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techniques and experience&#44; the study of hospitalisation and survival is also performed by dividing the 25 years of experience into two periods&#58; the first period&#44; from 1981 to 1992 &#40;pre-92&#41; and the second period&#44; from 1993 to 2005 &#40;post-92&#41;&#46; Major developments that occurred from the nineties and that justify this division include erythropoietin&#44; which began to be used in 1990&#44; CAPD double bag systems that were introduced in 1992 and automated PD &#40;APD&#41; with cyclers&#44; which began to be implemented in Spain in the early nineties&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In the results sections the following aspects are evaluated&#58; <span class="elsevierStyleItalic">1</span>&#41; self-sufficiency in carrying out PD&#44;<span class="elsevierStyleItalic"> 2&#41; </span>number and frequency of comorbid conditions at the start of PD&#44; such as obesity&#44; hypertension&#44; heart failure&#44; heart disease&#44; cerebral vascular disease and peripheral vascular disease&#44;<span class="elsevierStyleItalic"> 3&#41; </span>discontinuation of the technique<span class="elsevierStyleItalic">&#44; 4&#41; </span>hospitalisation and causes of admission&#44;<span class="elsevierStyleItalic"> 5&#41; </span>patient survival&#44; and<span class="elsevierStyleItalic"> 6</span>&#41; causes of death&#46; In all cases&#44; we compared data from patients with DM against those without DM&#44; and between Type 1 and Type 2 DM&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistical Analysis</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The continuous variables are expressed as average and standard deviation &#40;SD&#41;&#46; Comparisons were carried out using the Student&#39;s t or Chi-squared tests according to the nature of the variables&#46; Survival was analysed using the Kaplan-Meier log rank test and confidence intervals &#40;CI&#41;&#44; considering other events as appropriate and the forward conditional Cox regression model to identify the influence of risk factors&#46; In terms of patient mortality&#44; the event is death&#59; and leaving the programme for any other reason &#40;transplant&#44; transfer&#44; etc&#46;&#41; is considered a loss&#46; Discontinuation of the technique includes the move to HD&#44; transplantation and recovery of renal function&#59; the failure of the technique only includes transfer to HD&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The heterogeneity of the groups were analysed with the Chi-squared test for N-1 degrees of freedom with an alpha of &#46;05 for statistical significance&#46; Data are expressed as mean survival probability with 95&#37; CI&#46; Data were processed with the SPSS 16&#46;1 statistical software for Windows&#46;&#160;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Prevalence</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">DM prevalence and type changed over the two periods analysed&#44; so that in the period from 1981 to 1992&#44; 58&#37; of patients were diabetic and in the period from 1993 to 2005 the percentage dropped to 40&#46;5&#37;&#46; Meanwhile&#44; the type of diabetes changed in the two periods&#44; with a DM1 percentage of 39&#46;5&#37; and DM2 of 18&#37; in pre-92&#44; which is reversed to 16&#46;5 and 25&#46;9&#37;&#44; respectively&#44; in the post-92 period&#46; 93&#37; of Non-DM and 75&#37; of DM were self-sufficient for PD &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; and also 65&#37; of 44 blind patients or with severe impairment of visual acuity &#40;legally blind&#41;&#46; At the beginning of PD&#44; DM patients had high comorbidity&#44; higher than Non-DM patients &#40;Table 1&#41;&#46; 18&#46;6&#37; of DM compared to 4&#46;3&#37; of Non-DM &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; had four or more risk factors&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Admissions</span><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">DM patients are admitted more than Non-DM &#40;1&#46;38&#177;1&#46;1 vs 0&#46;88&#177;0&#46;9 admissions&#47;year&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; and have more days of accumulated stay &#40;20&#46;7&#177;25&#46;4 versus 13&#46;2&#177;19&#46;0 days&#47;patient&#47;year&#44; <span class="elsevierStyleItalic">P&#61;</span>&#46;018&#41;&#46; Peritoneal infection is the leading cause of hospital admission in all patient groups&#44; and has a higher rate for DM than Non-DM &#40;33 vs 28&#37;&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;05&#41; &#40;Table 2&#41;&#46; This is due mainly to the subgroup of Type 2 diabetes&#44; with 46&#46;2&#37; of admissions due to peritoneal infection compared to 22&#46;7&#37; of Type 1 DM &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; &#40;Table 2&#41;&#46; However&#44; no significant differences were found between Type 1 DM and Type 2 DM in the accumulated number of stays per year due to peritoneal infection &#40;11&#46;1&#177;18&#46;6 versus 7&#46;8&#177;14&#46;0 days&#47;patient&#47;year&#44; <span class="elsevierStyleItalic">P&#61;</span>&#46;150&#41;&#46; The percentage of patients hospitalised due to infectious peritonitis&#44; cardiovascular or dialysis technique-related problems&#44; is shown in Table 2&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">When analysing separately the two periods into which we divided the study&#44; we see a progressive tendency towards reduced admissions in all subgroups of patients&#46; Therefore&#44; the Non-DM move from 1&#46;2&#177;1&#46;1 in