uremia&#46; Knowledge and treatment all these factors may help reduce the risk of perioperative bleeding in patients with kidney disease&#46; "
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliography"
      "seccion" => array:1 [
        0 => array:1 [
          "bibliografiaReferencia" => array:1 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "REFERENCIAS:"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/20132514/0000002800000006/v0_201502091634/X2013251408004198/v0_201502091634/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "35445"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Short Reviews"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/20132514/0000002800000006/v0_201502091634/X2013251408004198/v0_201502091634/en/P-E-S-A328-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408004198?idApp=UINPBA000064"
]
Share
Journal Information

Statistics

Follow this link to access the full text of the article

Management of perioperative bleeding in renal patients
Manejo de la hemorragia perioperatoria en el paciente renal
MANUEL HERAS BENITOa, ROSA SANCHEZ HERNANDEZa, MARIA JOSE FERNANDEZ-REYESa, ANA ISABEL DIEZ LOBOb
a SERVICIO DE NEFROLOGIA HOSPITAL GENERAL DE SEGOVIA SEGOVIA, SEGOVIA, ESPAÑA,
b SERVICIO DE ANESTESIOLOGIA, HOSPITAL GENERAL DE SEGOVIA SEGOVIA, SEGOVIA, ESPAÑA,
Read
16521
Times
was read the article
5305
Total PDF
11216
Total HTML
Share statistics
 array:21 [
  "pii" => "X2013251408004198"
  "issn" => "20132514"
  "doi" => " "
  "estado" => "S300"
  "fechaPublicacion" => "2008-12-01"
  "documento" => "article"
  "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
  "subdocumento" => "fla"
  "cita" => "Nefrologia &#40;English Version&#41;. 2008;28:593-6"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 6561
    "formatos" => array:3 [
      "EPUB" => 255
      "HTML" => 5531
      "PDF" => 775
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:17 [
      "pii" => "X0211699508004190"
      "issn" => "02116995"
      "doi" => " "
      "estado" => "S300"
      "fechaPublicacion" => "2008-12-01"
      "documento" => "article"
      "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
      "subdocumento" => "fla"
      "cita" => "Nefrologia. 2008;28:593-6"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 33383
        "formatos" => array:3 [
          "EPUB" => 291
          "HTML" => 31786
          "PDF" => 1306
        ]
      ]
      "es" => array:11 [
        "idiomaDefecto" => true
        "titulo" => "Manejo de la hemorragia perioperatoria en el paciente renal"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "593"
            "paginaFinal" => "596"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Management of perioperative bleeding in renal patients"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "MANUEL HERAS BENITO, ROSA SANCHEZ HERNANDEZ, MARIA JOSE FERNANDEZ-REYES, ANA ISABEL DIEZ LOBO"
            "autores" => array:4 [
              0 => array:2 [
                "nombre" => "MANUEL"
                "apellidos" => "HERAS BENITO"
              ]
              1 => array:2 [
                "nombre" => "ROSA"
                "apellidos" => "SANCHEZ HERNANDEZ"
              ]
              2 => array:2 [
                "nombre" => "MARIA JOSE"
                "apellidos" => "FERNANDEZ-REYES"
              ]
              3 => array:2 [
                "nombre" => "ANA ISABEL"
                "apellidos" => "DIEZ LOBO"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "X2013251408004198"
          "doi" => " "
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408004198?idApp=UINPBA000064"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508004190?idApp=UINPBA000064"
      "url" => "/02116995/0000002800000006/v0_201502091415/X0211699508004190/v0_201502091415/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:17 [
    "pii" => "X201325140800427X"
    "issn" => "20132514"
    "doi" => " "
    "estado" => "S300"
    "fechaPublicacion" => "2008-12-01"
    "documento" => "article"
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Nefrologia &#40;English Version&#41;. 2008;28:597-606"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 3174
      "formatos" => array:3 [
        "EPUB" => 215
        "HTML" => 2507
        "PDF" => 452
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "titulo" => "Preliminary results of the Spanish Society of Nephrology multicenter study of quality performance measures&#58; hemodialysis outcomes can be improved"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "es"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "597"
