Relationship between kidney size and blood pressure profile in patients with autosomal dominant polycystic kidney disease without renal failure
Relación entre el tamaño renal y el perfil de presión arterial en pacientes con poliquistosis renal autosómica dominante sin insuficiencia renal
L.. Sans Atxera, A.. Roca-Cusachsb, R.. Torrac, F.. Caleroc, P.. Ariasd, J.. Ballarinc, P.. Fernández-Llamac
a Servicio de Nefrología, Hospital del Mar. Barcelona,
b Servicio de Medicina Interna, Unidad de Hipertensión. Hospital de la Santa Creu i Sant Pau. Universitat Autònoma de Barcelona,
c Servicio de Nefrología, Fundació Puigvert. Departament de Medicina (Universitat Autònoma de Barcelona). REDinREN. Instituto de Investigación Carlos III,
d Departamento de Enfermería, Fundació Puigvert. Barcelona,
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Universitat Autònoma de Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Servicio de Nefrología, Fundació Puigvert. Departament de Medicina (Universitat Autònoma de Barcelona). REDinREN. Instituto de Investigación Carlos III, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Departamento de Enfermería, Fundació Puigvert. Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Relación entre el tamaño renal y el perfil de presión arterial en pacientes con poliquistosis renal autosómica dominante sin insuficiencia renal" ] ] "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" => "10418_108_9205_en_10418_t1.jpg" "Alto" => 138 "Ancho" => 720 "Tamanyo" => 15072 ] ] "descripcion" => array:1 [ "en" => "Classification of BP according to measurements taken in the clinic and by ABPM" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION </span></p><p class="elsevierStylePara">Autosomal dominant polycystic kidney disease (ADPKD) is a genetic disease characterised by the presence of bilateral renal cysts that progressively increase in number and size.<span class="elsevierStyleSup">1 </span>It is the most common genetic disease affecting the kidneys and leads to terminal kidney failure as patients get into their 40s and 50s.<span class="elsevierStyleSup">2,3 </span></p><p class="elsevierStylePara">The leading cause of death in patients with polycystic kidney disease is cardiovascular disease, being arterial hypertension (AHT) its main determinant.<span class="elsevierStyleSup">4 </span>Both hypertension and the increase in renal size secondary to the growth of cysts<span class="elsevierStyleSup">1 </span>is correlated with a progressive deterioration of renal funcion in ADPKD. The onset of hypertension in these patients is common and in approximately 60% of cases the diagnosis is performed before any renal function impairment appears. It seems that the increase in kidney size<span class="elsevierStyleSup">5-7 </span>and the activity in the renin-angiotensin-aldosterone system<span class="elsevierStyleSup">8-10 </span>are primarily responsible for the development of hypertension in these patients. Studies in patients with ADPKD and normal renal function have shown the presence of target organ damage (increased left ventricular mass)<span class="elsevierStyleSup">11,12 </span>before developing AHT. This damage appears to be related more to the increase in systolic blood pressure (SBP) determined by ambulatory blood pressure monitoring (ABPM) than to the blood pressure (BP) measured at the clinic.<span class="elsevierStyleSup">12 </span></p><p class="elsevierStylePara">Twenty-four hour ABPM adds additional information to the BP measurements in the clinic (BPc) as it reports on the circadian rhythm and the variability of the BP. Furthermore, it identifies patients with masked hypertension (normal clinic BP and high ambulatory BP) and isolated clinic hypertension (high BP readings in the clinic and normal ambulatory BP). A non-physiological BP profile (non­dipper nocturnal pattern), a greater BP variability (average of standard deviations over 24 hours greater than 18 mmHg for SBP or greater than 15mmHg for DBP) and the presence of masked or isolated clinic hypertension have been related to greater cardiovascular risk.<span class="elsevierStyleSup">13-17 </span></p><p class="elsevierStylePara">Therefore, although hypertension is a key factor in cardiovascular morbidity and mortality in patients with polycystic disease, little is known about the pre-hypertensive stage. In addition, it is not known whether the increase in kidney size could be associated with a change in the BP profile and its variability. We therefore decided to evaluate the following points in patients with normotensive ADPKD <span class="elsevierStyleItalic">a priori </span>and with eGF by MDRD >60 mL/min/1.73 m<span class="elsevierStyleSup">2</span>:</p><p class="elsevierStylePara">1.    