the first period &#40;pre-92&#41; to 0&#46;63&#177;0&#46;64 in the second period &#40;post-92&#41; &#40;<span class="elsevierStyleItalic">P&#60;</span>&#46;01&#41;&#44; with a reduction in inpatient days &#40;32&#46;8&#177;25&#46;8 compared with 15&#46;1&#177;22&#46;6&#44;<span class="elsevierStyleItalic"> P&#60;&#46;0</span>1&#41;&#46; The same applies to DM patients&#44; whose admission rate decreases from 1&#46;58&#177;1&#46;18 in pre-92 to 1&#46;13&#177;1&#46;0 in post-92 &#40;<span class="elsevierStyleItalic">P&#60;</span>&#46;01&#41;&#44; with a consequent reduction of days of accrued stay &#40;51&#177;61 versus 40&#46;6&#177;48&#46;7&#44; <span class="elsevierStyleItalic">P&#60;</span>&#46;01&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Technique Change</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The analysis of technique changes are detailed in Table 2&#46; There were no differences in the transition to HD between DM and Non-DM but surprisingly&#44; the move to HD is more frequent in Type 1 DM &#40;39&#46;4&#37;&#41; than in Type 2 &#40;13&#46;5&#37;&#41;&#44; &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#46; As expected&#44; kidney transplantation was the main reason for discontinuing DP&#46; As such&#44; the amount of Non-DM patients who discontinued DP for this reason was twice that of DM patients &#40;Table 2&#41;&#46; Among diabetic patients who underwent transplantation&#44; 22&#46;7&#37; have Type 1 DM compared to only 5&#46;8&#37; of Type 2 DM&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Survival</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Some 48&#46;3&#37; of DM patients died in PD during the study period&#44; compared to 27&#46;4&#37; of Non-DM patients &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#44; with a HR of 1&#46;96 &#40;95&#37; CI&#44; 1&#46;1-3&#46;3&#41;&#46; The Kaplan-Meier analysis &#40;Figure 1&#41; reflects a higher survival rate for Non-DM patients&#44; although for up to 4 years they show a similar survival as Type 1 diabetics&#44; about 60&#37;&#44; and always higher than Type 2 DM&#46; The HR of Type 2 DM patients compared with Non-DM is 2&#46;18 &#40;95&#37; CI&#44; 1&#46;042-4&#46;51&#41;&#46; If we carry out a forward&#44; stepwise multivariate Cox regression analysis&#44; based on the age and added comorbidity&#44; the presence of Type 2 diabetes with a HR of 1&#46;96 &#40;95&#37; CI&#44; 1&#46;13-3&#46;39&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;01&#41;&#44; along with age with a HR of 1&#46;052 &#40;1&#46;019 to 1&#46;079&#41; &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; and cerebrovascular disease &#40;HR 4&#46;013&#44; 95&#37; CI&#44; 2&#46;119-7&#46;601&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; are the factors with greater weight in terms of mortality&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Survival by periods for each of the subgroups &#40;DM type 1&#44; DM Type 2 and Non-DM&#41; is shown in Figure 2&#44; Figure 3 and Figure 4&#44; where we can see a slight difference in survival between the two periods in Non-DM patients &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;046&#41; and a significant increase in DM1 patients &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;008&#41;&#44; without significant differences between the two periods in DM2 patients&#46; In the Cox regression analysis by periods&#44; Non-DM patients hypertension &#40;HR 1&#46;6&#44; 95&#37; CI&#44; 1&#46;17-1&#46;86&#44; <span class="elsevierStyleItalic">P&#61;</span>&#46;017&#41; and stroke &#40;HR 4&#46;7&#44; 95&#37;&#44; 1&#46;6 to 14&#46;4&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; mark the difference between the two periods&#46; In DM1 patients it is ischaemic heart disease &#40;HR 2&#46;6&#44; 95&#37; CI&#44; 0&#46;70-9&#46;92&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#46; In DM2 patients&#44; it is heart failure &#40;HR 1&#46;64&#44; 95&#37; CI&#44; 0&#46;67-3&#46;93&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; and stroke &#40;HR 6&#46;94&#44; 95&#37; CI&#44; 2&#46;32-20&#46;7&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; in both periods&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The leading cause of death in DM patients is a cardiovascular event&#46; Some 15&#46;3&#37; died due to heart problems compared with 8&#46;5&#37; of Non-DM &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; and stroke &#40;8&#46;5&#37; in DM compared to 2&#46;6&#37; in Non-DM&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;01&#41;&#46; Peritoneal infection as a cause of death is equal in both DM and Non-DM &#40;5&#46;1 vs 5&#46;1&#37;&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Our study describes the experience in treating PD at a single centre over 25 years&#46; Overall we found the best results in non-diabetic patients in the most recent period &#40;post-1992&#41;&#46; Although previous studies highlight the weight of DM as a prognostic factor&#44; it is important to have data from our area and for such a long period&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Most diabetic patients had injury in various organs and systems at the time of starting PD&#44; which determines a high comorbidity&#46; This&#44; in turn&#44; can influence their adaptation to the technique&#44; their maintenance on it and their survival&#46; With regard to adaptation&#44; it is relevant that we have achieved a sufficient level of self-care so that the patient is responsible for their dialysis&#44; even with the large number of DM patients who