Are simple renal cysts another manifestation of prelithiasis in infancy?
¿Los quistes renales simples son otra forma de manifestación de prelitiasis en la infancia?
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "337" "paginaFinal" => "341" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Víctor García Nieto, K. Dublan García, M.I. Luis Yanes" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Víctor" "apellidos" => "García Nieto" "email" => array:1 [ 0 => "vgarcianieto@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "K." "apellidos" => "Dublan García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "Iniciales" => "M.I." "apellidos" => "Luis Yanes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Nefrología Pediátrica., Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Servicio de Nefrología Pediátrica, Centro Médico Nacional La Raza IMSS, México, México, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Los quistes renales simples son otra forma de manifestación de prelitiasis en la infancia?" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION </span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Simple renal cysts are common in adults. They are located in the cortex, are usually unilateral, and have increased incidence after 40 years of age.<span class="elsevierStyleSup">1,2 </span>They are more frequent in males, left kidneys, and upper renal poles.<span class="elsevierStyleSup">3 </span>However, they are rare in infants and children, in whom they usually appear as solitary lesions. Some that are detected prenatally tend to disappear, even before birth.<span class="elsevierStyleSup">1 </span>They occasionally appear in multiple generations, such that some evidence has accumulated suggesting that it might be a rare form of a disease with an autosomal dominant pattern of inheritance.<span class="elsevierStyleSup">4 </span></p><p class="elsevierStylePara"> It has been suggested that these cysts originate from diverticula of the distal collecting duct. Therefore, these diverticula would increase in number in the kidneys of the elderly, probably as a result of thinning of the tubular basement membrane, which would explain the relationship between aging and simple renal cysts.<span class="elsevierStyleSup">1,5 </span></p><p class="elsevierStylePara"> Simple renal cysts rarely cause symptoms, although they have been occasionally associated with abdominal tumours or with flank pain.<span class="elsevierStyleSup">6 </span>In general, the association with symptoms has been considered a simple coincidence.<span class="elsevierStyleSup">5 </span>They are usually incidental ultrasound findings during the workup for urologyc problems, hypertension, or haematuria.<span class="elsevierStyleSup">6 </span>In 1930, Hepler suggested that the aetiology of simple renal cysts may be tubular obstruction, such that they would increase in size over time.<span class="elsevierStyleSup">7 </span>In this series, we wanted to know if simple renal cysts could be associated with a genetic predisposition for renal stone formation (prelithiasis). For that reason, we studied a group of children diagnosed with that entity to see if they were carriers of the two most common metabolic causes of urolithiasis (hypercalciuria and hypocitraturia) and if there was a history of urolithiasis in their families. <span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">PATIENTS AND METHODS </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patients </span></p><p class="elsevierStylePara">We studied 22 patients (12 males and 10 females) with a mean age at diagnosis of 5.67 ± 3.03 years (range: 1-13 years), followed in the outpatient Paediatric Nephrology clinic of the Nuestra Señora de Candelaria University Hospital for a period of 1.77 ± 3.68 years (range: 0-17 years) (table 1). The ultrasound examination had been requested for abdominal pain (n = 6, 26.1%), acute pyelonephritis (n = 5, 21.7%), cystitis (n = 2, 8.7%), recurrent urinary tract infections (n = 2, 8.7%), microscopic haematuria (n = 1, 4.3%), macroscopic haematuria (n = 1, 4.3%), nocturnal enuresis (n = 2, 8.7%), and hyperactive bladder (n = 1, 4.3%). One patient suffering from distal renal tubular acidosis (DRTA) began to have vomiting and had weight below the 3<span class="elsevierStyleSup">rd </span>percentile. The ultrasound for the remaining patient, who was asymptomatic, was requested for having two siblings with idiopathic hypercalciuria. The children’s parents were interviewed about any family history of urolithiasis. <span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> Methods </span></p><p class="elsevierStylePara"> In accordance with the criteria set by the Spanish Paediatric Nephrology Association, hypercalciuria was diagnosed in children between 1 and 2 years of age when the calcium/ creatinine quotient (UCa/UCr) from two isolated consecutive non-fasting urine samples was greater than 0.47mg/mg.