Whether there are differences between the BPc and the ABPM readings.</p><p class="elsevierStylePara">2.    The relationship between maximum kidney diameter and SBP, DBP and mean BP (MBP) over 24 hours, day and night, and pulse pressure (PP) obtained by 24-hour ABPM.</p><p class="elsevierStylePara">3.    If there is a relationship between maximum kidney diameter and the variability of BP or the circadian BP pattern.</p><p class="elsevierStylePara"> </p><ul> </ul><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHODS </span></p><p class="elsevierStylePara">We performed a transversal, observational study that included 37 patients with ADPKD from those who visited outpatient clinics, who were between the ages of 18 and 50 years, with eGF by MDRD >60 mL/min/1.73 m<span class="elsevierStyleSup">2 </span>and who were normotensive (patients with home BP <135/85 mmHg and not receiving treatment for hypertension).</p><p class="elsevierStylePara">The following information was collected from these 37 patients:</p><p class="elsevierStylePara">1. Three readings of SBP and DBP with the OMRON 705 IT blood pressure monitor (Tokyo, Japan), following the standard for BPc readings of the European Society of Hypertension (ESH),<span class="elsevierStyleSup">18 </span>using the average of three readings as the clinical BP value.</p><p class="elsevierStylePara">2. ABPM data (via the Dyasis Integra device) (Rueil-Malmaison, France).</p><p class="elsevierStylePara">- SBP, DBP and MBP (DBP + 1/3 pulse pressure (PP) (PP = SBP – DBP) during the day, night and over 24 hours. Heart rate and 24-hour PP.</p><p class="elsevierStylePara">- Percentage of nocturnal BP decrease with respect to the daytime SBP, DBP and MBP and quality of sleep on the ABPM date.</p><p class="elsevierStylePara">- Load index (percentage of BP measurements above the established target BP) for SBP and DBP during the day, night and over 24 hours.</p><p class="elsevierStylePara">- Typical or standard deviation of the average SBP and DBP during the day, night and over 24 hours. Maximum daytime, nightime and 24-hour SBP and DBP.</p><p class="elsevierStylePara">3. Anthropometric data: weight, height, body surface area and body mass index.</p><p class="elsevierStylePara">4. Mean maximum diameter of both kidneys (in millimetres) by renal ultrasound performed by ultrasound specialists who are expert in renovesical ultrasound, using a single measure.</p><p class="elsevierStylePara">According to the ABPM readings and following the recommendation in the 2007 ESH Guidelines,<span class="elsevierStyleSup">18 </span>patients are consider normotensive if they present a SBP <130 mmHg and a DBP <80 mmHG by ABPM over 24 hours.</p><p class="elsevierStylePara">The percentage of decrease in nocturnal MBP versus daytime MBP allows us to classify patients according to their BP profile:</p><p class="elsevierStylePara">1. Non-dipper pattern: nocturnal MBP decrease versus daytime MBP less than 10%.</p><p class="elsevierStylePara">2. Dipper pattern: nocturnal MBP decrease versus daytime MBP between 10 and 20%.</p><p class="elsevierStylePara">3. Riser pattern: nocturnal MBP higher than daytime MBP.</p><p class="elsevierStylePara">4. Extreme dipper pattern: nocturnal MBP decrease versus daytime MBP greater than 20%. The circadian profile was not assessed if the patient reported suffering from a bad night’s sleep.</p><p class="elsevierStylePara">Considering the BP readings obtained from the ABPM and the BPc, we can classify the patients into four groups:</p><p class="elsevierStylePara">1. White coat AHT: patients with high BPc ((>140/90 mmHg) and BP by ABPM over 24 hours <130/80 mmHg.</p><p class="elsevierStylePara">2. Masked AHT: patients with normal BPc (<140/90 mmHg) and high BP by ABPM over 24 hours ((>130/80 mmHg).</p><p class="elsevierStylePara">3. True AHT: patients with high BPc and BP by ABPM over 24 hours.</p><p class="elsevierStylePara">4. True normotensives: patients with normal BPc and BP by ABPM over 24 hours.</p><p class="elsevierStylePara">The statistical analysis was carried out with the SPSS software. The results are expressed as the mean ± standard deviation (SD) for the continuously distributed variables and as frequencies for the categorical variables.