          "paginaFinal" => "606"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Resultados del proyecto de mejora de la calidad de la asistencia en hemodi&#225;lisis&#58; estudio multic&#233;ntrico de indicadores de calidad de la Sociedad Espa&#241;ola de Nefrolog&#237;a &#40;SEN&#41;"
        ]
      ]
      "contieneResumen" => array:2 [
        "es" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => " Grupo de Gesti&#243;n de Calidad de la SEN, Jose M&#170; Alc&#225;zar, M&#170; Dolores Arenas, Fernando &#193;lvarez-Ude, Rafael Virto, Esther Rubio, Francisco Maduell, Pilar Fern&#225;ndez-Crespo, Manuel Angoso de Guzm&#225;n, Ram&#243;n Delgado, Carmen Santamar&#237;a, Manuel A&#46; Alonso, Sara Anaya, Antoni Bordils, Andr&#233;s Antol&#237;n, Emilio Gonzalez-Parra, Isabel P&#233;rez, &#193;lvaro Molina Ord&#225;s, Mercedes Fern&#225;ndez, Pablo Molina, Pilar S&#225;nchez, Francesc Barbosa, Luisa Palomares Solla, Jos&#233; Lacueva, Guillarmina Barril, Jos&#233; M&#170; Pastor, Carmen G&#225;mez Mat&#237;as, Pablo Mateos Hern&#225;ndez, Miguel Fulquet Nicolas, Francisco R&#237;os, Pablo Rebollo, Eduardo Parra"
          "autores" => array:32 [
            0 => array:1 [
              "apellidos" => "Grupo de Gesti&#243;n de Calidad de la SEN"
            ]
            1 => array:2 [
              "nombre" => "Jose M&#170;"
              "apellidos" => "Alc&#225;zar"
            ]
            2 => array:2 [
              "nombre" => "M&#170; Dolores"
              "apellidos" => "Arenas"
            ]
            3 => array:2 [
              "nombre" => "Fernando"
              "apellidos" => "&#193;lvarez-Ude"
            ]
            4 => array:2 [
              "nombre" => "Rafael"
              "apellidos" => "Virto"
            ]
            5 => array:2 [
              "nombre" => "Esther"
              "apellidos" => "Rubio"
            ]
            6 => array:2 [
              "nombre" => "Francisco"
              "apellidos" => "Maduell"
            ]
            7 => array:2 [
              "nombre" => "Pilar"
              "apellidos" => "Fern&#225;ndez-Crespo"
            ]
            8 => array:2 [
              "nombre" => "Manuel"
              "apellidos" => "Angoso de Guzm&#225;n"
            ]
            9 => array:2 [
              "nombre" => "Ram&#243;n"
              "apellidos" => "Delgado"
            ]
            10 => array:2 [
              "nombre" => "Carmen"
              "apellidos" => "Santamar&#237;a"
            ]
            11 => array:2 [
              "nombre" => "Manuel"
              "apellidos" => "A&#46; Alonso"
            ]
            12 => array:2 [
              "nombre" => "Sara"
              "apellidos" => "Anaya"
            ]
            13 => array:2 [
              "nombre" => "Antoni"
              "apellidos" => "Bordils"
            ]
            14 => array:2 [
              "nombre" => "Andr&#233;s"
              "apellidos" => "Antol&#237;n"
            ]
            15 => array:2 [
              "nombre" => "Emilio"
              "apellidos" => "Gonzalez-Parra"
            ]
            16 => array:2 [
              "nombre" => "Isabel"
              "apellidos" => "P&#233;rez"
            ]
            17 => array:2 [
              "nombre" => "&#193;lvaro"
              "apellidos" => "Molina Ord&#225;s"
            ]
            18 => array:2 [
              "nombre" => "Mercedes"
              "apellidos" => "Fern&#225;ndez"
            ]
            19 => array:2 [
              "nombre" => "Pablo"
              "apellidos" => "Molina"
            ]
            20 => array:2 [
              "nombre" => "Pilar"
              "apellidos" => "S&#225;nchez"
            ]
            21 => array:2 [
              "nombre" => "Francesc"
              "apellidos" => "Barbosa"
            ]
            22 => array:2 [
              "nombre" => "Luisa"
              "apellidos" => "Palomares Solla"
            ]
            23 => array:2 [
              "nombre" => "Jos&#233;"
              "apellidos" => "Lacueva"
            ]
            24 => array:2 [
              "nombre" => "Guillarmina"
              "apellidos" => "Barril"
            ]
            25 => array:2 [
              "nombre" => "Jos&#233; M&#170;"
              "apellidos" => "Pastor"
            ]
            26 => array:2 [
              "nombre" => "Carmen"
              "apellidos" => "G&#225;mez Mat&#237;as"
            ]
            27 => array:2 [
              "nombre" => "Pablo"
              "apellidos" => "Mateos Hern&#225;ndez"
            ]
            28 => array:2 [
              "nombre" => "Miguel"
              "apellidos" => "Fulquet Nicolas"
            ]
            29 => array:2 [
              "nombre" => "Francisco"
              "apellidos" => "R&#237;os"
            ]
            30 => array:2 [
              "nombre" => "Pablo"