<span class="elsevierStyleSup">8 </span></p><p class="elsevierStylePara"> Based on the results of So et al., hypercalciuria in children between 2 and 4 years of age was diagnosed when UCa/UCr was greater than 0.28mg/mg.<span class="elsevierStyleSup">9 </span>In children older than 4 years of age, the diagnosis of hypercalciuria was made when the UCa/UCr value under similar conditions was greater than 0.20mg/mg,<span class="elsevierStyleSup">10 </span>a number that corresponds to the 95<span class="elsevierStyleSup">th </span>percentile of a sample made up of 100 healthy children from a previous study conducted by our group.<span class="elsevierStyleSup">11 </span>Based on Stapleton and Kroovand’s criteria, the diagnosis of hypocitraturia was made when the value of the citrate/creatinine quotient was less than 400mg/g in two consecutively collected urine samples.<span class="elsevierStyleSup">12 </span>The glomerular filtration rate (GFR) was calculated according to the Schwartz formula.<span class="elsevierStyleSup">13 </span></p><p class="elsevierStylePara"> Renal concentrating ability was determined with desmopressin (DDAVP). Before emptying the bladder, 20μg of intranasal desmopressin or 0.2mg (200μg) of desmopressin in tablet form was administered. Then, three urine samples were collected at 90-minute intervals. Food intake was allowed during this period, although subjects were advised not to drink too much fluid. The maximum value of any of the three samples was taken as the test result.</p><p class="elsevierStylePara"> Measurements of calcium, citrate, and creatinine were made with standard techniques in an autoanalyser (Roche/Hitachi Modular<span class="elsevierStyleSup">®</span>). Osmolality was determined measuring freezing point depression in an Osmostat<span class="elsevierStyleSup">® </span>osmometer (Menarini). Ultrasound examinations were performed with an Orion<span class="elsevierStyleSup">® </span>ultrasound (Philips). <span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> Statistical methods </span></p><p class="elsevierStylePara"> Statistical analysis was performed using the SPSS software package (version 17.0; SPSS, Chicago, IL). Basic statistics were performed and the Mann-Whitney U test was used when the sample was distributed in two subgroups. Probability values less than 0.05 were considered significant. <span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS </span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Simple renal cysts were most commonly located on the left side (n = 12, 54.5%), while 10 were seen on the right side (45.4%). They were all located in the upper renal pole. In the 12 patients who had two ultrasound scans available, the size of the cysts on diagnosis was 23.9 ± 16.1mm while it was 21.5 ± 17.5mm at the end of the follow-up period (NS) (table 1). Two patients had been diagnosed with vesicoureteral reflux. Nine patients were found to have hypercalciuria (40.9%), two had hypocitraturia (9.1%), two had hypercalciuria associated with hypocitraturia (9.1%), and one had hypocitraturia in the setting of a DRTA (4.5%). There was a family history of urolithiasis in 13 families (59.1%) (table 1). In eight of them, the children with renal cysts had hypercalciuria or hypocitraturia, and the other five did not. In short, if we combine the existence of hypercalciuria or hypocitraturia in the children and their family histories, we see that there is some manifestation of urolithiasis in some family member in 19 of the 22 families studied (86.3%).</p><p class="elsevierStylePara"> Regarding renal function, only two patients (8.7%) had a defect in renal concentrating ability. None showed increased urinary elimination of microalbumin or decreased GFR. Furthermore, no patients had serum electrolyte abnormalities, except for the child with DRTA with hyperchloraemia on diagnosis (115mEq/l) (table 1).