</p><p class="elsevierStylePara">Given the small sample size, the normal distribution of variables was studied using the Kolmogorov-Smirnov and Shapiro-Wilks tests. After verifying the normality of the variables, the Student’s t-test was used to compare samples with two categories and ANOVA was used for those with three or more categories. For the non-parametric variables, the Mann-Whitney and Kruskall-Wallis tests were used depending on whether they had two or more categories.</p><p class="elsevierStylePara">To study the association between the mean maximum kidney diameter and the various data provided by the ABPM, the linear Pearson correlation coefficient was used. The distribution of categorical variables was analysed by means of the chi-squared test. A p less than 0.05 was considered statistically significant.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Blood pressure classification according to BP values obtained in the clinic and by ambulatory blood pressure monitoring </span></p><p class="elsevierStylePara">The 37 patients included were classified into four groups according to the BP obtained in the clinic and through 24-hour ABPM. Of these, 13 were true normotensives (35.1%), 9 were true hypertensives (24.3%), 4 patients had white coat hypertension (10.8%) and the remaining 11 (29.7%) had masked hypertension (Table 1).</p><p class="elsevierStylePara">Taking into account the average BP by ABPM over 24 hours and hypertension being diagnosed for a SBP >130 mmHg or a DBP >80 mmHg, 20 of the 37 patients (54%) initially selected as normotensives according to the home BP readings were diagnosed with AHT.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Relationship between kidney size and blood pressure characteristics </span></p><p class="elsevierStylePara">There is currently no standard of normality in relation to maximum kidney diameter in the general population but it is known that the maximum kidney diameter is correlated with height,<span class="elsevierStyleSup">19 </span>which was coherent with our population (r = 0.572, p = 0.016). The mean maximum diameter was measured for both kidneys of each individual and was adjusted for height.</p><p class="elsevierStylePara">We had set out to only assess normotensive patients with ADPKD but because we had a significant percentage of hypertensive patients, we decided to study whether there was any relationship among the total available population (37 patients) between the various parameters obtained by the ABPM and the mean kidney diameter adjusted for height. This analysis revealed a statistically significant negative correlation between a greater kidney size and a lower PP (r = -0.325, p = 0.05) (Figure 1).</p><p class="elsevierStylePara">Subsequently and because this was the main objective of the paper, the results in the subset of 17 normotensive patients by ABPM over 24 hours were analysed. Table 2 and Table 3 contain the demographic characteristics, kidney size and BP obtained in the clinic and by ABPM. When analysing the data from the group of the 17 normotensive patients, positive correlations were identified between average maximum kidney size adjusted for height and all parameters of ABPM with the exception of PP, without reaching statistical significance.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Kidney size, circadian profile and blood pressure variability </span></p><p class="elsevierStylePara">Clinically, the parameter used for assessing the BP pattern was the decrease in daytime to nightime MBP. In the group of 17 normotensive patients, there were no statistically significant differences in the maximum renal diameter adjusted for height between patients with a non-dipper pattern (n = 6), dipper pattern (n = 8) and extremely dipper pattern (n = 3) (p = 0.662) (Figure 2). None of the 17 patients reported a riser pattern.</p><p class="elsevierStylePara">Of the 17 normotensive patients, we decided to study those who had a physiological BP profile, maintaining 11 assessable patients with a dipper BP pattern.</p><p class="elsevierStylePara">In the group of 11 patients with dipper BP patterns according to the decrease in MBP, positive correlations were found, although not significant, between kidney size and all parameters (SBP, DBP, systolic and diastolic load index, SD of SBP and DBP) for daytime, nightime and 24-hour BP readings by ABPM, where diastolic load index over 24 hours showed the greatest positive correlation (p = 0.07). The nocturnal decrease in BP for this group had a negative correlation, although not statistically significant, with the increase in kidney size.