are blind&#46; As for continuation of the technique and survival&#44; our data shows increased mortality&#44; especially cardiovascular&#44; as other authors have also reported&#46;<span class="elsevierStyleSup">8&#44; 9</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">One of the merits of this study is that it brings together a long experience in a single centre&#44; more than 25 years&#46; This has allowed us to <a href="http&#58;&#47;&#47;www&#46;wordmagicsoft&#46;com&#47;diccionario&#47;en-es&#47;differentiate&#46;php" class="elsevierStyleCrossRefs">differentiate</a> two time periods&#44; in which progressive improvement is seen&#44; and although DM patients have a worse prognosis in both periods&#44; in post-92 an improvement is seen in survival in Non-DM and DM1 patients&#46; The worst prognosis of DM patients is often reported in the medical literature until the late nineties<span class="elsevierStyleSup">10-13</span> and more sporadically in recent years&#46;<span class="elsevierStyleSup">14-16</span> Accordingly&#44; the long-term trends described here are influenced by changes in the prescription of dialysis over time&#44; improvements in technology and greater experience in treating these patients&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Dividing the study into two phases&#44; with a time point in 1992&#44; coincides with major changes in PD technology&#44; such as the consolidation of double-bag systems and the introduction of new cyclers that have allowed an increasing number of patients in ADP&#46; A learning curve is common in almost all complex medical activities&#44; but here it is clear that this improvement in results is not limited to the first months or years of application of the technique&#44; but persists in time and can be maintained for years&#46;<span class="elsevierStyleSup">17</span> This improvement in overall performance is more evident in younger patients with Type 1 diabetes&#44; which have reduced mortality in the comparison between the two periods&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In one of the few recent studies on the evolution of DM patients on PD&#44; Fang et al&#46;<span class="elsevierStyleSup">15</span> indicate advanced age as the most important factor affecting mortality in diabetic patients&#46; Our results are along the same lines&#44; and age&#44; along with cardiovascular comorbidity are the most significant factors with regards the mortality of our patients&#46; Other authors report similar results&#44; describing how heart disease primarily affects DM2 patients&#46;<span class="elsevierStyleSup">14&#44;16</span> In our study the CV event with the greatest weight on outcome is stroke &#40;CVA&#41;&#46; Type 2 DM patients are older and have a higher prevalence of stroke&#44; and the three factors combine to worsen the prognosis of these patients&#46; Others have suggested the prognostic value of cerebrovascular disease in DM patients&#44; both in PD<span class="elsevierStyleSup">18</span> and in HD&#46;<span class="elsevierStyleSup">19</span> In a previous study by our group on survival in DM patients and the renal function with which they started PD&#44; cerebrovascular disease and heart failure also appear as the factors with greatest impact on mortality&#46;<span class="elsevierStyleSup">20</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The Type 1 and Type 2 DM patient profiles are completely different&#44; and therefore we analysed both groups separately&#46; Type 1 DM patients had similar survival rates to the Non-DM in the first 4 years of treatment&#44; as shown in Figure 1&#44; and improved survival and hospitalisation in the post-92 period&#44; which is not seen in the DM2 patients&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">We found a higher hospitalisation rate in diabetic patients&#44; especially in Type 2 diabetics&#44; although some studies do not report differences in hospitalisation between DM and Non-DM on PD&#46;<span class="elsevierStyleSup">14</span> We have previously discussed how technical advances can have lead to the improved results for the second period&#46; One recent study&#44; with a similar design which divides a long-term monitoring in two periods of time&#44; explained how technological advances in PD may influence the results&#46;<span class="elsevierStyleSup">21</span> A significant percentage of DM patients underwent kidney transplantation&#44; although due to their higher comorbidity&#44; it was a lower number than Non-DM&#46; The transfer to HD due to failure or fatigue of the technique is&#44; however&#44; same for the DM and Non-DM patients&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">This study has several limitations&#46; On one hand&#44; a long evolution involves the incorporation of changes and improvements in treatment&#44; but the prognosis for DM is maintained in both periods&#46; On the other hand&#44; as it is a single-centre study&#44; we cannot ensure that results can be generalised&#46; This is a retrospective study with asymmetry in the size of the groups&#44; which limits the survival analysis&#46; However&#44; we have included all patients who have gone through the PD programme&#44; data has been reviewed and a correct analysis was carried out&#46; Therefore&#44; this study provides a good description of PD treatment in the real world&#44; away from the constraints of clinical trials&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In conclusion&#44; in the 25 year monitoring&#44; diabetic patients had worse clinical status at the start of PD and