              "apellidos" => "Rebollo"
            ]
            31 => array:2 [
              "nombre" => "Eduardo"
              "apellidos" => "Parra"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "X0211699508004272"
        "doi" => " "
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508004272?idApp=UINPBA000064"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X201325140800427X?idApp=UINPBA000064"
    "url" => "/20132514/0000002800000006/v0_201502091634/X201325140800427X/v0_201502091634/en/main.assets"
  ]
  "itemAnterior" => array:17 [
    "pii" => "X2013251408004202"
    "issn" => "20132514"
    "doi" => " "
    "estado" => "S300"
    "fechaPublicacion" => "2008-12-01"
    "documento" => "article"
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Nefrologia &#40;English Version&#41;. 2008;28:587-92"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 4012
      "formatos" => array:3 [
        "EPUB" => 257
        "HTML" => 3155
        "PDF" => 600
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "titulo" => "The facilitator in acute kidney injury&#58; TWEAK"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "es"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "587"
          "paginaFinal" => "592"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "TWEAK&#44; el facilitador del da&#241;o renal agudo"
        ]
      ]
      "contieneResumen" => array:2 [
        "es" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Ana Bel&#233;n Sanz, Mar&#237;a Dolores S&#225;nchez-Nino, M&#46; Concepci&#243;n Izquierdo, Juan Antonio Moreno, Alvaro C&#46; Ucero, Alberto Benito-Mart&#237;n, Beatr&#237;z Santamaria, Carolina Burgos, Jes&#250;s Egido, Alberto Ort&#237;z, Marta Ru&#237;z-Ortega, Luis Miguel Blanco-Colio, Adri&#225;n Ramos, Sergio Berzal, Eli&#233;cer Coto"
          "autores" => array:15 [
            0 => array:2 [
              "nombre" => "Ana Bel&#233;n"
              "apellidos" => "Sanz"
            ]
            1 => array:2 [
              "nombre" => "Mar&#237;a Dolores"
              "apellidos" => "S&#225;nchez-Nino"
            ]
            2 => array:2 [
              "nombre" => "M&#46; Concepci&#243;n"
              "apellidos" => "Izquierdo"
            ]
            3 => array:2 [
              "nombre" => "Juan Antonio"
              "apellidos" => "Moreno"
            ]
            4 => array:2 [
              "nombre" => "Alvaro"
              "apellidos" => "C&#46; Ucero"
            ]
            5 => array:2 [
              "nombre" => "Alberto"
              "apellidos" => "Benito-Mart&#237;n"
            ]
            6 => array:2 [
              "nombre" => "Beatr&#237;z"
              "apellidos" => "Santamaria"
            ]
            7 => array:2 [
              "nombre" => "Carolina"
              "apellidos" => "Burgos"
            ]
            8 => array:2 [
              "nombre" => "Jes&#250;s"
              "apellidos" => "Egido"
            ]
            9 => array:2 [
              "nombre" => "Alberto"
              "apellidos" => "Ort&#237;z"
            ]
            10 => array:2 [
              "nombre" => "Marta"
              "apellidos" => "Ru&#237;z-Ortega"
            ]
            11 => array:2 [
              "nombre" => "Luis Miguel"
              "apellidos" => "Blanco-Colio"
            ]
            12 => array:2 [
              "nombre" => "Adri&#225;n"
              "apellidos" => "Ramos"
            ]
            13 => array:2 [
              "nombre" => "Sergio"
              "apellidos" => "Berzal"
            ]
            14 => array:2 [
              "nombre" => "Eli&#233;cer"
              "apellidos" => "Coto"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "X0211699508004205"
        "doi" => " "
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508004205?idApp=UINPBA000064"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408004202?idApp=UINPBA000064"
    "url" => "/20132514/0000002800000006/v0_201502091634/X2013251408004202/v0_201502091634/en/main.assets"
  ]
  "en" => array:13 [
    "idiomaDefecto" => true
    "titulo" => "Management of perioperative bleeding in renal patients"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "593"
        "paginaFinal" => "596"
      ]
    ]
    "autores" => array:1 [
      0 => array:3 [
        "autoresLista" => "MANUEL HERAS BENITO, ROSA SANCHEZ HERNANDEZ, MARIA JOSE FERNANDEZ-REYES, ANA ISABEL DIEZ LOBO"
        "autores" => array:4 [
          0 => array:4 [
            "nombre" => "MANUEL"
            "apellidos" => "HERAS BENITO"
            "email" => array:1 [
              0 => "manuhebe&#64;hotmail&#46;com"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "ROSA"
            "apellidos" => "SANCHEZ HERNANDEZ"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "MARIA JOSE"