</p><p class="elsevierStylePara">Since, strictly speaking, a dipper pattern should present a nocturnal decrease in both SBP and DBP greater than 10%, we investigated in the 17 normotensive patients whether the absence of a noctural decrease in SBP and/or DBP was associated with a greater maximum renal diameter adjusted for height. No significant differences were found in kidney size among patients with or without a dipper BP pattern.</p><p class="elsevierStylePara">Applying this criterion of a nocturnal SBP and DBP decrease of >10% versus daytime to define the dipper pattern, only 6 of the 17 patients had a dipper pattern, all with a proper night’s rest on the date of the ABPM. In these six patients, a trend was once again observed towards a positive correlation that approached statistical significance for the 24-hour mean DBP, the diastolic load index for day and night, with the 24-hour diastolic load index achieving statistical significance (r = 0.875, p = 0.023) (Table 4).</p><p class="elsevierStylePara">In the group of 11 patients without a dipper pattern of SBP and DBP, a positive and statistically significant correlation was observed (r = 0.623, p = 0.04) between the maximum kidney diameter adjusted for height and the standard deviation of DBP at night, which once again is a parameter that reflects the BP variability.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">The ABPM study of this group of patients who reported correct home BP readings allowed us to diagnose some 54.1% of them as hypertensive. The patients were not trained to carry out a proper home blood pressure monitoring (HBPM), which would have helped diagnose hypertension in some of the patients who reported being normotensive at home.</p><p class="elsevierStylePara">An important aspect of this study is that 11 of the 37 patients selected (29.7%) would not have been diagnosed with hypertension using only the clinical measurements, since they had masked AHT. Some studies have shown that patients with masked hypertension have more important subclinical organ damage than subjects with white coat hypertension or with grade I AHT, which causes this condition to carry a greater cardiovascular risk.<span class="elsevierStyleSup">15-17 </span>Population studies have also shown a significant increase in mortality in this subset of the population, which might become comparable to the established AHT.<span class="elsevierStyleSup">18 </span>The prevalence of masked AHT, according to the literature, varies between 6 and 26%. In the population studied, the prevalence of masked hypertension is very important and, if not detected and corrected, it can increase cardiovascular risk and the likelihood of developing target organs damages.</p><p class="elsevierStylePara">The existence of a statistically significant negative correlation between a greater maximum kidney diameter and a lower PP in the initial group of patients indirectly suggests an alteration of the DBP. The population studied was young, with an average age of approximately 38 years. As with our group, the general hypertensive young population is much more likely to have high DBP than SBP, which leads to a decrease in PP.</p><p class="elsevierStylePara">In the group of normotensive patients, no relationship was detected between kidney size and the alteration of the circadian BP cycle, although only a few patients were analysed. However, there remains a discernible trend towards a poorer BP profile associated with a poorer DBP to greater kidney diameter. This trend persists even in the group of normotensive patients with proper nocturnal decrease in MBP. The relationship between a greater diastolic load index over 24 hours to greater renal diameter in patients with dipper pattern of SBP and DBP is statistically significant. The load index (percentage of the BP readings by the ABPM that exceed the preset target BP) is one of the measures used for evaluating BP variability and it has been shown that an increased load index is related to greater target organ damage (left ventricular hypertrophy).<span class="elsevierStyleSup">20 </span>The trend towards increased diastolic load index as kidney size increases could ultimately be related to greater target organ involvement, which has been shown in some studies with this type of population.