had a poorer outcome in overall results such as hospitalisation and patient survival&#46; The leading cause of death is a cardiovascular event&#44; and it is possible that the vascular damage present before the start of the PD affects these results&#46; Therefore&#44; DM patients require special attention from the CKD early stages&#46; The programme experience and developments in PD may be responsible for the better results with Type 1 DM patients in the second half of the period&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Thanks to Dr J&#46; Portol&#233;s for his comments and advice on the statistical treatment of the study&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10553&#95;16025&#95;10789&#95;en&#95;10553&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10553_16025_10789_en_10553_f1.jpg" alt="Survival of Patients with Type 1 Diabetes &#40;DM1&#41;&#44; Type 2 &#40;DM2&#41; and Non-Diabetic &#40;ND&#41; in Peritoneal Dialysis &#40;PD&#41; "></img></a></p><p class="elsevierStylePara">Figure 1&#46; Survival of Patients with Type 1 Diabetes &#40;DM1&#41;&#44; Type 2 &#40;DM2&#41; and Non-Diabetic &#40;ND&#41; in Peritoneal Dialysis &#40;PD&#41; </p><p class="elsevierStylePara"><a href="grande&#47;10553&#95;16025&#95;10790&#95;en&#95;10553&#95;f2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10553_16025_10790_en_10553_f2.jpg" alt="Comparison of the Survival of Non-Diabetic Patients in the Two Study Periods "></img></a></p><p class="elsevierStylePara">Figure 2&#46; Comparison of the Survival of Non-Diabetic Patients in the Two Study Periods </p><p class="elsevierStylePara"><a href="grande&#47;10553&#95;16025&#95;10793&#95;en&#95;10553&#95;f3&#46;jpg" class="elsevierStyleCrossRefs"><img src="10553_16025_10793_en_10553_f3.jpg" alt="Comparison of the Survival of Type 1 Diabetic &#40;DM1&#41; Patients in the Two Study Periods "></img></a></p><p class="elsevierStylePara">Figure 3&#46; Comparison of the Survival of Type 1 Diabetic &#40;DM1&#41; Patients in the Two Study Periods </p><p class="elsevierStylePara"><a href="grande&#47;10553&#95;16025&#95;10795&#95;en&#95;10553&#95;f4&#46;jpg" class="elsevierStyleCrossRefs"><img src="10553_16025_10795_en_10553_f4.jpg" alt="Comparison of the Survival of Type 2 Diabetic &#40;DM2&#41; Patients in the Two Study Periods "></img></a></p><p class="elsevierStylePara">Figure 4&#46; Comparison of the Survival of Type 2 Diabetic &#40;DM2&#41; Patients in the Two Study Periods </p><p class="elsevierStylePara"><a href="10553&#95;108&#95;10786&#95;en&#95;w4777105871110553&#95;t1&#95;&#95;en&#46;ppt" class="elsevierStyleCrossRefs">10553&#95;108&#95;10786&#95;en&#95;w4777105871110553&#95;t1&#95;&#95;en&#46;ppt</a></p><p class="elsevierStylePara">Table 1&#46; Characteristics of diabetic and non-diabetic patients on PD and risk factors upon initiation of PD</p><p class="elsevierStylePara"><a href="10553&#95;108&#95;10787&#95;en&#95;w4777105871010553&#95;t2&#95;en&#46;ppt" class="elsevierStyleCrossRefs">10553&#95;108&#95;10787&#95;en&#95;w4777105871010553&#95;t2&#95;en&#46;ppt</a></p><p class="elsevierStylePara">Table 2&#46; Causes of Hospitalisation and PD Discontinuation in Diabetic and Non-Diabetic Patients</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Aims</span>&#58; To describe PD outcomes over 25 years in a single centre&#44; comparing hospitalisation rate&#44; technique withdrawal&#44; and survival between diabetic &#40;DM&#41; and non-diabetic &#40;NonDM&#41; patients&#46; Differences between type 1 &#40;DM1&#41; and type 2 &#40;DM2&#41; diabetics were also analysed&#46; <span class="elsevierStyleBold">Patients and methods&#58;</span> One hundred and eighteen DM patients &#40;52 year old average&#44; 74 men&#44; 44 female&#41; and 117 Non-DM &#40;53 year old average&#44; 64 men&#44; 53 female&#41;&#44; with at least 2 months on PD&#44; 25&#177;20 &#40;2-109&#41; and 29&#46;4&#177;27 &#40;2-159&#41; months respectively&#44; were included&#46; Diabetics were divided in 66 DM1 and 52 DM2&#46; The survival and hospitalisation study was also analysed in two different time periods&#58; before 1992 &#40;1981-1992&#41; and after 1992 &#40;1993-2005&#41;&#46; <span class="elsevierStyleBold">Results&#58;</span><span class="elsevierStyleBold"> </span>93&#37; Non-DM and 75&#37; DM were self-sufficient to manage the PD technique &#40;P&#60;&#46;001&#41; as well as 65&#37; of 44 blind patients&#46; 28&#37; of Non-DM and 15&#37; of DM received a renal allograft &#40;P&#60;&#46;001&#41;&#46; There was no difference in transfer to haemodialysis&#46; 18&#46;6&#37; of DM and 4&#46;3&#37; of Non-DM patients presented &#62;4 comorbid factors on starting PD &#40;P&#60;&#46;001&#41;&#46; Hospitalisation &#40;admissions&#47;year&#41; was higher in DM than in Non-DM patients &#40;3&#46;4 vs 1&#46;8&#44; P&#60;&#46;01&#41; and also hospitalisation length &#40;46 vs 22 days&#47;year&#44; P&#61;&#46;01&#41;&#44; without differences between DM1 and DM2&#46; Admissions due to cardiovascular events&#44; infections&#44; technical problems and peritonitis were more frequent in DM2 than in Non-DM and DM1 patients &#40;P&#60;&#46;05&#41;&#46; <span class="elsevierStyleBold">However&#44; DM2&#160;patients admitted to hospital for peritonitis did not spend more days in hospital than Non-DM or DM1 patients&#46;</span><span class="elsevierStyleBold"> </span>Mortality was 48&#37; in DM and 22&#37; in Non-DM &#40;P&#60;&#46;001&#41;&#46; Survival adjusted for comorbidity was higher in Non-DM &#40;P&#60;&#46;001&#41;&#46; Cerebrovascular disease was the highest risk factor for mortality in