            "apellidos" => "FERNANDEZ-REYES"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "ANA ISABEL"
            "apellidos" => "DIEZ LOBO"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "affb"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "SERVICIO DE NEFROLOGIA HOSPITAL GENERAL DE SEGOVIA SEGOVIA, SEGOVIA, ESPAÑA, "
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "affa"
          ]
          1 => array:3 [
            "entidad" => "SERVICIO DE ANESTESIOLOGIA, HOSPITAL GENERAL DE SEGOVIA SEGOVIA, SEGOVIA, ESPAÑA, "
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "affb"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Manejo de la hemorragia perioperatoria en el paciente renal"
      ]
    ]
    "textoCompleto" => "Patients with chronic kidney disease &#40;CKD&#41; often require surgery &#40;vascular accesses&#44; peripheral vascular disease&#44; <br></br>coronary disease&#44; etc&#46;&#41;&#46; The surgical risk in such patients&#44; in the same way as in the general population&#44; depends on <br></br>the type of surgery involved and on the elective or emergency nature of the operation&#46; However&#44; although the surgical risk is similar to that found in the general population&#44; morbidity-mortality among renal patients is much greater than in the general population&#46;1 <br></br><br></br>Recently&#44; a classification of CKD has been established involving 5 stages according to the degree of glomerular <br></br>filtration &#40;GF&#41;&#46;2 The aim of this classification is to allow the early identification of patients with renal disease&#44; and to <br></br>implement treatment measures destined to slow progression and&#47;or to ensure that patients requiring dialysis can receive such treatment under good conditions&#46; Renal patients that may require surgery and therefore are at a high risk of bleeding comprise individuals with CKD &#40;both in predialysis and among those receiving kidney replacement therapy&#41;&#44; patients with acute renal failure&#44; and renal transplant patients presenting chronic graft nephropathy&#46; <br></br><br></br>The association between bleeding and uremia has been well established for years&#46;3 Although the underlying <br></br>physiopathology is not fully clear&#44; a number of factors are accepted to be involved&#58; platelet dysfunction&#44; anemia <br></br>and drugs that interfere with platelet aggregation and clotting&#46;4 <br></br><br></br>Under physiological conditions&#44; the platelets circulate within the bloodstream in an inactive form&#46; Damage to the vascular wall activates the platelets&#44; with the purpose of generating a provisional thrombus and securing hemostasia&#46; <br></br><br></br>Such platelet activation comprises several phases&#58; Once vascular endothelial damage has occurred&#44; the platelets <br></br>adhere to the subendothelium via von Willebrand factor &#40;fvW&#41;&#46; The adhered platelets are activated&#44; and release the <br></br>contents of their granules&#58; ADP&#44; serotonin&#46; Posteriorly&#44; via platelet surface receptor IIb&#47;IIIa&#44; and through the <br></br>mediation of adhesion proteins &#40;fvW and fibrinogen&#41;&#44; the platelets aggregate among each other and with those already adhered to the subendothelium5&#44;6 &#40;see fig&#46; 1&#41;&#46; <br></br><br></br>Patients with uremia present an acquired platelet defect that accounts for the high risk of bleeding in nephropathic <br></br>patients&#46;7 In addition&#44; other factors such as anemia and drugs &#40;antiplatelet agents&#44; anticoagulants&#44; etc&#46;&#41; contribute to this acquired platelet defect&#46; <br></br><br></br>PLATELET DYSFUNCTION <br></br><br></br>Patients with nephropathy present defects in all the mechanisms implicated in platelet or provisional thrombus <br></br>formation&#46;4 <br></br><br></br>Adhesion defects&#58; Although in uremic patients the levels of fvW are normal or slightly elevated&#44; the activity of this factor is diminished8 &#191;thereby complicating platelet adhesion to the subendothelium&#46;9 In addition&#44; it has been seen that uremic patients have increased levels of prostacyclin10 and nitric oxide &#40;NO&#41;11&#191; both of which are potent inhibitors of platelet adhesion&#46; <br></br><br></br>Defects in granule content release&#58; An acquired defect is observed in the platelet granule contents&#44; resulting in <br></br>defective release of ADP&#44; serotonin and thromboxane A2&#46;12&#44;13 Calcium in turn is necessary for platelet activation&#44; <br></br>and these patients present alterations in intracellular calcium mobility&#46; 14 <br></br><br></br>Aggregation defects&#58; Defects have been