Renal function evolution and progressive factors in nefrectomized patients
Evolución de la función renal y factores de progresión en pacientes nefrectomizados
Read
9071
Timeswas read the article
2472
Total PDF
6599
Total HTML
Share statistics
array:21 [ "pii" => "X2013251410036140" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2010.Jan.10230" "estado" => "S300" "fechaPublicacion" => "2010-03-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2010;30:202-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4447 "formatos" => array:3 [ "EPUB" => 270 "HTML" => 3549 "PDF" => 628 ] ] "Traduccion" => array:1 [ "es" => array:17 [ "pii" => "X0211699510036143" "issn" => "02116995" "doi" => "10.3265/Nefrologia.pre2010.Jan.10230" "estado" => "S300" "fechaPublicacion" => "2010-03-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia. 2010;30:202-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 11135 "formatos" => array:3 [ "EPUB" => 273 "HTML" => 9841 "PDF" => 1021 ] ] "es" => array:12 [ "idiomaDefecto" => true "titulo" => "Evolución de la función renal y factores de progresión en pacientes nefrectomizados" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "202" "paginaFinal" => "207" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Renal function evolution and progressive factors in nefrectomized patients" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "1023018078_tripav30_n2_2010_t1_pag203.jpg" "Alto" => 179 "Ancho" => 525 "Tamanyo" => 20639 ] ] "descripcion" => array:1 [ "es" => "Clasificación en el momento actual según el filtrado glomerular" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Isabel Juan García, M.J. Puchades, M.A. Solís, B. Pascual, I. Torregrosa, C. Ramos, M. González, A. Miguel" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Isabel" "apellidos" => "Juan García" ] 1 => array:2 [ "Iniciales" => "M.J." "apellidos" => "Puchades" ] 2 => array:2 [ "Iniciales" => "M.A." "apellidos" => "Solís" ] 3 => array:2 [ "Iniciales" => "B." "apellidos" => "Pascual" ] 4 => array:2 [ "Iniciales" => "I." "apellidos" => "Torregrosa" ] 5 => array:2 [ "Iniciales" => "C." "apellidos" => "Ramos" ] 6 => array:2 [ "Iniciales" => "M." "apellidos" => "González" ] 7 => array:2 [ "Iniciales" => "A." "apellidos" => "Miguel" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "X2013251410036140" "doi" => "10.3265/Nefrologia.pre2010.Jan.10230" "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/X2013251410036140?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699510036143?idApp=UINPBA000064" "url" => "/02116995/0000003000000002/v0_201502091329/X0211699510036143/v0_201502091331/es/main.assets" ] ] "itemSiguiente" => array:17 [ "pii" => "X2013251410036132" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2010.Mar.10333" "estado" => "S300" "fechaPublicacion" => "2010-03-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2010;30:208-13" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4316 "formatos" => array:3 [ "EPUB" => 299 "HTML" => 3433 "PDF" => 584 ] ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Kinetic studies with hypertonic glucose permit better identification of ultrafiltration failure. What is the contribution of sodium sieving?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "208" "paginaFinal" => "213" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Las cinéticas con glucosa hipertónica permiten identificar mejor el fallo de ultrafiltración. ¿Qué aporta el cribado de sodio?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10333108_a10_f1.jpg" "Alto" => 637 "Ancho" => 1094 "Tamanyo" => 55263 ] ] "descripcion" => array:1 [ "en" => "DifNa according to ultrafiltration quartiles." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "María José Fernández-Reyes, M.A. Bajo Rubio, G. del Peso Gilsanz, P. Estrada, S. Sousa, R. Sánchez-Villanueva, M. Heras, M. Ossorio, C. Vega, R. Selgas" "autores" => array:10 [ 0 => array:2 [ "nombre" => "María José" "apellidos" => "Fernández-Reyes" ] 1 => array:2 [ "Iniciales" => "M.A." "apellidos" => "Bajo Rubio" ] 2 => array:2 [ "Iniciales" => "G." "apellidos" => "del Peso Gilsanz" ] 3 => array:2 [ "Iniciales" => "P." "apellidos" => "Estrada" ] 4 => array:2 [ "Iniciales" => "S." "apellidos" => "Sousa" ] 5 => array:2 [ "Iniciales" => "R." "apellidos" => "Sánchez-Villanueva" ] 6 => array:2 [ "Iniciales" => "M." "apellidos" => "Heras" ] 7 => array:2 [ "Iniciales" => "M." "apellidos" => "Ossorio" ] 8 => array:2 [ "Iniciales" => "C." "apellidos" => "Vega" ] 9 => array:2 [ "Iniciales" => "R." "apellidos" => "Selgas" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699510036135" "doi" => "10.3265/Nefrologia.pre2010.Mar.10333" "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/X0211699510036135?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251410036132?idApp=UINPBA000064" "url" => "/20132514/0000003000000002/v0_201502091606/X2013251410036132/v0_201502091606/en/main.assets" ] "itemAnterior" => array:17 [ "pii" => "X2013251410036159" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2010.Feb.10235" "estado" => "S300" "fechaPublicacion" => "2010-03-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2010;30:195-201" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 7847 "formatos" => array:3 [ "EPUB" => 349 "HTML" => 6828 "PDF" => 670 ] ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Analysis of psychological factors influencing peritoneal dialysis selection" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "195" "paginaFinal" => "201" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis de la influencia de los factores psicológicos en la elección de diálisis peritoneal" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10235108_a8_t1_demographic_characteristics_of_the_patients_who_agreed_to_participate.jpg" "Alto" => 856 "Ancho" => 1082 "Tamanyo" => 159855 ] ] "descripcion" => array:1 [ "en" => "Demographic characteristics of the patients who agreed to participate in the study (included) and patients who did not agree to participate (not included)" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Esther Ponz Clemente, J. C. Martínez Ocaña, D. Marquina Parra, C. Blasco Cabañas, C. Grau Pueyo, N. Mañé Buixó, M. García García" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Esther" "apellidos" => "Ponz Clemente" ] 1 => array:2 [ "Iniciales" => "J. C." "apellidos" => "Martínez Ocaña" ] 2 => array:2 [ "Iniciales" => "D." "apellidos" => "Marquina Parra" ] 3 => array:2 [ "Iniciales" => "C." "apellidos" => "Blasco Cabañas" ] 4 => array:2 [ "Iniciales" => "C." "apellidos" => "Grau Pueyo" ] 5 => array:2 [ "Iniciales" => "N." "apellidos" => "Mañé Buixó" ] 6 => array:2 [ "Iniciales" => "M." "apellidos" => "García García" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699510036151" "doi" => "10.3265/Nefrologia.pre2010.Feb.10235" "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/X0211699510036151?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251410036159?idApp=UINPBA000064" "url" => "/20132514/0000003000000002/v0_201502091606/X2013251410036159/v0_201502091606/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "titulo" => "Renal function evolution and progressive factors in nefrectomized patients" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "202" "paginaFinal" => "207" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Isabel Juan García, M.J. Puchades, M.A. Solís, B. Pascual, I. Torregrosa, C. Ramos, M. González, A. Miguel" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Isabel" "apellidos" => "Juan García" "email" => array:1 [ 0 => "ijuangar@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "M.J." "apellidos" => "Puchades" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "M.A." "apellidos" => "Solís" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "B." "apellidos" => "Pascual" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 4 => array:3 [ "Iniciales" => "I." "apellidos" => "Torregrosa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 5 => array:3 [ "Iniciales" => "C." "apellidos" => "Ramos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 6 => array:3 [ "Iniciales" => "M." "apellidos" => "González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 7 => array:3 [ "Iniciales" => "A." "apellidos" => "Miguel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Clínico Universitario de Valencia, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evolución de la función renal y factores de progresión en pacientes nefrectomizados" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "1023018078_tripav30_n2_2010_t1_pag203_copy1.jpg" "Alto" => 179 "Ancho" => 525 "Tamanyo" => 20639 ] ] "descripcion" => array:1 [ "en" => "Current stage according to glomerular filtration rate." ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION </span><span class="elsevierStyleBold"></span></p><p class="elsevierStylePara">Nephrology outpatient services receive a significant number of nephrectomised patients, who are referred after surgery, when there is a decrease in kidney function, or when another associated disease arises. Experimental studies have shown that after the reduction of renal mass, hyperfiltration develops. This is a compensatory mechanism that prevents glomerular filtration rate from decreasing<span class="elsevierStyleSup">1,2 </span>(preglomerular vasodilation, increase in nephron plasma flow and increase in glomerular intracapillary pressure).<span class="elsevierStyleSup">3 </span>The suspected diagnosis is based exclusively on clinical data, such as the appearance of proteinuria and a decrease in glomerular filtration rate. These changes can be harmful in the long term, especially if they are associated with risk factors, including arterial hypertension (HT), diabetes mellitus, dyslipidaemia, microalbuminuria, proteinuria, obesity, and others.<span class="elsevierStyleSup">4-6 </span>Published studies do not agree unanimously about the evolution of patients with a unilateral nephrectomy.<span class="elsevierStyleSup">7-10 </span>The few publications that we find on this topic present series of selected patients with no kidney disease prior to surgery, and they do not address patients with bilateral kidney disease.<span class="elsevierStyleSup">11,12 </span>With this in mind, the objectives for this project are to study how kidney function evolves in our nephrectomised patient population and to analyse for risk factors that may be involved in the evolution of a more advanced stage of kidney disease, whether at the time of the nephrectomy or throughout the progression of the disease, in order to be able to detect and control them at early stages. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">PATIENTS AND METHODS </span></p><p class="elsevierStylePara">We performed a retrospective observational study of cases and controls with patients who had undergone nephrectomy for different reasons. These patients were seen in our nephrology department at the Clinical University Hospital of Valencia between 2005 and 2007, and their progress was monitored from the nephrectomy up to the present. We examined 210 patients with a single functioning kidney and excluded 118 for not having undergone a nephrectomy. We therefore included 92 patients with an average follow-up time of 21 years (1-51 years). The study variables were the following: anthropometric data (sex, age, weight, height and body mass index [BMI]), reason for nephrectomy, glomerular filtration rate (GFR), (GFR evolution from the time of the procedure to the present, and time of initiation for stage 3, (GFR 30-59ml/min), stage 4 (GFR 15-29ml/min), stage 5 (GFR < 15ml/min) or stage 5D (dialysis).<span class="elsevierStyleSup">13 </span>Cardiovascular risk factors were proteinuria, HT, diabetes mellitus, dyslipidaemia and anaemia, as well as pharmacological treatments (ACEI and/or ARBs, statins and/or fibrates, erythropoietin and/or iron). Glomerular filtration rate was measured using creatinine clearance or MDRD depending on the time when the nephrectomy was performed (keep in mind that the method for measuring GFR has changed over the years). The study population was divided into two groups for further analysis. Group 1 consisted of patients whose GFR was > 60ml/min before surgery, and group 2 of patients whose GFR was above 60ml/min before surgery; both groups were analysed separately. SPSS 15 software was used for the statistical study, and the quantitative variables were compared for both groups using Student’s t-test and the Wilcoxon test depending on variable distribution. The Kaplan-Meier method was used to predict time of evolution. Meanwhile, binary multivariate logistic regression analysis was used to analyse the influence of different factors on the progression of chronic kidney disease (CKD). </p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS </span></p><p class="elsevierStylePara">The patient total was 46.92% male; patients’ average age was 67 years (22-89) and 53.08% of them had a left nephrectomy. The cause of the nephrectomy was pyelonephritis in 24 cases, tuberculosis in 13, lithiasis in 12, clear cell carcinoma in 12, congenital dysplasia in 7, adenocarcinoma in 6, other tumours in 8, traffic accidents in 4, hydronephrosis in 4, live donation in one and renal haematoma in one. Lithiasis in the reserved kidney was present in 17.39% of the patients, with subsequent episodes of renal colic or pyelonephritis. Group 1 (GFR < 60ml/min) consisted of 24 patients, 46% of which were male. They had the following characteristics at the time of the nephrectomy: average age 51 years (32-75), average GFR 48ml/min (18-59ml/min; 86% stage 3), 63% with HT and 8% with proteinuria. In this group, 58% did not experience decreased renal function during follow-up; in the rest (42%), there was an average delay of 20 years (10-30 years) to evolve from stage 4 to stage 5, and five cases needed renal replacement therapy (21%) (Table 1). Group 2 (GFR > 60ml/min) consisted of 68 patients, 44.2% of which were male. They had the following characteristics at the time of the surgical procedure: Average age 51.5 years (16-60), average GFR of 76.5ml/min (60-133.8ml/min), 34% with HT and 10% with proteinuria. In group 2, 80% reached stage 3 in an average of 17.47 years after the operation (1-48 years). These patients’ condition at present is as follows: 54.4% in stage 3; 17.64% in stage 4; 1.4% in stage 5, and 7.3% in stage 5D (Table 1). Throughout a follow-up period spanning an average of 22 years (6 to 33 years), 19.1% presented a GFR higher than 60ml/min. The risk factors for both population groups at the time of the nephrectomy and at the present time are shown in Table 2. Table 3 describes the treatment currently administered to patients. We find no significant differences. In the second group, 10% of the patients presented proteinuria. Throughout the follow-up period, we observe that 62% of the patients have had proteinuria, with an average level of 1.26g/24 h (0.3 to 4.9g/24 h). In group 1, corresponding to patients who had a decreased kidney function at the time of the surgery, 8% of the patients presented proteinuria; this number became 57.14%, with an average proteinuria level of 0.52g/24 h (0.3 to 1g/24 h). Evolution of kidney function in group 2 patients with proteinuria before the surgery was as follows: 44% in stage 3, 28% in stage 4 and 28% on renal replacement therapy (RRT). If we analyse our population by BMI, we find that those with a BMI higher than 30 are more likely to have proteinuria than those with a lower BMI, although we did not detect greater deterioration of kidney function (Table 4). In the group with a pre-surgery GFR higher than 60ml/min (group 1), 50% of the population reaches stage 3 in seven years according to the Kaplan-Meier curve (Figure 1). In group 2, the mean time to reach stage 5D is 23 years (19 to 27) (Figure 2). In group 1, progression from stage 4 to stage 5 occurs in a mean time of 10-30 years, and dialysis is needed in 24% of the cases. We must consider the presence of risk factors: 87.5% obesity, 71% HT, 57.14% proteinuria, 43% dyslipidaemia, 41.66% diabetes mellitus and 33.33% anaemia. All of the above favour the progression of kidney disease, although when we realize how long it takes for patients to progress to stage 4 or 5, we can state that evolution is slow. In group 2, the average time to reach stage 3 is 17.3 years after the surgery. Only 7% of the patients require RRT and 54% of the patients did not reach stage 4 or 5. After 22 years of follow-up, 19% of the patients in this group continued to maintain a GFR of more than 60ml/min. In the logistic regression analysis, the only variable predicting evolution toward renal failure is GFR at the time of the nephrectomy; patients with proteinuria tended to present a decrease in filtration that was not statistically significant. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">In our study, the only significant factor for predicting CKD progression was GFR below 60ml/min at the time of surgery, which results in a faster decrease in GFR. We cannot ignore the fact that this study has an important limitation, due to being a retrospective study with many years of follow-up. Furthermore, it has a selection bias, since the patients in the study include both those who were referred after surgery or at such time as they presented a slight decrease in renal function and those who had another type of associated cardiovascular disease. As we see in other studies of healthy nephrectomised patients, the decrease in GFR also occurs very slowly in our study.<span class="elsevierStyleSup">14,15 </span>The average time in which a patient in the group with GFR > 60 reached stage 3 was 17.3 years. In other studies, progression is slower and patients present statistically significant comorbidity factors such as obesity and proteinuria.<span class="elsevierStyleSup">16,17 </span>The rapid decrease in GFR in these patients is therefore related not only to the hyperfiltration phenomenon but also to the associated risk factors. If we analyse proteinuria considering GFR, we see that patients in the higher GFR group present increased proteinuria. This is because if GFR decreases, then the glomerulus ability to excrete proteins is also less; the lower the GFR, the lower the proteinuria. However, we also observe that over time, there has been an increase in proteinuria in both groups. The measurement technique employed has probably had an effect; proteinuria was initially measured using a 24-hour proteinuria test. This type of technique tends to lead to proteinuria assessment errors due to the difficulty quantifying the true volume in diuresis. The technique that best reflects proteinuria level is the urinary protein-creatinine index, which is the one used today. At the same time, we observe a significant increase in proteinuria over time, and one that is larger than that observed in studies of nephrectomised patients with no associated risk factors,<span class="elsevierStyleSup">18 </span>due to most of our patients presenting an associated condition along with proteinuria at the time of the nephrectomy. Among the six patients that received RRT, four presented kidney diseases that tend to affect both kidneys (two had tuberculosis [TB], one had pyelonephritis, and the last had renal lithiasis). Therefore, at the time of surgery, these patients had a lower renal mass. In our group, six patients presented a notably longer follow-up time (surgeries performed between 1956 and 1962) and the reason for the surgical procedure was renal lithiasis in four cases and pyelonephritis in the other two. In this group, we observe that the patients’ GFRs were not below 60ml/min, and that after 43 and 36 years of followup in our department, none has needed RRT and their mean GFR is 32.28ml/min (range: 48 to 23ml/min). At present, all of these patients have HT and 66.6% present proteinuria, which is under good control with pharmacological treatment. These are the patients with the longest follow-up and examination histories in our department, and they seem to be progressing well. If we analyse our patients by their BMI, we see that present more proteinuria (differences are not significant), but we do not observe differences having to do with renal failure progression. This is because there are high numbers of obese patients in both groups. This result differs from findings in the study by Praga et al. These authors evaluated the correlation between obesity and decreased GFR due to hyperfiltration in a group of patients with unilateral nephrectomies. They observed that obesity in the nephrectomised patients favours developing proteinuria and renal failure.<span class="elsevierStyleSup">19-21 </span>We may therefore conclude that in the study population, the only significant factor for predicting CKD progression in nephrectomised patients is a GFR below 60ml/min at the time of surgery. Furthermore, we observe a tendency toward progression to renal failure in patients with proteinuria </p><p class="elsevierStylePara"><a href="grande/1023018078_tripav30_n2_2010_t1_pag203_copy1.jpg" class="elsevierStyleCrossRefs"><img src="1023018078_tripav30_n2_2010_t1_pag203_copy1.jpg" alt="Current stage according to glomerular filtration rate."></img></a></p><p class="elsevierStylePara">Table 1. Current stage according to glomerular filtration rate.</p><p class="elsevierStylePara"><a href="grande/1023018078_tripav30_n2_2010_t2_pag204.jpg" class="elsevierStyleCrossRefs"><img src="1023018078_tripav30_n2_2010_t2_pag204.jpg" alt="Risk factors for groups 1 and 2 at the time of the nephrectomy and at prese"></img></a></p><p class="elsevierStylePara">Table 2. Risk factors for groups 1 and 2 at the time of the nephrectomy and at prese</p><p class="elsevierStylePara"><a href="grande/10230108_a9_t3_treatment_for_groups_1_and_2_at_present.jpg" class="elsevierStyleCrossRefs"><img src="10230108_a9_t3_treatment_for_groups_1_and_2_at_present.jpg" alt="Treatment for groups 1 and 2 at present"></img></a></p><p class="elsevierStylePara">Table 3. Treatment for groups 1 and 2 at present</p><p class="elsevierStylePara"><a href="grande/10230108_a9_t4_classification_according_to_bmi_at_the_time_of_the_nephrectomy.jpg" class="elsevierStyleCrossRefs"><img src="10230108_a9_t4_classification_according_to_bmi_at_the_time_of_the_nephrectomy.jpg" alt="Classification according to BMI at the time of the nephrectomy and the stages of renal failure patients have reached, and according to current presence of proteinuria."></img></a></p><p class="elsevierStylePara">Table 4. Classification according to BMI at the time of the nephrectomy and the stages of renal failure patients have reached, and according to current presence of proteinuria.</p><p class="elsevierStylePara"><a href="grande/10230108_a9_f1_survival_before_reaching_stage_3_in_group_2_patients.jpg" class="elsevierStyleCrossRefs"><img src="10230108_a9_f1_survival_before_reaching_stage_3_in_group_2_patients.jpg" alt="Survival before reaching stage 3 in group 2 patients (GFR > 60ml/min) following the nephrectomy."></img></a></p><p class="elsevierStylePara">Figure 1. Survival before reaching stage 3 in group 2 patients (GFR > 60ml/min) following the nephrectomy.</p><p class="elsevierStylePara"><a href="grande/10230108_a9_f2.jpg" class="elsevierStyleCrossRefs"><img src="10230108_a9_f2.jpg" alt="Survival before reaching stage 5D in group 1 patients (GFR < 60ml/min) following the nephrectomy."></img></a></p><p class="elsevierStylePara">Figure 2. Survival before reaching stage 5D in group 1 patients (GFR < 60ml/min) following the nephrectomy.</p>" "pdfFichero" => "P1-E47-S1877-A10230-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437417" "palabras" => array:1 [ 0 => "Monorreno quirúrgico" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437419" "palabras" => array:1 [ 0 => "Proteinuria" ] ] ] "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437418" "palabras" => array:1 [ 0 => "Surgical solitary kidney patients" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437420" "palabras" => array:1 [ 0 => "Proteinuria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "<p class="elsevierStylePara">Data recorded from external visit in hospitals, reflects high number of nephrectomized patients. Most of these patients were remitted after any surgery or deteriorizated renal function or any other associated pathology. Several studies of nephrectomized patients are reported in literature concerning both healthy patients and comorbility factors, and renal function and its evolution are evaluated. However, obtained results present a wide variability, which needs to be assessed. In this study we present a retrospective observational study of 92 one-kidney surgical patients, visited in Nephrology surgery of University Clinic Hospital. Patients presented an average age of 67 years old (range 22-89 years old), and a post-surgery monitoring of 21 years. Population was divided in two groups according with their glomerular filtration (FG). Before surgery, group 1 presented FG <60 ml/min and group 2 >60 ml/min, respectively. Group 1 patients (a total of 24 patients) presented an FG average of 48 ml/min, 8% had proteinuria and 63% presented high blood pressure. 21% of them needed an average of 20 years (10-30 years) to reach E4 and E5 steps and in general, most of them progressed to insufficient renal chronic disease. Five cases achieved renal therapy replacement. Group 2 patients, composed of a total of 68 patients, had an FG average of 76.5 ml/min, and 10% of patients presented proteinuria and 34% HTA; however, 80% of group 2 patients achieve E3 step with average age of 17 years, and a post-surgery of 47 years (1-48 years). A total of 19.1 % presented an FG higher 60 ml/min with an average development of 22 years along their evolution. According to the results obtained it is suggested that monorrenal surgical patients present a low progression of renal disease and it is also observed a progressive tendency to the chronic renal failure due to emerging of proteinuria.</p>" ] "es" => array:1 [ "resumen" => "<p class="elsevierStylePara">A las consultas externas de nefrología acude un importante número de pacientes nefrectomizados, quienes son remitidos tras la cirugía o bien cuando presentan un deterioro de la función renal o alguna otra patología asociada. Existen diferentes estudios sobre pacientes nefrectomizados en los que se valoran la función renal y su evolución (tanto en sanos como en pacientes con factores de comorbilidad), con unos resultados muy variables. Presentamos un estudio observacional y retrospectivo sobre 92 pacientes, monorrenos quirúrgicos, atendidos en las consultas de nefrología de nuestro centro, con una edad promedio de 67 años (rango, 22-89 años) y con un promedio de seguimiento posterior a la cirugía de 21 años. La población fue dividida en dos grupos según el filtrado glomerular (FG): los pacientes del grupo 1 presentaban un FG inferior a 60 ml/min antes de la cirugía y los del grupo 2 presentaban un FG superior a 60 ml/min. En el grupo 1, en el momento de la nefrectomía, 24 pacientes tenían un FG promedio de 48 ml/min, el 63% hipertensión arterial (HTA) y el 8% presentaban proteinuria. El 21% de los pacientes del grupo 1 tardó 20 años de promedio (10-30 años) en entrar en estadios 4 y 5, y 5 casos evolucionaron hasta necesitar terapia renal sustitutiva. El grupo 2 estaba formado por 68 pacientes con un FG promedio de 76,5 ml/min, un 34% con HTA y un 10% con proteinuria. El 80% del grupo 2 alcanzó el estadio 3 en un promedio de 17,47 años después de la intervención quirúrgica (1-48 años). El 19,1% presentaron, a lo largo de su evolución, un FG superior a 60 ml/min, tras una media de 22 años de evolución. Nuestros resultados indican que los pacientes monorrenos quirúrgicos presentan una progresión de la enfermedad renal muy lenta, y se observa una tendencia a la progresión de la insuficiencia renal al presentar proteinuria.</p>" ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "1023018078_tripav30_n2_2010_t1_pag203_copy1.jpg" "Alto" => 179 "Ancho" => 525 "Tamanyo" => 20639 ] ] "descripcion" => array:1 [ "en" => "Current stage according to glomerular filtration rate." ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "1023018078_tripav30_n2_2010_t2_pag204.jpg" "Alto" => 381 "Ancho" => 1080 "Tamanyo" => 76843 ] ] "descripcion" => array:1 [ "en" => "Risk factors for groups 1 and 2 at the time of the nephrectomy and at prese" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Tab. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10230108_a9_t3_treatment_for_groups_1_and_2_at_present.jpg" "Alto" => 210 "Ancho" => 533 "Tamanyo" => 20089 ] ] "descripcion" => array:1 [ "en" => "Treatment for groups 1 and 2 at present" ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Tab. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10230108_a9_t4_classification_according_to_bmi_at_the_time_of_the_nephrectomy.jpg" "Alto" => 194 "Ancho" => 1094 "Tamanyo" => 32848 ] ] "descripcion" => array:1 [ "en" => "Classification according to BMI at the time of the nephrectomy and the stages of renal failure patients have reached, and according to current presence of proteinuria." ] ] 4 => array:7 [ "identificador" => "fig5" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10230108_a9_f1_survival_before_reaching_stage_3_in_group_2_patients.jpg" "Alto" => 530 "Ancho" => 527 "Tamanyo" => 29808 ] ] ] 5 => array:8 [ "identificador" => "fig6" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10230108_a9_f2.jpg" "Alto" => 548 "Ancho" => 529 "Tamanyo" => 28480 ] ] "descripcion" => array:1 [ "en" => "Survival before reaching stage 5D in group 1 patients (GFR < 60ml/min) following the nephrectomy." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Brenner BM, Meyer TW, Hostetter TH. Dietary protein intake and the progressive nature of kidney disease: The role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular esclerosis in aging, renal ablation and intrinsic renal disease. N Engl J Med 1982;307:652-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7050706" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Flores O, Mac Laughlin M, Gallego B, López-Novoa JM. Factores que desencaden en glomeruloesclerosis después de la reducción de la masa renal. Nefrologia 1996;26(Supl. 3):14-21." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Rennke HG. Structural alterations associated with glomerular hyperfiltration. En: Mitch WE, Brenner BM, Stein JH (eds.). The Progressive Nature of Renal Disease. New York: Churchill Livingstone, 1986;111-31." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "itemHostRev" => array:3 [ "pii" => "S1525861013001692" "estado" => "S300" "issn" => "15258610" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Neil B, Ramesh Prasad GV, Knoll G, Muirhead N, Thiessen-Phil-brook H, Yang RC, et al. Meta-analysis: risk for hypertension in living kidney donors. Ann Intern Med 2006;145(3):185-96. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16880460" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Hunsicker LG, Adler S, Caggiula A, et al. Predictors of the progression of renal disease in the modification of diet in renal disease study. Kidney Int 1997;51(6):1908-19. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9186882" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "itemHostRev" => array:3 [ "pii" => "S0378512212001545" "estado" => "S300" "issn" => "03785122" ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Fogo AB. Progression versus regression of chronic kidney disease. Nephrol Dial Transplant 2006;21(2):281-4. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16311260" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Kasiske BL, Ma JZ, Louis TA, Swan SK. Long-term effects of reduced renal mass in humans. Kidney Int 1995;48:814-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7474669" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Narkum-Burgess DM, Nolan CR, Norman JE, Page WF, Miller PL, Meyer TW. Forty-five year follow-up after uninephrectomy. Kidney Int 1993;43:1110-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/8510390" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Argueso LR, Ritchey ML, Boyle ET, Milliner DS, Bergstralh EJ, Kramer SA. Prognosis of children with solitary kidney after unilateral nephrectomy. J Urol 1992;148:747-51. <a href="http://www.ncbi.nlm.nih.gov/pubmed/1640559" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lent V, Harth J. Nephropathy in remmant kidneys: pathological proteinuria after unilateral nephrectomy. J Urol 1994;152:312-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/8015059" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ommen ES, Winston JA, Murphy B. Medical risks in living kidney donors: absence of proof is not proof of absence. Clin J Am Soc Nephrol 2006;1:885-95. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17699301" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Goldfarb DA, Matin SF, Braun WE, Schreiber MJ, Mastroianni B, Papajcik D, et al. Renal outcome 25 years after donor nephrectomy. J Urol 2001;166:2043-50." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "K/DOQI clinical practice guidelines for chronic kidney disease. Evaluation, classification, and stratification. Kidney Disease Outcome Quality Initiative. Am J Kidney Dis 2002;39(Suppl 1):S1-266." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Riehl J, Schmitt H, Bongrtz D, Bergmann D, Sieberth HG. Long-term follow-up of kidney donors: a longitudinal study. Nephrol Dial Transplant 1997;12:1615-21. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9269638" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ibrahim HN, Fole R, LiPing Tan BS, Rogers T, Bailey RF, Guo H, et al. Long-term consequences of kidney donation. N Engl J Med 2009;360-5." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Young A, Storsley L, Garg AX, Treleaven D, Nguan CY, Cuerden MS, et al. Health outcomes for living kidney donors with isolated medical abnormalities: a systematic review. Am J Transplant 2008;8:1878-90. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18671676" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Textor SC, Taler SJ, Driscoll N, et al. Blood pressure and renal function after kidney donation from hypertensive living donors. Transplantation 2004;78:276-82. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15280690" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Garg AX. Proteinuria and reduced kidney function in living kidney donors: a systematic review, meta-analysis, and meta-regression. Kidney Int 2006;70:1801-10. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17003822" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Praga M, Morales E, Herrero JC, Revilla Y, Bello I, Díaz González R. Disminución de la masa renal funcionante y proteinuria. Nefrologia 1998;28(Supl. 1):17-22. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18957007" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Morales E, Herrero JC, Revilla Y, Domínguez-Gil B, Bello I, Díaz González R, et al. Influence of obesity on the appearance of proteinuria and renal insufficiency in patients with renal mass reduction. Nephrol Dial Transplant 1999;14:A47." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Praga M, Hernández E, Morales E, Campos AP, Valero MA, León M. Clinical features and long-term outcome of obesity-associated focal segmental glomerulosclerosis. Nephrol Dial Transplant 2001;16:1790-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11522860" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003000000002/v0_201502091606/X2013251410036140/v0_201502091606/en/main.assets" "Apartado" => array:4 [ "identificador" => "35441" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Originals" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003000000002/v0_201502091606/X2013251410036140/v0_201502091606/en/P1-E47-S1877-A10230-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251410036140?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 9 | 15 |
| 2024 October | 55 | 53 | 108 |
| 2024 September | 61 | 38 | 99 |
| 2024 August | 62 | 59 | 121 |
| 2024 July | 72 | 30 | 102 |
| 2024 June | 85 | 46 | 131 |
| 2024 May | 73 | 54 | 127 |
| 2024 April | 47 | 37 | 84 |
| 2024 March | 37 | 39 | 76 |
| 2024 February | 41 | 50 | 91 |
| 2024 January | 46 | 27 | 73 |
| 2023 December | 33 | 42 | 75 |
| 2023 November | 44 | 40 | 84 |
| 2023 October | 50 | 31 | 81 |
| 2023 September | 50 | 40 | 90 |
| 2023 August | 56 | 25 | 81 |
| 2023 July | 81 | 35 | 116 |
| 2023 June | 56 | 31 | 87 |
| 2023 May | 56 | 31 | 87 |
| 2023 April | 37 | 16 | 53 |
| 2023 March | 45 | 25 | 70 |
| 2023 February | 34 | 19 | 53 |
| 2023 January | 40 | 19 | 59 |
| 2022 December | 52 | 38 | 90 |
| 2022 November | 45 | 27 | 72 |
| 2022 October | 46 | 49 | 95 |
| 2022 September | 57 | 28 | 85 |
| 2022 August | 47 | 43 | 90 |
| 2022 July | 47 | 50 | 97 |
| 2022 June | 60 | 45 | 105 |
| 2022 May | 60 | 24 | 84 |
| 2022 April | 84 | 61 | 145 |
| 2022 March | 76 | 55 | 131 |
| 2022 February | 50 | 49 | 99 |
| 2022 January | 42 | 31 | 73 |
| 2021 December | 55 | 40 | 95 |
| 2021 November | 65 | 36 | 101 |
| 2021 October | 75 | 40 | 115 |
| 2021 September | 32 | 35 | 67 |
| 2021 August | 56 | 36 | 92 |
| 2021 July | 66 | 32 | 98 |
| 2021 June | 56 | 33 | 89 |
| 2021 May | 59 | 33 | 92 |
| 2021 April | 112 | 81 | 193 |
| 2021 March | 73 | 32 | 105 |
| 2021 February | 89 | 17 | 106 |
| 2021 January | 31 | 16 | 47 |
| 2020 December | 22 | 18 | 40 |
| 2020 November | 43 | 4 | 47 |
| 2020 October | 25 | 13 | 38 |
| 2020 September | 29 | 8 | 37 |
| 2020 August | 42 | 5 | 47 |
| 2020 July | 50 | 12 | 62 |
| 2020 June | 52 | 4 | 56 |
| 2020 May | 57 | 15 | 72 |
| 2020 April | 36 | 22 | 58 |
| 2020 March | 64 | 10 | 74 |
| 2020 February | 79 | 19 | 98 |
| 2020 January | 82 | 24 | 106 |
| 2019 December | 77 | 22 | 99 |
| 2019 November | 49 | 18 | 67 |
| 2019 October | 52 | 16 | 68 |
| 2019 September | 60 | 19 | 79 |
| 2019 August | 51 | 16 | 67 |
| 2019 July | 33 | 22 | 55 |
| 2019 June | 36 | 22 | 58 |
| 2019 May | 37 | 24 | 61 |
| 2019 April | 40 | 36 | 76 |
| 2019 March | 36 | 19 | 55 |
| 2019 February | 23 | 14 | 37 |
| 2019 January | 25 | 17 | 42 |
| 2018 December | 56 | 42 | 98 |
| 2018 November | 55 | 7 | 62 |
| 2018 October | 45 | 12 | 57 |
| 2018 September | 58 | 15 | 73 |
| 2018 August | 48 | 14 | 62 |
| 2018 July | 52 | 23 | 75 |
| 2018 June | 46 | 17 | 63 |
| 2018 May | 41 | 16 | 57 |
| 2018 April | 62 | 10 | 72 |
| 2018 March | 60 | 14 | 74 |
| 2018 February | 47 | 12 | 59 |
| 2018 January | 56 | 10 | 66 |
| 2017 December | 61 | 9 | 70 |
| 2017 November | 48 | 12 | 60 |
| 2017 October | 44 | 8 | 52 |
| 2017 September | 44 | 12 | 56 |
| 2017 August | 30 | 9 | 39 |
| 2017 July | 33 | 11 | 44 |
| 2017 June | 37 | 9 | 46 |
| 2017 May | 46 | 9 | 55 |
| 2017 April | 27 | 10 | 37 |
| 2017 March | 31 | 7 | 38 |
| 2017 February | 31 | 10 | 41 |
| 2017 January | 24 | 7 | 31 |
| 2016 December | 57 | 6 | 63 |
| 2016 November | 49 | 6 | 55 |
| 2016 October | 79 | 4 | 83 |
| 2016 September | 136 | 6 | 142 |
| 2016 August | 178 | 7 | 185 |
| 2016 July | 150 | 12 | 162 |
| 2016 June | 118 | 0 | 118 |
| 2016 May | 125 | 0 | 125 |
| 2016 April | 76 | 0 | 76 |
| 2016 March | 78 | 0 | 78 |
| 2016 February | 108 | 0 | 108 |
| 2016 January | 81 | 0 | 81 |
| 2015 December | 114 | 0 | 114 |
| 2015 November | 97 | 0 | 97 |
| 2015 October | 92 | 0 | 92 |
| 2015 September | 74 | 0 | 74 |
| 2015 August | 61 | 0 | 61 |
| 2015 July | 69 | 0 | 69 |
| 2015 June | 34 | 0 | 34 |
| 2015 May | 33 | 0 | 33 |
| 2015 April | 6 | 0 | 6 |
Show all