DM&#46; Mortality was higher in DM2 than in DM1 and Non-DM&#40;P&#60;&#46;001&#41;&#46; Age &#40;HR 1&#46;052&#44; P&#61;&#46;001&#41;&#44; DM2 &#40;HR 1&#46;96&#44; P&#60;&#46;01&#41; and cerebrovascular disease &#40;HR 4&#46;01&#44; P&#60;&#46;001&#41; were the most important risk factors&#46; In the post-1992 period&#44; the hospitalisation rate and survival improved in DM1 and Non-DM patients&#46; <span class="elsevierStyleBold">Conclusions&#58;</span> DM patients more often require outside assistance to perform PD and have more comorbidity&#44; lower survival&#44; and higher admissions than Non-DM&#44; but there is no difference in HD discontinuation&#46; Age and cardiovascular comorbidity are the factors involved in mortality&#46; Technological advances and cumulative center experience may achieve dialysis outcome improvements in diabetic patients&#46;</p> <p class="elsevierStylePara">¿</p>"
      ]
      "es" => array:1 [
        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold"> <span class="elsevierStyleBold">Objetivos&#58;</span> Describir la experiencia de 25 a&#241;os de tratamiento con di&#225;lisis peritoneal &#40;DP&#41; en un solo centro&#44; comparando la hospitalizaci&#243;n&#44; abandono de la t&#233;cnica y supervivencia entre pacientes diab&#233;ticos &#40;DM&#41; y no diab&#233;ticos &#40;NoDM&#41; y analizando las diferencias entre diab&#233;ticos tipo 1 &#40;DM 1&#41; y tipo 2 &#40;DM 2&#41;&#46; <span class="elsevierStyleBold">Material y m&#233;todos&#58;</span> Se incluyen 118 DM &#40;52 a&#241;os&#44; 74 hombres y 44 mujeres&#41; con&#44; al menos&#44; 2 meses de permanencia en DP y media de 25 &#177; 20 meses &#40;2-109&#41;&#44; divididos en 66 con DM 1 &#40;45 a&#241;os&#41; y 52 con DM 2 &#40;65 a&#241;os&#41; y 117 NoDM &#40;53 a&#241;os&#44; 64 hombres y 53 mujeres&#41;&#44; con un tiempo en DP de 29&#44;4 &#177; 27 meses &#40;2-159&#41;&#46; Por el largo per&#237;odo estudiado&#44; en el an&#225;lisis de hospitalizaci&#243;n y de supervivencia se eval&#250;a&#44; adem&#225;s&#44; el seguimiento en dos per&#237;odos&#58; 1981 a 1992 &#40;pre-92&#41; y 1993 a 2005 &#40;post-92&#41;&#46; <span class="elsevierStyleBold">Resultados&#58;</span> El 93&#37; de los NoDM y el 75&#37; de los DM fueron autosuficientes para realizar DP &#40;p &#60;0&#44;001&#41; y tambi&#233;n el 65&#37; de 44 pacientes ciegos&#46; Han sido sometidos a trasplante el 28&#37; NoDM frente al 15&#37; DM &#40;p &#60;0&#46;001&#41; y no hay diferencia en la transferencia a HD&#46; El 18&#44;6&#37; de los DM frente al 4&#44;3&#37; de los NoDM &#40;p &#60;0&#46;001&#41; presentan cuatro o m&#225;s factores com&#243;rbidos al iniciar DP&#46; La hospitalizaci&#243;n &#40;ingresos&#47;a&#241;o&#41; fue mayor en DM &#40;3&#44;4 frente a 1&#44;8&#41; que en NoDM &#40;p &#60;0&#44;01&#41; y tambi&#233;n los d&#237;as&#47;a&#241;o &#40;46 frente a 22&#59; p &#60;0&#44;01&#41;&#44; sin que exista diferencia entre DM 1 y DM 2&#46; Los ingresos por causas cardiovasculares&#44; infecciones&#44; problemas t&#233;cnicos e infecci&#243;n peritoneal fueron m&#225;s frecuentes en DM 2 &#40;p &#60;0&#44;05&#41; que en NoDM y DM 1&#44; pero no los d&#237;as de ingreso por peritonitis&#46; El 48&#37; de los DM y el 22&#37; de los NoDM fallecen &#40;p &#60;0&#44;001&#41;&#46; La supervivencia ajustada a factores de comorbilidad es mayor en NoDM &#40;p &#60;0&#44;001&#41;&#44; con la enfermedad cerebrovascular como factor mayor de impacto en la mortalidad de DM&#46; La mortalidad es mayor en DM 2 que en DM 1 y NoDM &#40;p &#60;0&#44;001&#41;&#46; La edad &#40;HR 1&#44;052&#59; p &#60;0&#44;001&#41;&#44; la condici&#243;n de DM 2 &#40;HR 1&#44;96&#59; p &#60;0&#44;01&#41; y la enfermedad cerebrovascular &#40;HR 4&#44;01&#59; p &#60;0&#44;001&#41; son los m&#225;s importantes factores de riesgo&#46; En el per&#237;odo post-92 mejora de manera importante la tasa de hospitalizaci&#243;n y la supervivencia de pacientes NoDM y&#44; sobre todo&#44; de DM 1&#46; <span class="elsevierStyleBold">Conclusi&#243;n&#58;</span> Los pacientes con DM precisan m&#225;s frecuentemente ayuda para realizar la DP y presentan m&#225;s comorbilidad&#44; menor supervivencia y mayor hospitalizaci&#243;n que los pacientes NoDM&#44; mientras que es comparable la tasa de abandono de la t&#233;cnica&#46; La edad y las complicaciones cardiovasculares &#40;sobre todo cerebrales&#41; son los factores implicados en la mayor mortalidad&#46; Los avances tecnol&#243;gicos y la mayor experiencia de los centros pueden mejorar las expectativas de los DM en di&#225;lisis&#46;</span></p>"
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            1 => array:3 [
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                  ]
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                    0 => null
                  ]
                ]
              ]
            ]
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                  "contribucion" => array:1 [
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                  ]
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                    0 => null
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
              "etiqueta" => "15"
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                0 => array:3 [
                  "referenciaCompleta" => "Miguel A, García-Ramón R, Pérez-Contreras J, et al. Comorbidity and mortality in peritoneal dialysis: a comparative study of type 1 and type 2 diabetes versus nondiabetic patients. Peritoneal dialysis and diabetes. Nephron 2002;90:290-6."