identified in the activity of the IIb&#47;IIIa surface receptors&#46;15 The accumulation of certain substances such as urea&#44; creatinine&#44; phenols&#44; and guanidosuccinic acid have been related to <br></br>defects in platelet aggregation&#46; The fact that uremic patients subjected to dialysis subsequently showed improved binding of fibrinogen to the IIb&#47;IIIa platelet surface receptor has been attributed to the presence in the plasma of renal patients of an unidentified platelet inhibiting factor&#46;4 <br></br><br></br>ANEMIA <br></br><br></br>One of the main factors contributing to the appearance of anemia in CKD is a deficient production of erythropoietin <br></br>&#40;EPO&#41;&#44; associated to the drop in GF&#46; Other factors such as aluminum toxicity&#44; infections or inflammatory processes can also contribute to the appearance of anemia&#46;16 Rheological studies have shown that the red blood cells travel through the bloodstream in the center of the vascular lumen &#191; radially displacing the platelets&#44; which therefore find it easier to adhere to the endothelium&#46; A reduction in red cell mass implies that the platelets circulate more dispersedly&#44; thereby complicating their adhesion to the vascular wall and formation of the platelet thrombus&#46;17 <br></br><br></br>ANTIPLATELET DRUGS <br></br><br></br>The use of these drugs in renal patients implies a prolongation of bleeding time with respect to the general population&#46;18 Glycoprotein &#40;GP&#41; IIb&#47;IIIa inhibitors prevent binding of the adhesion proteins to the platelet surface receptors&#44; as a result of which platelet aggregation is inhibited&#46;19 Among the GP IIb&#47;IIIa inhibitors&#44; abciximab&#44; a monoclonal antibody with a short half-life &#40;10-30 minutes&#41;&#44; requires no dose adjustment in renal failure&#44; since the platelet-abciximab complex is mainly eliminated via the splenic route&#46; In contrast&#44; other GP IIb&#47;IIIa inhibitors such as tirofiban or eptifibatide require dose adjustments in patients with advanced CKD&#46; <br></br><br></br>ANTICOAGULANT DRUGS <br></br><br></br>Heparin is needed in these patients&#44; due to their important co-morbidity and the risk of thrombotic events&#59; in such individuals&#44; bleeding and thrombosis may coincide&#46; <br></br><br></br>Unfractionated heparin is a heterogeneous mixture of glycosaminoglycans with molecular weights in the range of <br></br>3&#44;000-30&#44;000 Da&#46; Low molecular weight heparin &#40;LMWH&#41; is composed of fragments of unfractionated heparin with a <br></br>molecular weight of about 5&#44;000 Da&#46; Both types of heparin exert their anticoagulant effects by binding to and activating antithrombin III&#44; accelerating interaction between the latter and factor Xa and thrombin &#191;which is inactivated as a result&#46; Unfractionated heparin is generally administered via the intravenous route for systemic anticoagulation&#44; and is monitored by means of the activated partial thromboplastin time &#40;aPTT&#41;&#46; LMWH in turn is generally administered subcutaneously&#46;19 Due to the fundamentally renal clearance of LMWH&#44; recent editorials and reviews recommend unfractionated heparin anticoagulation in patients with serum creatinine levels of over 2 mg&#47;dl&#44; or with creatinine clearance &#60; 30 ml&#47;min&#46;20&#44;21 In those cases where the use of LMWH is decided in renal patients&#44; <br></br>it is advisable to reduce the dose 50&#37;&#44; and to administer a single daily dose&#44; with monitorization of anti-Xa factor&#46;19 <br></br><br></br>OTHER DRUGS <br></br><br></br>Beta-lactam antibiotics &#40;penicillins&#44; cephalosporins&#44; etc&#46;&#41; also have been related to prolonged bleeding time as a <br></br>result of alterations in the platelet membrane&#46; 22 In turn&#44; nonsteroidal antiinflammatory drugs &#40;NSAIDs&#41; cause platelet dysfunction through reversible cyclooxygenase &#40;COX&#41; inhibition&#46;23 <br></br><br></br>CLINICAL MANIFESTATIONS <br></br><br></br>Patients with kidney disease are more susceptible to bleeding in the context of surgery or invasive procedures&#46;17 Gastrointestinal bleeding has been described as the most common bleeding complication in patients subjected to dialysis &#40;esophagitis&#44; gastritis&#44; duodenitis&#44; etc&#46;&#41;&#46;4 Cerebrovascular hemorrhage in turn is more common than in the general population&#46; A Japanese study reported an incidence of 637 cases per 100&#44;000 inhabitants and year &#191; this representing a 5-fold greater incidence than in the general population&#44;24 with a greater presence in younger patients&#44; and a poorer prognosis than in the general population&#46; Retroperitoneal