</p><p class="elsevierStylePara"> When the sample was separated between patients with hypercalciuria or hypocitraturia and those with normal metabolic studies, differences were only found, obviously, in urinary calcium elimination. When the sample was separated between patients with a family history of urolithiasis and those without a family history, differences were seen in maximum urinary osmolality (951.6 ± 120.8 versus 1,059.1 ± 116.3mOsm/kg) (p = 0.04). <span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Simple renal cysts must meet three sonographic criteria in order to be specifically identified. The mass is round, with welldefined borders and smooth walls; there is an absence of interior echoes, and a strong echo is confirmed from the posterior wall, indicating good transmission through the cyst. On computerised axial tomography, the characteristics of a simple cyst are that it is neatly separated from the surrounding parenchyma, has a thin, smooth wall, the cystic fluid is homogeneous with density close to that of water, and there is no enhancement of the mass after administration of contrast.<span class="elsevierStyleSup">2 </span>Simple renal cysts are rare in infancy. They are generally detected incidentally. In a large series reported by McHugh et al., in which 16,102 paediatric patients were studied by ultrasound, renal cysts were detected in 0.22%.<span class="elsevierStyleSup">14 </span>In newborns and children up to 18 years of age, an incidence of 0.1 to 0.45% has been published.<span class="elsevierStyleSup">5 </span>In contrast, the prevalence increases up to 11.9% in adults.<span class="elsevierStyleSup">6 </span></p><p class="elsevierStylePara"> In the natural history of simple renal cysts, it has been observed that their size can increase occasionally over time. In the previously mentioned study by McHugh et al., of 22 children who underwent ultrasound monitoring for 5 years, it was observed that the size had not changed in 17 of the cases (74%).<span class="elsevierStyleSup">14 </span>In contrast, Terada et al., in a longitudinal study conducted in adults, reported a gradual progressive growth in the size and number of renal cysts, although more quickly in patients under 50 years old.<span class="elsevierStyleSup">6 </span>In this series, we observed no difference in the size of the cysts during the follow-up period.</p><p class="elsevierStylePara"> The precise mechanism of simple renal cyst formation is not well defined. Two possible mechanisms have been suggested. The first is an increase of intrarenal ammonia production. This induces cyst formation through various mechanisms, including complement activation, stimulation of synthesis of DNA and RNA, proteins, and various metabolic factors associated with renal ammoniogenesis.<span class="elsevierStyleSup">15 </span>The second proposed mechanism is chronic hypokalaemia, which has been described as causing structural and functional anomalies, including increased growth of renal cells,<span class="elsevierStyleSup">16 </span>a defect in renal concentrating ability, interstitial fibrosis or chronic inflammation, and formation of renal cysts.<span class="elsevierStyleSup">17 </span>This type of cyst formation has been reported in primary hyperaldosteronism,<span class="elsevierStyleSup">18,19 </span>DRTA,<span class="elsevierStyleSup">20-22 </span>Bartter’s syndrome,<span class="elsevierStyleSup">23,24 </span>and in apparent mineralocorticoid excess syndrome.<span class="elsevierStyleSup">25 </span>Meanwhile, acquired renal cysts have been observed in chronic kidney disease.<span class="elsevierStyleSup">26 </span>None of our patients had this last disease or hypokalaemia.</p><p class="elsevierStylePara"> In our sample, 86.3% of patients (n = 19) had hypercalciuria, hypocitraturia, or a family history of kidney stones. The prevalence of hypercalciuria in our patients (n = 11, 50%) is much higher than what has been described in the general population. In a previously cited study, we reported that the prevalence of hypercalciuria in healthy children on the island of Tenerife was 3.8%.<span class="elsevierStyleSup">11 </span>In other populations, the reported prevalence of hypercalciuria varies between 0.6<span class="elsevierStyleSup">27 </span>and 12.5%.<span class="elsevierStyleSup">28</span>We are unaware of any description of the prevalence of hypocitraturia in a control infant population.