                  "contribucion" => array:1 [
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              ]
            ]
            15 => array:3 [
              "identificador" => "bib16"
              "etiqueta" => "16"
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                0 => array:3 [
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                  "contribucion" => array:1 [
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                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "16 Portolés J, Corchete E, López-Sánchez P, Coronel F, Ocaña J, Ortiz A, y GCDP. Los pacientes diabéticos tipo 2 presentan peor evolución que los no diabéticos en diálisis peritoneal a expensas de su comorbilidad cardiovascular. Nefrologia 2009;29:336-42. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19668306" 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" => "Piraino B, Minev E, Bernardini J, Bender FH. Does experience with PD matter? Perit Dial Int 2009;29:256-61. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19458292" 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" => "Miguel Carrasco A, García Ramón R, Gómez Roldán C, et al. Morbimortalidad en los pacientes diabéticos con IRC en diálisis peritoneal. En: Coronel F (ed.). Diálisis peritoneal y diabetes. Barcelona: Editorial Médica JIMS, S.L., 1999;13-8."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib20"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Mattana J, Effiong C, Gooneratne R, Singhal PC. Risk of fatal cerebrovascular accident in patients on peritoneal dialysis versus hemodialysis. J Am Soc Nephrol 1997;8:1342-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9259364" 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" => "Coronel F, Cigarrán S, Herrero JA. Early initiation of peritoneal dialysis in diabetic patients. Scand J Urol Nephrol 2009;43:148-53. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19085460" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib22"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Moraes TP, Pecoits-Filho R, Ribeiro SC, et al. Peritoneal dialysis in Brazil: Twenty-five years of experience in a single center. Perit Dial Int 2009;29:492-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19776039" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
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Morbidity and Mortality in Diabetic Patients on Peritoneal Dialysis. Twenty-five Years of Experience at a Single Centre
Morbimortalidad en pacientes diabéticos en diálisis peritoneal. Experiencia de 25 años en un solo centro
, Francisco Coronelb, F.. Coronelc, Secundino Cigarránd, S.. Cigarráne, Jose Antonio Herrerof, J.A.. Herrerog
b Nefrologia, Hospital Clínico San Carlos, MADRID MADRID Spain,
c Servicio de Nefrología, Hospital Clínico San Carlos, Madrid
d Nefrologia, Hospital da Costa, Burela, Lugo, Spain,
e Servicio de Nefrología, Hospital da Costa, Burela, Lugo,
f Nefrologia, Hospital Clínico de San Carlos, MADRID, MADRID, Spain,
g Servicio de Nefrología, Hospital Clínico San Carlos, Madrid,
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in relation to the severity of multi-organ systemic diseases such as diabetes mellitus &#40;DM&#41;&#46; After a period of frequent publications on the development of diabetic patients on dialysis&#44; in recent years literature searches only reveal reviews of the topic and there are few original articles&#46; However&#44; the characteristics of diabetic patients starting haemodialysis &#40;HD&#41; or PD in recent years have changed&#44; and unlike the eighties and nineties&#44; the inclusion of diabetic patients on dialysis today occurs if they are suffering from Type 2 diabetes&#46; DM has become a true pandemic&#44; with a higher prevalence of adult DM&#46;<span class="elsevierStyleSup">7</span> This difference can change the outcome of patients on renal replacement therapy&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The aim of this study is to provide the experience of a single centre over 25 years of treating diabetic patients with PD&#44; analysing survival and hospitalisation in relation to non-diabetic patients&#44; and studying the difference between Type 1 and Type 2 diabetics&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">PATIENTS AND METHOD </span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">After years of intermittent use of PD in a small number of patients and the description of CAPD in 1977&#44; the Hospital Cl&#237;nico San Carlos &#40;Madrid&#41; started the CAPD programme in 1981 and in 1982 they included the first diabetic patient&#46; It is a retrospective&#44; observational study on patients who started the PD programme at this centre&#44; since the programme&#39;s inception until 2005&#46; Data has been collected from 235 patients with PD stays over 2 months and with sufficient documentation to follow-up &#40;in 12 patients the clinical history data were insufficient to evaluate&#41;&#44; 118 diabetics &#40;50&#46;2&#37;&#41; who met the criteria for diabetic nephropathy and 117 non-diabetics &#40;Non-DM&#41; &#40;49&#46;8&#37;&#41;&#46; Demographic data on DM and Non-DM are shown in Table 1&#46; Age&#44; gender distribution&#44; PD time and accumulated follow-up time were not different between DM and Non-DM patients&#46; The DM patient group consisted of 66 Type 1 DM&#44; 44&#46;9&#177;10&#46;4 years &#40;41 men and 25 women&#41; and accumulated follow-up time of 2&#46;08 years&#44; and 