hematomas &#40;spontaneous or secondary to venous catheter placement&#41; also deserve mention in patients with kidney disease&#46;17 <br></br><br></br>DIAGNOSTIC TESTS <br></br><br></br>There is currently no effective screening test for platelet dysfunction&#46; Neither bleeding time nor PFA-100 &#40;platelet function analyzer&#44; a prototype of a new generation of analyzers designed to screen platelet function defects&#41; is sufficiently sensitive to detect platelet defects in asymptomatic individuals&#46; Bleeding time is dependent upon the type of incision made&#44; the characteristics of the skin&#44; and patient cooperation &#191;while PFA-100 can yield prolonged readings in patients with low hematocrit values and normal platelet function&#46; In a study of 148 patients with known platelet alterations&#44; bleeding time sensitivity was found to be 36&#37;&#44; versus 30&#37; for PFA-100&#46; The combined sensitivity was 48&#37;&#46;25 <br></br><br></br>PREVENTION AND PERIOPERATIVE TREATMENT OF UREMIC BLEEDING <br></br><br></br>Considering that a range of factors intervene in the physiopathology of uremic bleeding&#44; each of them must be <br></br>addressed when preventive and treatment measures are contemplated&#46; For increased simplicity&#44; these measures <br></br>can be classified as general and specific&#58; <br></br><br></br>a&#41; General measures&#58; <br></br><br></br>1&#46; Eliminate uremic toxins&#58; The toxins accumulated in the context of uremia contribute to platelet dysfunction&#46; Their <br></br>treatment by means of kidney replacement therapy contributes to improve platelet function and shorten bleeding <br></br>time&#46;4 Both hemodialysis and peritoneal dialysis are equally effective in clearing toxins&#44; and thus in preventing perioperative bleeding&#46; In the case of patients with advanced CKD who require programmed surgery&#44; dialysis may be started before surgery is performed&#46; In the case of patients enrolled in a hemodialysis program&#44; dialysis is to be performed before the operation&#46;1&#44;26 In order to prevent bleeding&#44; hemodialysis is to be performed without heparin&#44; and with frequent flushing of the system&#46; If hemodialysis has been performed with heparin&#44; it is advisable to wait a prudent period of time before moving the patient to the operating room&#46;17 <br></br><br></br>2&#46; Correction of anemia&#58; The use of human recombinant EPO and derived analogs helps improve anemia associated <br></br>with chronic renal failure&#46;16&#44;27 Its use requires the availability of adequate iron deposits&#59; in this sense&#44; the administration of oral or intravenous iron may prove necessary&#46;1 With these measures it is possible to correct anemia associated to CKD&#44; and shorten bleeding time&#46; A period of 2-6 weeks may be needed from the time of administration of EPO to the obtainment of an adequate response in hematocrit level&#46; The use of such agents therefore should be started early&#44; before the patient is moved to the operating room&#46;27 Blood transfusions are not recommended on a chronic basis&#44; since immunization may result in patients who in future may require a kidney transplant&#46;28 Blood transfusions are indicated in cases of acute bleeding and emergency surgery&#46;1 <br></br><br></br>3&#46; Withdrawal of medication &#40;antiplatelet and anticoagulant drugs&#41;&#58; The suspension of antiplatelet drugs should <br></br>be individualized according to the type of surgery involved&#44; with due evaluation of the risk&#47;benefit ratio associated <br></br>with suspension &#40;i&#46;e&#46;&#44; thrombosis&#47;bleeding&#41;&#46; 29 In general&#44; antiplatelet medication should be suspended at least 72 <br></br>hours before the operation&#46;1 Likewise&#44; the suspension of oral anticoagulation is advised&#44; with the introduction of <br></br>heparin&#44; and avoiding the use of drugs commonly used in surgical services&#44; such as NSAIDs &#191;which reversibly <br></br>inhibit COX and thus entail an increased bleeding risk&#46;4 <br></br><br></br>b&#41; Specific measures&#58; <br></br><br></br>1&#46; Desmopressin&#58; Desmopressin is a synthetic derivative of vasopressin-ADH&#44; with a comparatively lesser pressor <br></br>effect&#46; Its mechanism of action in the prevention and treatment of uremic bleeding is related to the release of factor <br></br>VIII and fvW multimers from the endothelium&#46; Desmopressin is administered at a dose of 0&#46;3 mg&#47;kg i&#46;v&#46;&#47;s&#46;c in <br></br>15-30 minutes&#46; The time to onset of activity is 30-60 minutes&#44; with a duration of 6-12 hours&#46; As a result&#44; the main <br></br>indication of desmopressin is the prevention