<span class="elsevierStyleSup">12 </span></p><p class="elsevierStylePara">Given the importance of the results obtained in this study, it is necessary to expand the sample size to confirm the findings and to evaluate the possible relationship that these findings may have to subclinical involvement of target organs.</p><p class="elsevierStylePara">In conclusion, the single reading of BPc in patients with ADPKD and normal renal function leaves many hypertensive patients undiagnosed given the high prevalence of masked AHT. ABPM-assisted examination helps to identify these patients early on.</p><p class="elsevierStylePara">The analysis of the overall group of 37 patients, as well as the separate analysis of the group of normotensive patients, show a statistically significant relationship between greater renal size and a worse performance of DBP, as revealed by a lower PP in the former group and a greater variability in DBP in the latter group. This data shows a worse DBP profile as compared to SBP. These findings indicate that a relationship might exist along the entire evolution of the disease between renal growth and DBP alteration.</p><p class="elsevierStylePara"><a href="grande/10418_108_9205_en_10418_t1.jpg" class="elsevierStyleCrossRefs"><img src="10418_108_9205_en_10418_t1.jpg" alt="Classification of BP according to measurements taken in the clinic and by ABPM "></img></a></p><p class="elsevierStylePara">Table 1. Classification of BP according to measurements taken in the clinic and by ABPM </p><p class="elsevierStylePara"><a href="grande/10418_108_9206_en_10418_t2.jpg" class="elsevierStyleCrossRefs"><img src="10418_108_9206_en_10418_t2.jpg" alt="Demographic and clinical characteristics of the normotensive population confirmed by 24-hour ABPM (n = 17) "></img></a></p><p class="elsevierStylePara">Table 2. Demographic and clinical characteristics of the normotensive population confirmed by 24-hour ABPM (n = 17) </p><p class="elsevierStylePara"><a href="grande/10418_108_9207_en_10418_t3.jpg" class="elsevierStyleCrossRefs"><img src="10418_108_9207_en_10418_t3.jpg" alt="BP readings by ABPM of the normotensive population (n = 17) "></img></a></p><p class="elsevierStylePara">Table 3. BP readings by ABPM of the normotensive population (n = 17) </p><p class="elsevierStylePara"><a href="grande/10418_108_9208_en_10418_t4.jpg" class="elsevierStyleCrossRefs"><img src="10418_108_9208_en_10418_t4.jpg" alt="Study of the relationship between average renal diameter adjusted for height and the variability of BP in the group of normotensives with a dipper pattern of SBP and DBP (n = 6) "></img></a></p><p class="elsevierStylePara">Table 4. Study of the relationship between average renal diameter adjusted for height and the variability of BP in the group of normotensives with a dipper pattern of SBP and DBP (n = 6) </p><p class="elsevierStylePara"><a href="grande/10418_108_9209_en_10418_f1.jpg" class="elsevierStyleCrossRefs"><img src="10418_108_9209_en_10418_f1.jpg" alt="Linear regression line between height adjusted average renal diameter and pressure differential in the overall population (n = 37). "></img></a></p><p class="elsevierStylePara">Figure 1. Linear regression line between height adjusted average renal diameter and pressure differential in the overall population (n = 37). </p><p class="elsevierStylePara"><a href="grande/10418_108_9210_en_10418_f2.jpg" class="elsevierStyleCrossRefs"><img src="10418_108_9210_en_10418_f2.jpg" alt="Height adjusted average renal diameter as a function of the circadian BP profile in the normotensive group (n = 17)."></img></a></p><p class="elsevierStylePara">Figure 2. Height adjusted average renal diameter as a function of the circadian BP profile in the normotensive group (n = 17).</p>" "pdfFichero" => "P1-E503-S2272-A10418-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec441679" "palabras" => array:4 [ 0 => "Poliquistosis renal autosómica dominante" 1 => "Tamaño renal" 2 => "Monitorización ambulatoria de la presión arterial" 3 => "Perfil circadiano de la presión arterial" ] ] ] "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec441680" "palabras" => array:5 [ 0 => "Autosomic dominant polycystic kidney disease" 1 => "Renal size" 2 => "Ambulatory monitoring of blood pressure" 3 => "Blood pressure profile" 4 => "Blood pressure variability" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Antecedentes: </span>El aumento del tamaño renal desempeña un papel importante en el desarrollo de la hipertensión arterial (HTA) en pacientes con poliquistosis renal autosómica dominante (PQRAD) con función renal normal. <span class="elsevierStyleBold">Material y métodos: </span>Se han practicado a 37 pacientes con PQRAD, filtrado glomerular estimado (FGe) por MDRD >60 ml/min/1,73 m² y supuestamente normotensos, una monitorización de la presión arterial (MAPA) y una ecografía renovesical para investigar la posible relación entre el aumento del tamaño renal y un perfil patológico de presión arterial (PA) en estadios de prehipertensión. <span class="elsevierStyleBold">Resultados: </span>13 pacientes resultaron ser normotensos, 11 presentaron HTA enmascarada, 4 tuvieron HTA de bata blanca y 9, HTA verdadera.