52 Type 2 DM&#44; 62&#46;6 years &#40;33 men and 19 women&#41; and 2&#46;1 years accumulated follow-up time&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The aetiologies of the renal disease most common in Non-DM patients are divided into interstitial 14&#46;4&#37;&#44; 12&#46;6&#37; vascular-ischaemic&#44; 6&#46;5&#37; glomerular&#44; 4&#46;8&#37; polycystic disease&#44; and the rest belong to other causes and unknown origin&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Due to changes that occur over such a long period of follow-up in terms of material&#44; techniques and experience&#44; the study of hospitalisation and survival is also performed by dividing the 25 years of experience into two periods&#58; the first period&#44; from 1981 to 1992 &#40;pre-92&#41; and the second period&#44; from 1993 to 2005 &#40;post-92&#41;&#46; Major developments that occurred from the nineties and that justify this division include erythropoietin&#44; which began to be used in 1990&#44; CAPD double bag systems that were introduced in 1992 and automated PD &#40;APD&#41; with cyclers&#44; which began to be implemented in Spain in the early nineties&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In the results sections the following aspects are evaluated&#58; <span class="elsevierStyleItalic">1</span>&#41; self-sufficiency in carrying out PD&#44;<span class="elsevierStyleItalic"> 2&#41; </span>number and frequency of comorbid conditions at the start of PD&#44; such as obesity&#44; hypertension&#44; heart failure&#44; heart disease&#44; cerebral vascular disease and peripheral vascular disease&#44;<span class="elsevierStyleItalic"> 3&#41; </span>discontinuation of the technique<span class="elsevierStyleItalic">&#44; 4&#41; </span>hospitalisation and causes of admission&#44;<span class="elsevierStyleItalic"> 5&#41; </span>patient survival&#44; and<span class="elsevierStyleItalic"> 6</span>&#41; causes of death&#46; In all cases&#44; we compared data from patients with DM against those without DM&#44; and between Type 1 and Type 2 DM&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistical Analysis</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The continuous variables are expressed as average and standard deviation &#40;SD&#41;&#46; Comparisons were carried out using the Student&#39;s t or Chi-squared tests according to the nature of the variables&#46; Survival was analysed using the Kaplan-Meier log rank test and confidence intervals &#40;CI&#41;&#44; considering other events as appropriate and the forward conditional Cox regression model to identify the influence of risk factors&#46; In terms of patient mortality&#44; the event is death&#59; and leaving the programme for any other reason &#40;transplant&#44; transfer&#44; etc&#46;&#41; is considered a loss&#46; Discontinuation of the technique includes the move to HD&#44; transplantation and recovery of renal function&#59; the failure of the technique only includes transfer to HD&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The heterogeneity of the groups were analysed with the Chi-squared test for N-1 degrees of freedom with an alpha of &#46;05 for statistical significance&#46; Data are expressed as mean survival probability with 95&#37; CI&#46; Data were processed with the SPSS 16&#46;1 statistical software for Windows&#46;&#160;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Prevalence</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">DM prevalence and type changed over the two periods analysed&#44; so that in the period from 1981 to 1992&#44; 58&#37; of patients were diabetic and in the period from 1993 to 2005 the percentage dropped to 40&#46;5&#37;&#46; Meanwhile&#44; the type of diabetes changed in the two periods&#44; with a DM1 percentage of 39&#46;5&#37; and DM2 of 18&#37; in pre-92&#44; which is reversed to 16&#46;5 and 25&#46;9&#37;&#44; respectively&#44; in the post-92 period&#46; 93&#37; of Non-DM and 75&#37; of DM were self-sufficient for PD &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; and also 65&#37; of 44 blind patients or with severe impairment of visual acuity &#40;legally blind&#41;&#46; At the beginning of PD&#44; DM patients had high comorbidity&#44; higher than Non-DM patients &#40;Table 1&#41;&#46; 18&#46;6&#37; of DM compared to 4&#46;3&#37; of Non-DM &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; had four or more risk factors&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Admissions</span><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">DM patients are admitted more than Non-DM &#40;1&#46;38&#177;1&#46;1 vs 0&#46;88&#177;0&#46;9 admissions&#47;year&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; and have more days of accumulated stay &#40;20&#46;7&#177;25&#46;4 versus 13&#46;2&#177;19&#46;0 days&#47;patient&#47;year&#44; <span class="elsevierStyleItalic">P&#61;</span>&#46;018&#41;&#46; Peritoneal infection is the leading cause of hospital admission in all patient groups&#44; and has a higher rate for DM than Non-DM &#40;33 vs 28&#37;&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;05&#41; &#40;Table 2&#41;&#46; This is due mainly to the subgroup of Type 2 diabetes&#44; with 46&#46;2&#37; of admissions due to peritoneal infection compared to 22&#46;7&#37; of Type 1 DM &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; &#40;Table 2&#41;&#46; However&#44; no significant differences were found between Type 1 DM and Type 2 DM in the accumulated number of stays per year due to peritoneal