and treatment of acute bleeding&#44; and as treatment prior to invasive <br></br>procedures such as biopsies&#46;17&#44;30 In a recent review of recommendations based on evidence for the management <br></br>of uremic bleeding&#44; the use of desmopressin was included with grade I recommendation and evidence A&#44; with <br></br>avoidance of the administration of a second dose &#40;tachyphylaxis&#41;&#46;31 <br></br><br></br>2&#46; Cryoprecipitates&#58; Upon thawing frozen plasma&#44; the supernatant was found to contain fibrinogen&#44; fibronectin&#44; <br></br>factor VII and factor VIII&#46; The use of these cryoprecipitates shortens bleeding time in uremic patients&#46; The <br></br>underlying mechanism of action is based on the provision of these factors&#46; Administration consists of 10 U via the <br></br>intravenous route&#44; and the effect is noted within one hour&#44; with a duration of 12-24 hours&#46; The fact that cryoprecipitates constitute a potential source of infection has limited their use to those cases refractory to desmopressin and with frequent blood transfusions&#46;17&#44;32 <br></br><br></br>3&#46; Estrogens&#58; The observation that patients with von Willebrand disease and hereditary telangiectasia improved <br></br>during pregnancy led to the use of estrogens for the prevention of bleeding&#46; The underlying mechanism of action in the prevention of bleeding is not fully clear&#46; L-arginine &#40;a precursor of nitric oxide&#41; is believed to be inhibited&#44; thereby improving platelet aggregation&#46; Most studies involving estrogens for the prevention of uremic bleeding have used the intravenous route &#40;0&#46;6 mg&#47;kg&#47;day&#41;&#44; though use has also been made of the oral &#40;50 mg&#47;day&#41; or transdermal route &#40;50-100 mg twice a week&#41;&#46; The effect appears after 24 hours&#44; with a peak after 5-7 days&#44; and <br></br>persists for two weeks&#46; This slower onset of action causes estrogen to be used mainly for elective and chronic <br></br>preparation prior to surgery&#46;17&#44;29&#44;33 4&#46; Antifibrinolytic agents&#58; The systemic <br></br><br></br>inflammation present in uremia is associated with activation of the fibrinolytic system&#46; As a result&#44; the use of such agents &#40;tranexamic acid&#41; could shorten bleeding time in uremia&#46;34 <br></br><br></br>The management of perioperative bleeding in uremic patients can be summarized as follows&#58; <br></br><br></br>1&#46; Minor surgery&#44; tooth extractions&#44; biopsies and emergency surgery&#58; general measures &#43; desmopressin&#46; <br></br><br></br>2&#46; Programmed major surgery&#58; general measures &#43; conjugated estrogens 5 days before the operation &#43; <br></br>desmopressin one hour before surgery&#46; <br></br><br></br>In conclusion&#58; <br></br><br></br>Patients with chronic kidney disease requiring surgery are at a high risk of bleeding&#44; due to multiple factors &#40;platelet <br></br>dysfunction&#44; anemia&#44; drugs&#44; etc&#46;&#41;&#46; Knowledge of these factors and the adoption of a multifactor approach to deal with each of them will allow safe surgery &#191;reducing the high risk of bleeding in these subjects&#46; <br></br>"
    "pdfFichero" => "P-E-S-A328-EN.pdf"
    "tienePdf" => true
    "PalabrasClave" => array:2 [
      "es" => array:4 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec440419"
          "palabras" => array:1 [
            0 => "Enfermedad Renal Cr&#243;nica"
          ]
        ]
        1 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec440421"
          "palabras" => array:1 [
            0 => "Perioperatoria"
          ]
        ]
        2 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec440423"
          "palabras" => array:1 [
            0 => "Hemorragia"
          ]
        ]
        3 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec440425"
          "palabras" => array:1 [
            0 => "Uremia"
          ]
        ]
      ]
      "en" => array:4 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec440420"
          "palabras" => array:1 [
            0 => "Chronic Kidney Disease"
          ]
        ]
        1 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec440422"
          "palabras" => array:1 [
            0 => "Perioperative"
          ]
        ]
        2 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec440424"
          "palabras" => array:1 [
            0 => "Bleeding"
          ]
        ]
        3 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec440426"
          "palabras" => array:1 [
            0 => "Uremia"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "es" => array:1 [
        "resumen" => "RESUMEN&#58; Los pacientes con enfermedad renal cr&#243;nica &#40;ERC&#41; frecuentemente requieren ser intervenidos quir&#250;rgicamente y tienen alto riesgo de hemorragia perioperatoria&#46; La disfunci&#243;n plaquetaria adquirida por acumulaci&#243;n de toxinas ur&#233;micas &#44; la anemia asociada al descenso del filtrado glomerular &#40;FG&#41; y diversos f&#225;rmacos&#44; son los principales factores implicados en la fisiopatolog&#237;a de la hemorragia en la uremia&#46; El conocimiento y abordaje de todos estos factores&#44; reducir&#225; el riesgo de hemorragia perioperatoria en el paciente con enfermedad renal&#46; "
      ]
      "en" => array:1 [
        "resumen" => "SUMMARY&#58; Patients with chronic kidney disease &#40;ERC&#41; frequently need to be surgically treated and are at high risk of perioperative bleeding&#46; The platelet dysfunction acquired by accumulation of uremic toxins&#44; anemia associated with the decline of glomerular filtration &#40;FG&#41; and various drugs&#44; are the main factors involved in the pathophysiology of bleeding in uremia&#46; Knowledge and treatment all these factors may help reduce the risk of perioperative bleeding in patients with kidney disease&#46; "
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliography"
      "seccion" => array:1 [
        0 => array:1 [
          "bibliografiaReferencia" => array:1 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "REFERENCIAS:"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/20132514/0000002800000006/v0_201502091634/X2013251408004198/v0_201502091634/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "35445"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Short Reviews"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/20132514/0000002800000006/v0_201502091634/X2013251408004198/v0_201502091634/en/P-E-S-A328-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408004198?idApp=UINPBA000064"
]
Article information
ISSN: 20132514
Original language: English
DOI:
The statistics are updated each day
Year/Month Html Pdf Total
2024 November 15 17 32
2024 October 55 487 542
2024 September 94 129 223
2024 August 120 198 318
2024 July 77 145 222
2024 June 92 123 215
2024 May 97 136 233
2024 April 109 108 217
2024 March 79 102 181
2024 February 55 124 179
2024 January 64 71 135
2023 December 68 112 180
2023 November 49 135 184
2023 October 47 137 184
2023 September 39 95 134
2023 August 55 97 152
2023 July 91 100 191
2023 June 68 115 183
2023 May 85 92 177
2023 April 66 103 169
2023 March 60 70 130
2023 February 62 64 126
2023 January 68 55 123
2022 December 57 65 122
2022 November 52 61 113
2022 October 84 69 153
2022 September 88 80 168
2022 August 107 74 181
2022 July 69 72 141
2022 June 78 61 139
2022 May 82 65 147
2022 April 107 72 179
2022 March 118 111 229
2022 February 126 64 190
2022 January 102 56 158
2021 December 69 50 119
2021 November 89 55 144
2021 October 136 57 193
2021 September 149 73 222
2021 August 109 55 164
2021 July 176 46 222
2021 June 115 42 157
2021 May 141 44 185
2021 April 291 43 334
2021 March 158 47 205
2021 February 165 27 192
2021 January 149 39 188
2020 December 124 22 146
2020 November 134 30 164
2020 October 112 30 142
2020 September 120 22 142
2020 August 115 36 151
2020 July 106 19 125
2020 June 134 34 168
2020 May 105 29 134
2020 April 115 31 146
2020 March 128 25 153
2020 February 141 32 173
2020 January 145 37 182
2019 December 140 23 163
2019 November 181 35 216
2019 October 175 29 204
2019 September 174 32 206
2019 August 155 42 197
2019 July 150 43 193
2019 June 117 22 139
2019 May 110 24 134
2019 April 191 45 236
2019 March 112 36 148
2019 February 84 40 124
2019 January 119 35 154
2018 December 139 26 165
2018 November 128 15 143
2018 October 130 8 138
2018 September 128 24 152
2018 August 95 15 110
2018 July 92 16 108
2018 June 68 12 80
2018 May 58 11 69
2018 April 78 6 84
2018 March 62 10 72
2018 February 54 5 59
2018 January 48 9 57
2017 December 75 8 83
2017 November 56 3 59
2017 October 57 10 67
2017 September 39 10 49
2017 August 50 6 56
2017 July 61 10 71
2017 June 50 5 55
2017 May 47 11 58
2017 April 49 8 57
2017 March 32 10 42
2017 February 38 9 47
2017 January 27 12 39
2016 December 63 10 73
2016 November 83 9 92
2016 October 77 12 89
2016 September 137 9 146
2016 August 176 3 179
2016 July 154 7 161
2016 June 144 0 144
2016 May 144 0 144
2016 April 92 0 92
2016 March 75 0 75
2016 February 96 0 96
2016 January 107 0 107
2015 December 105 0 105
2015 November 75 0 75
2015 October 84 0 84
2015 September 84 0 84
2015 August 70 0 70
2015 July 58 0 58
2015 June 49 0 49
2015 May 58 0 58
2015 April 5 0 5
Show all

Follow this link to access the full text of the article

Idiomas
Nefrología (English Edition)
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?