<span class="elsevierStyleBold"> </span>Se ha observado en los pacientes normotensos con patrón reductor de la PA una correlación positiva y estadísticamente significativa entre el tamaño renal y la variabilidad de la presión arterial diastólica (PAD). <span class="elsevierStyleBold">Conclusiones: </span>La MAPA permite realizar un diagnóstico precoz de la HTA e identificar a pacientes con hipertensión enmascarada. Este trabajo sugiere que en pacientes normotensos con PQRAD existe una posible relación entre el tamaño renal y un perfil de PA con mayor riesgo cardiovascular.</p>" ] "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Background:</span> Enlargement of renal size plays an important role in the development of hypertension in patients with autosomic dominant polycystic kidney disease (ADPKD) and normal renal function. <span class="elsevierStyleBold">Methods:</span> A 24h blood pressure monitoring (ABPM) and a renal ecography have been performed in 37 patients with ADPKD and estimated glomerular filtration rate >60 ml/min/1,73m<span class="elsevierStyleSup">2</span>  to study the relationship between renal size and an altered blood pressure profile in prehypertension stages. <span class="elsevierStyleBold">Results:</span> 13 patients had normal blood pressure, 11 were diagnosed of masked hypertension, 4 had white coat hypertension and 9 had  hypertension. We have found in the normotensive group with a dipper blood pressure profile a positive and statistically significant relationship between renal size and diastolic blood pressure variability. <span class="elsevierStyleBold">Conclusions:</span> ABPM helps to make an early diagnosis of hypertension and to identify those patients with masked hypertension. This study suggests a relationship between renal size and a blood pressure profile linked to a major cardiovasular risk in normotensive patients with ADPKD.</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" => "10418_108_9205_en_10418_t1.jpg" "Alto" => 138 "Ancho" => 720 "Tamanyo" => 15072 ] ] "descripcion" => array:1 [ "en" => "Classification of BP according to measurements taken in the clinic and by ABPM" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10418_108_9206_en_10418_t2.jpg" "Alto" => 230 "Ancho" => 350 "Tamanyo" => 21658 ] ] "descripcion" => array:1 [ "en" => "Demographic and clinical characteristics of the normotensive population confirmed by 24-hour ABPM (n = 17)" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Tab. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10418_108_9207_en_10418_t3.jpg" "Alto" => 247 "Ancho" => 720 "Tamanyo" => 43260 ] ] "descripcion" => array:1 [ "en" => "BP readings by ABPM of the normotensive population (n = 17)" ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Tab. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10418_108_9208_en_10418_t4.jpg" "Alto" => 84 "Ancho" => 345 "Tamanyo" => 9124 ] ] "descripcion" => array:1 [ "en" => "Study of the relationship between average renal diameter adjusted for height and the variability of BP in the group of normotensives with a dipper pattern of SBP and DBP (n = 6)" ] ] 4 => array:8 [ "identificador" => "fig5" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10418_108_9209_en_10418_f1.jpg" "Alto" => 278 "Ancho" => 350 "Tamanyo" => 13410 ] ] "descripcion" => array:1 [ "en" => "Linear regression line between height adjusted average renal diameter and pressure differential in the overall population (n = 37)." ] ] 5 => array:8 [ "identificador" => "fig6" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10418_108_9210_en_10418_f2.jpg" "Alto" => 283 "Ancho" => 349 "Tamanyo" => 13112 ] ] "descripcion" => array:1 [ "en" => "Height adjusted average renal diameter as a function of the circadian BP profile in the normotensive group (n = 17)." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Grantham JJ, Torres VE, Chapman AB, Guay-Woodford LM, Bae KT, King BF Jr, et al.; CRISP Investigators. 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Hypertension\u{A0}2002;39:710-4. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11882636" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003000000005/v0_201502091651/X2013251410050630/v0_201502091651/en/main.assets" "Apartado" => array:4 [ "identificador" => "35444" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Short Originals" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003000000005/v0_201502091651/X2013251410050630/v0_201502091651/en/P1-E503-S2272-A10418-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251410050630?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 6 | 10 |
| 2024 October | 84 | 45 | 129 |
| 2024 September | 76 | 36 | 112 |
| 2024 August | 70 | 74 | 144 |
| 2024 July | 87 | 35 | 122 |
| 2024 June | 99 | 39 | 138 |
| 2024 May | 98 | 39 | 137 |
| 2024 April | 96 | 40 | 136 |
| 2024 March | 73 | 24 | 97 |
| 2024 February | 52 | 36 | 88 |
| 2024 January | 53 | 25 | 78 |
| 2023 December | 60 | 39 | 99 |
| 2023 November | 56 | 36 | 92 |
| 2023 October | 64 | 35 | 99 |
| 2023 September | 71 | 32 | 103 |
| 2023 August | 67 | 32 | 99 |
| 2023 July | 89 | 52 | 141 |
| 2023 June | 94 | 36 | 130 |
| 2023 May | 93 | 39 | 132 |
| 2023 April | 101 | 28 | 129 |
| 2023 March | 77 | 36 | 113 |
| 2023 February | 64 | 16 | 80 |
| 2023 January | 58 | 29 | 87 |
| 2022 December | 77 | 43 | 120 |
| 2022 November | 85 | 30 | 115 |
| 2022 October | 108 | 43 | 151 |
| 2022 September | 63 | 33 | 96 |
| 2022 August | 75 | 42 | 117 |
| 2022 July | 62 | 48 | 110 |
| 2022 June | 91 | 33 | 124 |
| 2022 May | 84 | 30 | 114 |
| 2022 April | 101 | 65 | 166 |
| 2022 March | 79 | 39 | 118 |
| 2022 February | 98 | 48 | 146 |
| 2022 January | 137 | 46 | 183 |
| 2021 December | 55 | 43 | 98 |
| 2021 November | 70 | 39 | 109 |
| 2021 October | 126 | 53 | 179 |
| 2021 September | 83 | 32 | 115 |
| 2021 August | 93 | 37 | 130 |
| 2021 July | 79 | 42 | 121 |
| 2021 June | 85 | 38 | 123 |
| 2021 May | 122 | 37 | 159 |
| 2021 April | 226 | 32 | 258 |
| 2021 March | 99 | 25 | 124 |
| 2021 February | 111 | 14 | 125 |
| 2021 January | 66 | 14 | 80 |
| 2020 December | 67 | 18 | 85 |
| 2020 November | 64 | 9 | 73 |
| 2020 October | 50 | 15 | 65 |
| 2020 September | 57 | 7 | 64 |
| 2020 August | 73 | 6 | 79 |
| 2020 July | 88 | 16 | 104 |
| 2020 June | 78 | 14 | 92 |
| 2020 May | 69 | 8 | 77 |
| 2020 April | 76 | 28 | 104 |
| 2020 March | 92 | 10 | 102 |
| 2020 February | 101 | 18 | 119 |
| 2020 January | 106 | 13 | 119 |
| 2019 December | 116 | 20 | 136 |
| 2019 November | 153 | 15 | 168 |
| 2019 October | 146 | 10 | 156 |
| 2019 September | 171 | 25 | 196 |
| 2019 August | 101 | 17 | 118 |
| 2019 July | 120 | 21 | 141 |
| 2019 June | 97 | 10 | 107 |
| 2019 May | 109 | 17 | 126 |
| 2019 April | 148 | 26 | 174 |
| 2019 March | 73 | 23 | 96 |
| 2019 February | 71 | 15 | 86 |
| 2019 January | 100 | 18 | 118 |
| 2018 December | 136 | 39 | 175 |
| 2018 November | 123 | 18 | 141 |
| 2018 October | 116 | 16 | 132 |
| 2018 September | 123 | 11 | 134 |
| 2018 August | 96 | 20 | 116 |
| 2018 July | 74 | 13 | 87 |
| 2018 June | 56 | 7 | 63 |
| 2018 May | 81 | 12 | 93 |
| 2018 April | 87 | 4 | 91 |
| 2018 March | 59 | 11 | 70 |
| 2018 February | 64 | 8 | 72 |
| 2018 January | 67 | 11 | 78 |
| 2017 December | 77 | 11 | 88 |
| 2017 November | 61 | 10 | 71 |
| 2017 October | 68 | 6 | 74 |
| 2017 September | 55 | 17 | 72 |
| 2017 August | 47 | 13 | 60 |
| 2017 July | 67 | 10 | 77 |
| 2017 June | 56 | 16 | 72 |
| 2017 May | 82 | 15 | 97 |
| 2017 April | 48 | 8 | 56 |
| 2017 March | 41 | 14 | 55 |
| 2017 February | 66 | 8 | 74 |
| 2017 January | 25 | 17 | 42 |
| 2016 December | 71 | 5 | 76 |
| 2016 November | 82 | 14 | 96 |
| 2016 October | 118 | 13 | 131 |
| 2016 September | 193 | 3 | 196 |
| 2016 August | 209 | 8 | 217 |
| 2016 July | 171 | 12 | 183 |
| 2016 June | 161 | 0 | 161 |
| 2016 May | 174 | 0 | 174 |
| 2016 April | 133 | 0 | 133 |
| 2016 March | 102 | 0 | 102 |
| 2016 February | 136 | 0 | 136 |
| 2016 January | 107 | 0 | 107 |
| 2015 December | 107 | 0 | 107 |
| 2015 November | 85 | 0 | 85 |
| 2015 October | 76 | 0 | 76 |
| 2015 September | 103 | 0 | 103 |
| 2015 August | 76 | 0 | 76 |
| 2015 July | 72 | 0 | 72 |
| 2015 June | 39 | 0 | 39 |
| 2015 May | 62 | 0 | 62 |
| 2015 April | 5 | 0 | 5 |
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