infection &#40;11&#46;1&#177;18&#46;6 versus 7&#46;8&#177;14&#46;0 days&#47;patient&#47;year&#44; <span class="elsevierStyleItalic">P&#61;</span>&#46;150&#41;&#46; The percentage of patients hospitalised due to infectious peritonitis&#44; cardiovascular or dialysis technique-related problems&#44; is shown in Table 2&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">When analysing separately the two periods into which we divided the study&#44; we see a progressive tendency towards reduced admissions in all subgroups of patients&#46; Therefore&#44; the Non-DM move from 1&#46;2&#177;1&#46;1 in the first period &#40;pre-92&#41; to 0&#46;63&#177;0&#46;64 in the second period &#40;post-92&#41; &#40;<span class="elsevierStyleItalic">P&#60;</span>&#46;01&#41;&#44; with a reduction in inpatient days &#40;32&#46;8&#177;25&#46;8 compared with 15&#46;1&#177;22&#46;6&#44;<span class="elsevierStyleItalic"> P&#60;&#46;0</span>1&#41;&#46; The same applies to DM patients&#44; whose admission rate decreases from 1&#46;58&#177;1&#46;18 in pre-92 to 1&#46;13&#177;1&#46;0 in post-92 &#40;<span class="elsevierStyleItalic">P&#60;</span>&#46;01&#41;&#44; with a consequent reduction of days of accrued stay &#40;51&#177;61 versus 40&#46;6&#177;48&#46;7&#44; <span class="elsevierStyleItalic">P&#60;</span>&#46;01&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Technique Change</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The analysis of technique changes are detailed in Table 2&#46; There were no differences in the transition to HD between DM and Non-DM but surprisingly&#44; the move to HD is more frequent in Type 1 DM &#40;39&#46;4&#37;&#41; than in Type 2 &#40;13&#46;5&#37;&#41;&#44; &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#46; As expected&#44; kidney transplantation was the main reason for discontinuing DP&#46; As such&#44; the amount of Non-DM patients who discontinued DP for this reason was twice that of DM patients &#40;Table 2&#41;&#46; Among diabetic patients who underwent transplantation&#44; 22&#46;7&#37; have Type 1 DM compared to only 5&#46;8&#37; of Type 2 DM&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Survival</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Some 48&#46;3&#37; of DM patients died in PD during the study period&#44; compared to 27&#46;4&#37; of Non-DM patients &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#44; with a HR of 1&#46;96 &#40;95&#37; CI&#44; 1&#46;1-3&#46;3&#41;&#46; The Kaplan-Meier analysis &#40;Figure 1&#41; reflects a higher survival rate for Non-DM patients&#44; although for up to 4 years they show a similar survival as Type 1 diabetics&#44; about 60&#37;&#44; and always higher than Type 2 DM&#46; The HR of Type 2 DM patients compared with Non-DM is 2&#46;18 &#40;95&#37; CI&#44; 1&#46;042-4&#46;51&#41;&#46; If we carry out a forward&#44; stepwise multivariate Cox regression analysis&#44; based on the age and added comorbidity&#44; the presence of Type 2 diabetes with a HR of 1&#46;96 &#40;95&#37; CI&#44; 1&#46;13-3&#46;39&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;01&#41;&#44; along with age with a HR of 1&#46;052 &#40;1&#46;019 to 1&#46;079&#41; &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; and cerebrovascular disease &#40;HR 4&#46;013&#44; 95&#37; CI&#44; 2&#46;119-7&#46;601&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; are the factors with greater weight in terms of mortality&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Survival by periods for each of the subgroups &#40;DM type 1&#44; DM Type 2 and Non-DM&#41; is shown in Figure 2&#44; Figure 3 and Figure 4&#44; where we can see a slight difference in survival between the two periods in Non-DM patients &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;046&#41; and a significant increase in DM1 patients &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;008&#41;&#44; without significant differences between the two periods in DM2 patients&#46; In the Cox regression analysis by periods&#44; Non-DM patients hypertension &#40;HR 1&#46;6&#44; 95&#37; CI&#44; 1&#46;17-1&#46;86&#44; <span class="elsevierStyleItalic">P&#61;</span>&#46;017&#41; and stroke &#40;HR 4&#46;7&#44; 95&#37;&#44; 1&#46;6 to 14&#46;4&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; mark the difference between the two periods&#46; In DM1 patients it is ischaemic heart disease &#40;HR 2&#46;6&#44; 95&#37; CI&#44; 0&#46;70-9&#46;92&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#46; In DM2 patients&#44; it is heart failure &#40;HR 1&#46;64&#44; 95&#37; CI&#44; 0&#46;67-3&#46;93&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; and stroke &#40;HR 6&#46;94&#44; 95&#37; CI&#44; 2&#46;32-20&#46;7&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; in both periods&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The leading cause of death in DM patients is a cardiovascular event&#46; Some 15&#46;3&#37; died due to heart problems compared with 8&#46;5&#37; of Non-DM &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; and stroke &#40;8&#46;5&#37; in DM compared to 2&#46;6&#37; in Non-DM&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;01&#41;&#46; Peritoneal infection as a cause of death is equal in both DM and Non-DM &#40;5&#46;1 vs 5&#46;1&#37;&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Our study describes the experience in treating PD at a single centre over 25 years&#46; Overall we found the best results in non-diabetic patients in the most recent period &#40;post-1992&#41;&#46; