End stage renal disease associated with diabetes in the Canary Islands: a public health problem with significant human suffering and high economic costs
La enfermedad renal terminal asociada con diabetes en las Islas Canarias: un problema de salud pública, de elevado sufrimiento humano y alto coste económico
Read
7813
Timeswas read the article
2088
Total PDF
5725
Total HTML
Share statistics
array:21 [ "pii" => "X2013251410050524" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2010.Jun.10455" "estado" => "S300" "fechaPublicacion" => "2010-07-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2010;30:381-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3623 "formatos" => array:3 [ "EPUB" => 254 "HTML" => 2871 "PDF" => 498 ] ] "Traduccion" => array:1 [ "es" => array:17 [ "pii" => "X0211699510050527" "issn" => "02116995" "doi" => "10.3265/Nefrologia.pre2010.Jun.10455" "estado" => "S300" "fechaPublicacion" => "2010-07-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia. 2010;30:381-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 7462 "formatos" => array:3 [ "EPUB" => 295 "HTML" => 6600 "PDF" => 567 ] ] "es" => array:9 [ "idiomaDefecto" => true "titulo" => "La enfermedad renal terminal asociada con diabetes en las Islas Canarias: un problema de salud pública, de elevado sufrimiento humano y alto coste económico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "381" "paginaFinal" => "384" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "End stage renal disease associated with diabetes in the Canary Islands: a public health problem with significant human suffering and high economic costs" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "V. Lorenzo, M. Boronat" "autores" => array:2 [ 0 => array:2 [ "Iniciales" => "V." "apellidos" => "Lorenzo" ] 1 => array:2 [ "Iniciales" => "M." "apellidos" => "Boronat" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "X2013251410050524" "doi" => "10.3265/Nefrologia.pre2010.Jun.10455" "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/X2013251410050524?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699510050527?idApp=UINPBA000064" "url" => "/02116995/0000003000000004/v0_201502091427/X0211699510050527/v0_201502091427/es/main.assets" ] ] "itemSiguiente" => array:17 [ "pii" => "X2013251410050516" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2010.Jun.10463" "estado" => "S300" "fechaPublicacion" => "2010-07-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2010;30:385-93" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6837 "formatos" => array:3 [ "EPUB" => 282 "HTML" => 5522 "PDF" => 1033 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Growth factors and renal regeneration" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "385" "paginaFinal" => "393" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Factores de crecimiento y regeneración renal" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Flaquer, P. Romagnani, J.M. Cruzado" "autores" => array:3 [ 0 => array:2 [ "Iniciales" => "M." "apellidos" => "Flaquer" ] 1 => array:2 [ "Iniciales" => "P." "apellidos" => "Romagnani" ] 2 => array:2 [ "Iniciales" => "J.M." "apellidos" => "Cruzado" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699510050519" "doi" => "10.3265/Nefrologia.pre2010.Jun.10463" "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/X0211699510050519?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251410050516?idApp=UINPBA000064" "url" => "/20132514/0000003000000004/v0_201502091652/X2013251410050516/v0_201502091652/en/main.assets" ] "itemAnterior" => array:17 [ "pii" => "X2013251410050297" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2010.Jul.10549" "estado" => "S300" "fechaPublicacion" => "2010-07-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2010;30:0" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2735 "formatos" => array:3 [ "EPUB" => 261 "HTML" => 2053 "PDF" => 421 ] ] "en" => array:5 [ "idiomaDefecto" => true "titulo" => "Abstracts of the XXXVIII Congress of the Andalucian Society of Nephrology" "tieneTextoCompleto" => 0 "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "0" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resúmenes del XXXVIII Congreso de la Sociedad Andaluza de Nefrología" ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X021169951005029X" "doi" => "10.3265/Nefrologia.pre2010.Jul.10549" "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/X021169951005029X?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251410050297?idApp=UINPBA000064" "url" => "/20132514/0000003000000004/v0_201502091652/X2013251410050297/v0_201502091652/en/main.assets" ] "en" => array:10 [ "idiomaDefecto" => true "titulo" => "End stage renal disease associated with diabetes in the Canary Islands: a public health problem with significant human suffering and high economic costs" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "381" "paginaFinal" => "384" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "V. Lorenzo, M. Boronat" "autores" => array:2 [ 0 => array:4 [ "Iniciales" => "V." "apellidos" => "Lorenzo" "email" => array:1 [ 0 => "vls243@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "M." "apellidos" => "Boronat" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Médico adjunto. Servicio de Nefrología, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Médico adjunto. Sección de Endocrinología, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La enfermedad renal terminal asociada con diabetes en las Islas Canarias: un problema de salud pública, de elevado sufrimiento humano y alto coste económico" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">THE INCIDENCE OF END STAGE RENAL DISEASE ASSOCIATED WITH DIABETES (ESRD-DM) IN THE CANARY ISLANDS IS THREE TIMES THE NATIONAL AVERAGE</span></p><p class="elsevierStylePara">The high incidence and prevalence of patients with end stage renal disease (ESRD) in the Canary Islands (CI) has been well-documented for more than a decade.<span class="elsevierStyleSup">1-3</span> While successive annual registries of the Spanish Society of Nephrology (S.E.N.) show a national average incidence of 125-130 patients per million population (ppm) per year, the Canary Islands report an incidence around 180-185 ppm.<span class="elsevierStyleSup">3,4</span></p><p class="elsevierStylePara">A detailed analysis of primary kidney disease among the Autonomous Communities (AC) shows that this difference is due to the high proportion of diabetic patients that begin dialysis in the CI. The rest of the kidney diseases, although with variations between AC, do not have a relevant impact on the total incidence rate.<span class="elsevierStyleSup">1</span> The national average incidence of ESRD-DM is found in the range of 20-30 ppm, while in the Canary Islands these values were three times higher, 65 ppm.<span class="elsevierStyleSup">3,4</span> From these observations, we quickly coined the phrase “in the Canary Islands there is a lot of diabetes” as the most probable explanation for the high rate of ESRD-DM.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">THE PREVALENCE OF SELF-REPORTED DIABETES IN THE CANARY ISLANDS DOES NOT EXPLAIN THIS PHENOMENON</span></p><p class="elsevierStylePara">However, this supposition is not clear. The challenge is to answer the following question: Is the high incidence of ESRD-DM due to a high prevalence of diabetes in the general population? Preliminary studies suggest this possibility;<span class="elsevierStyleSup">5,6</span> however, two more recent population studies describe a relatively high prevalence with respect to other regions in Spain, but not so disproportionate as to explain the high rate of chronic kidney complications.<span class="elsevierStyleSup">7,8</span> In any case, there are no comparative homogeneous studies on the prevalence of diabetes in the general Spanish population. It is not possible to compare the studies that have been published because of the methodology that they used, moreover, they only focus on the prevalence in certain areas.</p><p class="elsevierStylePara">In a recent study, we analysed the prevalence of diabetes in the adult Spanish population, based on surveys by the Ministry of Health and Consumer Affairs conducted in 2003 and 2006.<span class="elsevierStyleSup">9</span> The main limitation of this source is that it only includes known diabetes, or “self-reported”, based on individual surveys. However, it is the only source of data that provides homogeneous information. The analysis of this data showed that the prevalence of self-reported diabetes in the surveys of 2003 and 2006 was within the range of 4-8% in Spain, and very close to 7% in the CI, in both surveys.<span class="elsevierStyleSup">10</span> That is, the prevalence of diabetes in the CI does not explain the alarming incidence of ESRD-DM.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">A DIABETIC PATIENT IN THE CANARY ISLANDS HAS 3.9-FOLD HIGHER RISK OF NEEDING DIALYSIS THAN A DIABETIC PATIENT IN THE REST OF SPAIN</span></p><p class="elsevierStylePara">The ESRD-DM incidence data published in patient registries or scientific journals is usually expressed in per million population. This hampers our evaluation of the influence of the prevalence of diabetes in the general population on the epidemiology of ESRD-DM. With the aim of clarifying this concept, we analysed the incidence of ESRD-DM in relation to the rate of patients at risk, that is, to diabetic individuals in the general population.<span class="elsevierStyleSup">10</span> Using the Poisson regression model, along with the surveys from 2003 and 2006 to give strength to the model, and controlling by age groups, we see that a diabetic patient in the CI has 3.9 times (95% CI, 3.1-4.9) the risk of dialysis with respect to the rest of the AC in Spain. The difference between other CAs was small. Of particular interest is that in the age group older than 75 years the differences are most striking, with ESRD-DM incidence being seven times higher in the CI than the Spanish average. A difference of this magnitute between regions of the same country has no precedent and needs a thorough analysis of the factors leading to these circumstances.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">DIABETES IN THE CANARY ISLANDS STARTS EARLY AND IS ASSOCIATED WITH GREATER MORBIDITY AND MORTALITY</span></p><p class="elsevierStylePara">The analysis by age groups provided us with additional relevant information. One in four diabetics (25%) in the CI were less than 45 years old while in the rest of Spain this percentage is in the range of 8-12%. That is, globally there is not a higher prevalence of diabetes, but the diabetes mellitus starts earlier. At the other end of the age spectrum, we found more epidemiologic information of interest: in the group older than 75, the proportion of diabetic individuals was significantly less in the CI. In other words, compared with the rest of Spain, in the CI diabetes mellitus starts early, the time of exposure to the disease increases, and as a consequence, the risk of chronic complications such as nephropathy and the number of fatal outcomes increases. This is most evident in the older age groups and is consistent with data from the Ministry of Health, which show that the CI are among the regions with highest mortality associated with diabetes.<span class="elsevierStyleSup">11</span> The combined analysis of data helps us understand the high rate of ESRD-DM when we use the population at risk as the denominator, i.e., diabetics in the general population.</p><p class="elsevierStylePara">Although we have taken another step forward, the reasons for the early development of diabetes in the CI and the high morbidity and long-term mortality remain unclear.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">POSSIBLE BIASES AND LIMITATIONS OF THIS ANALYSIS</span></p><p class="elsevierStylePara">1. Statistical use of known or self-reported diabetes instead of the real prevalence of diabetes. It was the only consistent source of data for comparative analysis. It could be questioned that the prevalence of “hidden” diabetes is not uniform between AC. There are data supporting that the ratio of known and unknown diabetes is approximately 50%, and does not significantly change between regions. <span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara">2. Renal patient registries do not use standard criteria to assign primary renal disease. It is another potential source of bias, although it is unlikely to explain such a difference.</p><p class="elsevierStylePara">3. Is it possible that patients survive longer and therefore develop ESRD more frequently? This hypothesis is not sustainable, because as we noted previously, the mortality associated with diabetes and cardiovascular complications is higher in the CI.</p><p class="elsevierStylePara">4. Uneven distribution of health resources. Since the Spanish health system provides universal coverage throughout the country, this factor cannot be decisive in the proportion of patients starting dialysis between regions.</p><p class="elsevierStylePara">5. Different criteria for acceptance of home dialysis patients. This should be taken into account, but it is difficult to be sure about this considering the information available. Spanish registration data of renal patients show some differences in the average age of the incidents. However, the average age of onset is similar in the CI and several AC in which the incidence of ESRD-DM is clearly lower. This should affect all causes of ESRD, and is highly unlikely to explain the magnitude of the differences displayed between the IC and the rest of Spain.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">COULD THERE BE A GENETIC BASIS?</span></p><p class="elsevierStylePara">Without doubt, this is a factor to be taken into account, although we lack information. The population of the CI is mainly of European origin, with a native minority mainly of North African origin.<span class="elsevierStyleSup">13</span> Currently there are initiatives to investigate genes that may confer sensibility to early development of diabetes and nephropathy, although it will be a difficult task given the size and heterogeneity of the genes involved.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">SOCIOCULTURAL DEPRIVATION AND DISPARITY:</span><span class="elsevierStyleBold"> AN UNFAVOURABLE SCENARIO FOR PUBLIC HEALTH</span></p><p class="elsevierStylePara">Countless studies show that sociocultural deprivation and disparity are independent predictors of morbidity and mortality in all health scenarios.<span class="elsevierStyleSup">14-16</span> In countries with great population heterogeneity we find this relation to be most evident. To be more explicit, the expressions “deprivation” and “sociocultural disparity” can be considered synonyms of “poverty” and “social inequality”. As a consequence, the poor use less health resources, have lower compliance with treatment, and inadequate diet and health habits. We must add that, in more depressed areas, access to health resources is frequently more limited. In this context, population-based epidemiologic studies have shown that low sociocultural and health levels are associated with obesity,<span class="elsevierStyleSup">17 </span>cardiovascular complications,<span class="elsevierStyleSup">11 </span>the development of diabetes and ESRD.<span class="elsevierStyleSup">18</span> All of these adverse health conditions are more common in the CI than in the rest of Spain.<span class="elsevierStyleSup">19,20</span> Therefore, it is likely that sociocultural deprivation and disparity are major factors in the early onset of diabetes and the disproportionate incidence of ESRD-DM in the CI.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">THE ECONOMIC IMPACT OF HAEMODIALYSIS:</span><span class="elsevierStyleBold"> THE SAVINGS ARE IN PREVENTION</span></p><p class="elsevierStylePara">The analysis of the global cost of treatment can help find areas for improvement in terms of health and economy (see article by Lorenzo, et al. “Economic Evaluation of Haemodialysis. Analysis of Cost Components Based on Patient-Specific Data” <span class="elsevierStyleItalic">in this edition of the Journal).</span> Ours is the first study in Spain that analyses the cost by expenditure component, based on individual patient data, and which introduces the Diagnosis-Related Group (DRG) as the source of the cost of hospitalisations. The average annual cost per patient was 40,070 euros, of which approximately half are attributed to the hemodialysis sessions, followed by drug costs; while costs for hospitalisation are third, accounting for 17% of the overall cost.</p><p class="elsevierStylePara">One interesting lesson was that once haemodialysis was initiated, the economic impact is quite similar between patients, except for extreme cases of hospitalisation. This is because approximately 78% of the cost is due to the haemodialysis sessions (51%) and common medications (27%), without major differences between patients. From this analysis it appears that the economic savings is in the prevention of ESRD. Once on dialysis, the saving margins are very narrow.</p><p class="elsevierStylePara">This consideration is of special significance in the CI, where the incidence of ESRD-DM is three times the national average,<span class="elsevierStyleSup">1,2</span> representing a differential incidence of 80 diabetic patients more per year. If we reduced the incidence rate to the national average, this would generate an annual cost savings of 3.2 million Euros. Considering a survival of 85%, 70% and 65% in the first three years on haemodialysis (data from the Renal Patients Registry of the Canary Islands), the savings accumulated in a three-year period would be in the range of 15-25 million Euros.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">PROPOSAL FOR EARLY ACTION IN THE PUBLIC HEALTH FIELD </span></p><p class="elsevierStylePara">We are facing a devastating disease that, even though it has a universal dimension, is particularly serious in our region. Its increasing prevalence carries a significant human suffering and an enormous burden on the health budget. The different incidence rate among regions in a single country suggests that in the CI we are facing a combination of sociocultural factors associated with different access to health resources and, probably, also with a genetic basis.</p><p class="elsevierStylePara">To prevent or mitigate its impact is an urgent task and it requires a coordinated, patient and sustained effort from all health and social agents. The benefits of an effort of this type may be achieved in the long-term, but it is an absolute priority that is even more relevant if we consider that there is real room for improvement. It is well known that changes in lifestyle and the early use of renoprotective drugs can delay or even prevent the onset of chronic complications, such as diabetic nephropathy.<span class="elsevierStyleSup">21-23 </span>The most important thing is to act early. We are not facing a “renal” health problem, but rather a public health problem. To be considered as such, it must meet three basic requirements<span class="elsevierStyleSup">24</span>: <span class="elsevierStyleItalic">1)</span> a chronic disease with high-impact on morbidity and mortality, quality of life and costs, <span class="elsevierStyleItalic">2)</span> be unequally distributed, affecting socio-cultural groups with the greatest deprivation, and <span class="elsevierStyleItalic">3)</span> available prevention strategies are not yet developed. Diabetes and more specifically diabetic nephropathy in the CI meet all these criteria.</p>" "pdfFichero" => "P1-E501-S2438-A10455-EN.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lorenzo V, Martín Urcuyo B. Análisis epidemiológico del incremento de insuficiencia renal terminal asociada a diabetes mellitus tipo 2. Nefrologia 2000;20:77-81. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11190112" 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" => "Lorenzo V, Sánchez E, Vega N, Hernández D. Renal replacement therapy in the Canary Islands: demographic and survival analysis. J Nephrol 2006;19:97-103. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16523433" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ceballos M, López-Revuelta K, Saracho R, et al. Informe de diálisis y trasplante correspondiente al año 2002 de la Sociedad Española de Nefrología y Registros Autonómicos. Nefrologia 2005;25:121-9." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "López RK, Saracho R, García LF, et al. Informe de diálisis y trasplante año 2001 de la Sociedad Española de Nefrología y Registros Autonómicos. Nefrologia 2004;24:21-33." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "itemHostRev" => array:3 [ "pii" => "S1474442207700285" "estado" => "S300" "issn" => "14744422" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "De Pablos-Velasco PL, Martínez-Martín FJ, Rodríguez-Pérez F, et al. Prevalence and determinants of diabetes mellitus and glucose intolerance in a Canarian Caucasian population-comparison of the 1997 ADA and the 1985 WHO criteria. The Guia Study. Diabet Med 2001;18:235-41. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11318846" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "6.\u{A0}Martínez-Castelao A, De Álvaro F,\u{A0}Gorriz JL. Epidemiology of diabetic nephropathy in Spain. Kidney Int 2005;Suppl:S20-S24." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Boronat M, Varillas VF, Saavedra P, et al. Diabetes mellitus and impaired glucose regulation in the Canary Islands (Spain): prevalence and associated factors in the adult population of Telde, Gran Canaria. Diabet Med 2006;23:148-55. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16433712" 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" => "Cabrera de León A, Rodríguez-Pérez MC, Del Castillo-Rodríguez JC, et al. Estimación del riesgo coronario en la población de Canarias aplicando la ecuación de Framingham. Med Clin (Barc) 2006;126:521-6." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ministerio de Sanidad y Consumo. Health Statistics. Encuesta Nacional de Salud, 2009. Availabe at:\u{A0}http://www.msc.es/en/estadEstudios/estadisticas/encuestaNacional/home.htm\u{A0}" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "10.\u{A0}Lorenzo V, Boronat M, Saavedra P, et al. Disproportionately high incidence of diabetes-related end-stage renal disease in the Canary Islands. An analysis based on estimated population at risk. Nephrol Dial Transplant. Advance Access published on January 11, 2010. doi:10.1093/ndt/gfp761" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "itemHostRev" => array:3 [ "pii" => "S0140673608606947" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Villar AF, Banegas B Jr., Rodríguez AF, Del Rey CJ. Mortalidad cardiovascular en España y sus Comunidades Autónomas (1975-1992). Med Clin (Barc) 1998;110:321-7." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Goday A. Epidemiología de la diabetes y sus complicaciones no coronarias. Rev Esp Cardiol 2002;55:657-70. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12113725" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "13.\u{A0}Maca-Meyer N, Arnay M, Rando JC, et al. Ancient mtDNA analysis and the origin of the Guanches. Eur J Hum Genet 2004;12:155-62. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14508507" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "14.\u{A0}Jones CA, Krolewski AS, Rogus J, et al. Epidemic of end-stage renal disease in people with diabetes in the United States population: do we know the cause? Kidney Int 2005;67:1684-91. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15840014" 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" => "15.\u{A0}Bruce MA, Beech BM, Crook ED, et al. Association of Socioeconomic Status and CKD Among African Americans: The Jackson Heart Study. Am J Kidney Dis 2010." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Norris K, Nissenson AR. Race, gender, and socioeconomic disparities in CKD in the United States. J Am Soc Nephrol 2008;19:1261-70. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18525000" 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" => "Aranceta J, Pérez RC, Serra ML, et al. Prevalencia de obesidad en España: resultados del estudio SEEDO 2000. Med Clin (Barc) 2003;120:608-12." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "18.\u{A0}Ward MM. Socioeconomic status and the incidence of ESRD. Am J Kidney Dis 2008;51:563-72. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18371532" 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" => "19.\u{A0}Navarro López V, Benach de Rovira J.\u{A0}Social inequities of health in Spain. Report of the Scientific Commission for the Study of Social Inequities in Health in Spain. Rev Esp Salud Publica 1996;70:505-36." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "itemHostRev" => array:3 [ "pii" => "S1474442204007082" "estado" => "S300" "issn" => "14744422" ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Gutiérrez-Fisac JL, Rodríguez AF, Guallar-Castillón P, et al. Determinants of geographical variations in body mass index (BMI) and obesity in Spain. Int J Obes Relat Metab Disord 1999;23:342-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/10340810" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lorenzo V, Perestelo l, Barroso M, Torres A, Nazco J. Evaluación económica de la hemodiálisis. Análisis de los componentes del coste basado en datos individuales. Nefrologia 2010;30(4):x-x." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 21 => array:3 [ "identificador" => "bib22" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Gaede P, Vedel P, Parving HH, Pedersen O. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study. Lancet 1999;353:617-22. <a href="http://www.ncbi.nlm.nih.gov/pubmed/10030326" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 22 => array:3 [ "identificador" => "bib23" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003;348:383-93. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12556541" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 23 => array:3 [ "identificador" => "bib24" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Postma MJ, De ZD. The economic benefits of preventing end-stage renal disease in patients with type 2 diabetes mellitus. Nephrol Dial Transplant 2009;24:2975-83. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19605601" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 24 => array:3 [ "identificador" => "bib25" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "25.\u{A0}Schoolwerth AC, Engelgau MM, Hostetter TH, et al. Chronic kidney disease: a public health problem that needs a public health action plan. Prev Chronic Dis 2006;3:A57. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16539798" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003000000004/v0_201502091652/X2013251410050524/v0_201502091652/en/main.assets" "Apartado" => array:4 [ "identificador" => "35429" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorials" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003000000004/v0_201502091652/X2013251410050524/v0_201502091652/en/P1-E501-S2438-A10455-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251410050524?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 7 | 12 |
| 2024 October | 53 | 34 | 87 |
| 2024 September | 72 | 30 | 102 |
| 2024 August | 79 | 53 | 132 |
| 2024 July | 51 | 24 | 75 |
| 2024 June | 67 | 43 | 110 |
| 2024 May | 71 | 30 | 101 |
| 2024 April | 50 | 34 | 84 |
| 2024 March | 47 | 27 | 74 |
| 2024 February | 36 | 39 | 75 |
| 2024 January | 45 | 34 | 79 |
| 2023 December | 30 | 20 | 50 |
| 2023 November | 38 | 33 | 71 |
| 2023 October | 67 | 38 | 105 |
| 2023 September | 71 | 26 | 97 |
| 2023 August | 31 | 25 | 56 |
| 2023 July | 54 | 24 | 78 |
| 2023 June | 58 | 22 | 80 |
| 2023 May | 88 | 30 | 118 |
| 2023 April | 76 | 19 | 95 |
| 2023 March | 78 | 28 | 106 |
| 2023 February | 72 | 14 | 86 |
| 2023 January | 39 | 27 | 66 |
| 2022 December | 39 | 28 | 67 |
| 2022 November | 44 | 31 | 75 |
| 2022 October | 35 | 34 | 69 |
| 2022 September | 36 | 31 | 67 |
| 2022 August | 46 | 47 | 93 |
| 2022 July | 27 | 39 | 66 |
| 2022 June | 52 | 52 | 104 |
| 2022 May | 57 | 33 | 90 |
| 2022 April | 27 | 34 | 61 |
| 2022 March | 50 | 47 | 97 |
| 2022 February | 42 | 38 | 80 |
| 2022 January | 46 | 30 | 76 |
| 2021 December | 49 | 35 | 84 |
| 2021 November | 38 | 34 | 72 |
| 2021 October | 97 | 44 | 141 |
| 2021 September | 58 | 28 | 86 |
| 2021 August | 50 | 31 | 81 |
| 2021 July | 44 | 35 | 79 |
| 2021 June | 38 | 21 | 59 |
| 2021 May | 85 | 32 | 117 |
| 2021 April | 118 | 76 | 194 |
| 2021 March | 80 | 13 | 93 |
| 2021 February | 82 | 19 | 101 |
| 2021 January | 32 | 14 | 46 |
| 2020 December | 29 | 7 | 36 |
| 2020 November | 38 | 9 | 47 |
| 2020 October | 26 | 7 | 33 |
| 2020 September | 19 | 5 | 24 |
| 2020 August | 31 | 13 | 44 |
| 2020 July | 25 | 5 | 30 |
| 2020 June | 17 | 5 | 22 |
| 2020 May | 34 | 10 | 44 |
| 2020 April | 33 | 17 | 50 |
| 2020 March | 34 | 15 | 49 |
| 2020 February | 30 | 20 | 50 |
| 2020 January | 38 | 20 | 58 |
| 2019 December | 34 | 15 | 49 |
| 2019 November | 45 | 15 | 60 |
| 2019 October | 7 | 6 | 13 |
| 2019 September | 25 | 17 | 42 |
| 2019 August | 9 | 9 | 18 |
| 2019 July | 29 | 22 | 51 |
| 2019 June | 18 | 8 | 26 |
| 2019 May | 19 | 16 | 35 |
| 2019 April | 26 | 29 | 55 |
| 2019 March | 16 | 15 | 31 |
| 2019 February | 27 | 16 | 43 |
| 2019 January | 12 | 11 | 23 |
| 2018 December | 65 | 27 | 92 |
| 2018 November | 85 | 14 | 99 |
| 2018 October | 51 | 8 | 59 |
| 2018 September | 46 | 16 | 62 |
| 2018 August | 29 | 14 | 43 |
| 2018 July | 31 | 11 | 42 |
| 2018 June | 30 | 14 | 44 |
| 2018 May | 31 | 9 | 40 |
| 2018 April | 21 | 5 | 26 |
| 2018 March | 36 | 12 | 48 |
| 2018 February | 20 | 3 | 23 |
| 2018 January | 24 | 5 | 29 |
| 2017 December | 26 | 8 | 34 |
| 2017 November | 30 | 5 | 35 |
| 2017 October | 22 | 4 | 26 |
| 2017 September | 30 | 14 | 44 |
| 2017 August | 26 | 7 | 33 |
| 2017 July | 31 | 11 | 42 |
| 2017 June | 17 | 5 | 22 |
| 2017 May | 32 | 11 | 43 |
| 2017 April | 25 | 7 | 32 |
| 2017 March | 15 | 41 | 56 |
| 2017 February | 19 | 3 | 22 |
| 2017 January | 16 | 6 | 22 |
| 2016 December | 72 | 7 | 79 |
| 2016 November | 73 | 7 | 80 |
| 2016 October | 89 | 7 | 96 |
| 2016 September | 137 | 4 | 141 |
| 2016 August | 160 | 3 | 163 |
| 2016 July | 122 | 1 | 123 |
| 2016 June | 113 | 0 | 113 |
| 2016 May | 125 | 0 | 125 |
| 2016 April | 82 | 0 | 82 |
| 2016 March | 94 | 0 | 94 |
| 2016 February | 85 | 0 | 85 |
| 2016 January | 104 | 0 | 104 |
| 2015 December | 94 | 0 | 94 |
| 2015 November | 71 | 0 | 71 |
| 2015 October | 75 | 0 | 75 |
| 2015 September | 56 | 0 | 56 |
| 2015 August | 84 | 0 | 84 |
| 2015 July | 50 | 0 | 50 |
| 2015 June | 40 | 0 | 40 |
| 2015 May | 64 | 0 | 64 |
| 2015 April | 6 | 0 | 6 |
Show all