</p><p class="elsevierStylePara"> An interesting question related to the discussion of our results is the absence of hypercalciuria in some children with renal cysts despite a positive family history of urolithiasis. We must remember that daily urinary excretion of calcium depends on various factors, primarily diet, intestinal absorption of calcium, and bone formation rate. Any change in these factors can result in a change in calciuria. Furthermore, this parameter is modified not only by daily calcium intake but also by the intake of other nutrients, such as sodium, animal protein, whole grains, and omega-3 fatty acids. We have observed that some children suffering from familiar hypercalciuria show transient normalisation of calciuria around the age of puberty, probably due to increased body calcium requirements. In this sense, many of the children diagnosed with idiopathic hypercalciuria and osteopenia improved their bone mineral needs upon reaching puberty. <span class="elsevierStyleSup">29 </span>When puberty ends and growth has concluded, calcium excretion may increase once again. That phenomenon of transient decline in calciuria has also been observed in healthy adolescents.<span class="elsevierStyleSup">30 </span>In short, if a child has a normal one-time metabolic study, the child may still have had at least hypercalciuria at a younger age.</p><p class="elsevierStylePara"> However, the inverse may be true. That is to say, cases of hypercalciuria without a family history of urolithiasis may be due to temporary fluctuations in calcium elimination and not to true hypercalciuria.</p><p class="elsevierStylePara"> Given that simple renal cysts are assumed to be acquired, a possible first causal mechanism could be mechanical, that is, that the cyst could occur secondary to an intratubular obstruction caused by crystalluria.</p><p class="elsevierStylePara"> As previously mentioned, another aetiologic possibility for cyst formation is increased ammonia production.<span class="elsevierStyleSup">15 </span>In patients with idiopathic hypercalciuria, progression to an incomplete distal tubular acidosis has been described.<span class="elsevierStyleSup">31 </span>This is characterised, in the absence of spontaneous acidosis, by alkaline urine and urinary pH greater than 5.35, even after overload with CLNH<span class="elsevierStyleSup">4</span>.<span class="elsevierStyleSup">31,32 </span>However, urinary ammonia is not decreased but rather increased, which sets up, on the other hand, the absence of free hydrogen ions in the urine and makes decreasing the urinary pH impossible.<span class="elsevierStyleSup">30 </span>In contrast, the elimination of titratable acidity is greatly reduced. Its origin lies in a proximal tubular dysfunction, in which ammonia synthesis would be stimulated, perhaps, by an intracellular acidosis of unknown origin. We have also shown the existence of this dysfunction of renal acidification capacity in children with idiopathic hypercalciuria.<span class="elsevierStyleSup">33 </span></p><p class="elsevierStylePara"> Our hypothesis is supported by the results of the study by Chang et al. in 2007.<span class="elsevierStyleSup">5 </span>The frequency of urolithiasis in the group with cysts (n = 62) was 24.2% versus 11.5% in the control group (n = 515) (p < 0.001). Although these authors did not discuss any explanation in relation to their findings, they admitted that “renal stones may be a risk factor for the presence of simple renal cysts”.<span class="elsevierStyleSup">5 </span></p><p class="elsevierStylePara"> In short, whatever the cause, our hypothesis is that the two entities, renal cysts and a genetic predisposition to form renal calculi (prelithiasis), are related. Thus, the presence of simple renal cysts would join other well-known signs and symptoms that reveal the condition of carrying a genetic predisposition for kidney stone formation.<span class="elsevierStyleSup">34,35 </span></p><p class="elsevierStylePara"> New, larger studies, in particular in the adult population, are needed in order to demonstrate the association described in this study, as well as the possible pathological mechanisms involved.  </p><p class="elsevierStylePara"><a href="grande/10442_18030_5601_en_table1.jpg" class="elsevierStyleCrossRefs"><img src="10442_18030_5601_en_table1.gif" alt="Ultrasound and metabolic characteristics of the study patients"></img></a></p><p class="elsevierStylePara">Table 1. Ultrasound and metabolic characteristics of the study patients</p>" "pdfFichero" => "P1-E46-S1853-A10442-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437177" "palabras" => array:1 [ 0 => "Urolitiasis" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437179" "palabras" => array:1 [ 0 => "Hipocitraturia" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437181" "palabras" => array:1 [ 0 => "Hipercalciuria" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437183" "palabras" => array:1 [ 0 => "Quiste renal simple" ] ] ] "en" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437178" "palabras" => array:1 [ 0 => "Urolithiasis" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437180" "palabras" => array:1 [ 0 => "Hypocitraturia" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437182" "palabras" => array:1 [ 0 => "Hypercalciuria" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437184" "palabras" => array:1 [ 0 => "Simple renal cyst" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleItalic">Simple renal cysts are uncommon lesions in paediatric</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">patients. In the absence of hypokalaemia or an increase in</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">the production of NH+, the cause of simple renal cysts is</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">unknown. Hepler, in 1930, suggested that they may be</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">caused by a tubular obstruction. We prospectively studied the</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">presence of hypercalciuria or hypocitraturia as well as the</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">family history of urolithiasis in a group of children diagnosed</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">sonographically with simple renal cysts. The average age of the</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">22 patients (12M, 10F) was 6.04 ± 2.9 years at the time of</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">diagnosis. The ultrasound examination had been requested due</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">to urinary tract infection, abdominal pain, haematuria or other</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">disorders. The cysts were slightly more frequent on the left side</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">(54.5%). All were located in the upper kidney pole. 14 patients</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">were found to have hypercalciuria and/or hypocitraturia</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">(hypercalciuria n = 11, 50%). Thirteen families had history of</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">renal stones. The metabolic abnormalities associated with calculi</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">in children and/or family history of stones were present in 19</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">families (86.3%). Our hypothesis is that both entities, renal cysts,</span><span class="elsevierStyleItalic"><span class="elsevierStyleSup"> </span></span><span class="elsevierStyleItalic">and genetic predisposition to kidney stones, are related.</span><span class="elsevierStyleSup"> </span></p>" ] "es" => array:1 [ "resumen" => "<p class="elsevierStylePara">Los quistes renales simples son lesiones poco frecuentes en pacientes<span class="elsevierStyleSup"> </span>pediátricos. En ausencia de hipopotasemia o de un incremento<span class="elsevierStyleSup"> </span>en la producción de NH<span class="elsevierStyleInf">4</span><span class="elsevierStyleSup"> +</span>, se desconoce el origen de<span class="elsevierStyleSup"> </span>los mismos. Hepler, en 1930, propuso que su causa podría ser<span class="elsevierStyleSup"> </span>una obstrucción tubular. Hemos estudiado de forma prospectiva<span class="elsevierStyleSup"> </span>la presencia de hipercalciuria o de hipocitraturia, así como<span class="elsevierStyleSup"> </span>los antecedentes familiares de litiasis en un grupo de niños<span class="elsevierStyleSup"> </span>diagnosticados ecográficamente de quistes renales simples. Al<span class="elsevierStyleSup"> </span>diagnóstico, la edad media de los 22 pacientes (12 varones y<span class="elsevierStyleSup"> </span>10 mujeres) fue de 6,04 ± 2,9 años. El estudio ecográfico se había<span class="elsevierStyleSup"> </span>solicitado por infección de vías urinarias, dolor abdominal,<span class="elsevierStyleSup"> </span>hematuria u otros. Los quistes fueron ligeramente más frecuentes<span class="elsevierStyleSup"> </span>en el lado izquierdo (54,5%). Todos estaban ubicados<span class="elsevierStyleSup"> </span>en el polo renal superior. En 14 pacientes (63,6%) se demostró<span class="elsevierStyleSup"> </span>que eran portadores de hipercalciuria o hipocitraturia (hipercalciuria<span class="elsevierStyleSup"> </span>n = 11, 50%). En 13 familias existían antecedentes<span class="elsevierStyleSup"> </span>de litiasis renal. En conjunto, las anomalías metabólicas estudiadas<span class="elsevierStyleSup"> </span>causantes de cálculos en los niños o los antecedentes<span class="elsevierStyleSup"> </span>familiares de litiasis estaban presentes en 19 familias (86,3%).<span class="elsevierStyleSup"> </span>Nuestra hipótesis es que ambas entidades, quistes renales y<span class="elsevierStyleSup"> </span>predisposición genética a padecer cálculos renales, están relacionadas.<span class="elsevierStyleSup"> </span></p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "10442_18030_5601_en_table1.jpg" "imagenAlto" => 553 "imagenAncho" => 790 "imagenTamanyo" => 468229 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Ultrasound and metabolic characteristics of the study patients" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Bisceglia M, Galliani C, Senger CH, Stallone C, Sessa A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 3 | 12 |
| 2024 October | 76 | 33 | 109 |
| 2024 September | 99 | 26 | 125 |
| 2024 August | 94 | 64 | 158 |
| 2024 July | 75 | 27 | 102 |
| 2024 June | 128 | 50 | 178 |
| 2024 May | 86 | 35 | 121 |
| 2024 April | 106 | 36 | 142 |
| 2024 March | 53 | 26 | 79 |
| 2024 February | 55 | 35 | 90 |
| 2024 January | 50 | 27 | 77 |
| 2023 December | 56 | 36 | 92 |
| 2023 November | 59 | 36 | 95 |
| 2023 October | 69 | 30 | 99 |
| 2023 September | 86 | 31 | 117 |
| 2023 August | 85 | 23 | 108 |
| 2023 July | 107 | 39 | 146 |
| 2023 June | 85 | 34 | 119 |
| 2023 May | 111 | 45 | 156 |
| 2023 April | 102 | 23 | 125 |
| 2023 March | 115 | 28 | 143 |
| 2023 February | 55 | 13 | 68 |
| 2023 January | 74 | 40 | 114 |
| 2022 December | 81 | 39 | 120 |
| 2022 November | 78 | 30 | 108 |
| 2022 October | 61 | 47 | 108 |
| 2022 September | 91 | 30 | 121 |
| 2022 August | 84 | 50 | 134 |
| 2022 July | 64 | 53 | 117 |
| 2022 June | 64 | 44 | 108 |
| 2022 May | 69 | 47 | 116 |
| 2022 April | 90 | 48 | 138 |
| 2022 March | 109 | 63 | 172 |
| 2022 February | 129 | 49 | 178 |
| 2022 January | 71 | 30 | 101 |
| 2021 December | 67 | 45 | 112 |
| 2021 November | 73 | 34 | 107 |
| 2021 October | 85 | 46 | 131 |
| 2021 September | 52 | 43 | 95 |
| 2021 August | 65 | 33 | 98 |
| 2021 July | 57 | 28 | 85 |
| 2021 June | 48 | 24 | 72 |
| 2021 May | 75 | 32 | 107 |
| 2021 April | 172 | 37 | 209 |
| 2021 March | 74 | 33 | 107 |
| 2021 February | 88 | 17 | 105 |
| 2021 January | 59 | 21 | 80 |
| 2020 December | 59 | 18 | 77 |
| 2020 November | 51 | 24 | 75 |
| 2020 October | 31 | 9 | 40 |
| 2020 September | 49 | 10 | 59 |
| 2020 August | 39 | 15 | 54 |
| 2020 July | 49 | 14 | 63 |
| 2020 June | 56 | 35 | 91 |
| 2020 May | 49 | 23 | 72 |
| 2020 April | 58 | 25 | 83 |
| 2020 March | 67 | 28 | 95 |
| 2020 February | 72 | 35 | 107 |
| 2020 January | 76 | 36 | 112 |
| 2019 December | 73 | 39 | 112 |
| 2019 November | 92 | 34 | 126 |
| 2019 October | 54 | 15 | 69 |
| 2019 September | 56 | 23 | 79 |
| 2019 August | 32 | 21 | 53 |
| 2019 July | 40 | 37 | 77 |
| 2019 June | 48 | 18 | 66 |
| 2019 May | 48 | 29 | 77 |
| 2019 April | 56 | 43 | 99 |
| 2019 March | 46 | 26 | 72 |
| 2019 February | 29 | 15 | 44 |
| 2019 January | 56 | 20 | 76 |
| 2018 December | 81 | 34 | 115 |
| 2018 November | 98 | 21 | 119 |
| 2018 October | 76 | 13 | 89 |
| 2018 September | 63 | 19 | 82 |
| 2018 August | 47 | 19 | 66 |
| 2018 July | 45 | 15 | 60 |
| 2018 June | 31 | 13 | 44 |
| 2018 May | 35 | 11 | 46 |
| 2018 April | 62 | 12 | 74 |
| 2018 March | 39 | 11 | 50 |
| 2018 February | 46 | 8 | 54 |
| 2018 January | 70 | 14 | 84 |
| 2017 December | 49 | 11 | 60 |
| 2017 November | 32 | 15 | 47 |
| 2017 October | 36 | 5 | 41 |
| 2017 September | 29 | 13 | 42 |
| 2017 August | 32 | 5 | 37 |
| 2017 July | 34 | 13 | 47 |
| 2017 June | 34 | 6 | 40 |
| 2017 May | 36 | 9 | 45 |
| 2017 April | 23 | 18 | 41 |
| 2017 March | 19 | 4 | 23 |
| 2017 February | 21 | 9 | 30 |
| 2017 January | 24 | 15 | 39 |
| 2016 December | 52 | 3 | 55 |
| 2016 November | 79 | 13 | 92 |
| 2016 October | 138 | 12 | 150 |
| 2016 September | 126 | 4 | 130 |
| 2016 August | 166 | 6 | 172 |
| 2016 July | 137 | 9 | 146 |
| 2016 June | 117 | 0 | 117 |
| 2016 May | 143 | 0 | 143 |
| 2016 April | 109 | 0 | 109 |
| 2016 March | 89 | 0 | 89 |
| 2016 February | 109 | 0 | 109 |
| 2016 January | 96 | 0 | 96 |
| 2015 December | 107 | 0 | 107 |
| 2015 November | 72 | 0 | 72 |
| 2015 October | 85 | 0 | 85 |
| 2015 September | 65 | 0 | 65 |
| 2015 August | 65 | 0 | 65 |
| 2015 July | 54 | 0 | 54 |
| 2015 June | 26 | 0 | 26 |
| 2015 May | 74 | 0 | 74 |
| 2015 April | 6 | 0 | 6 |
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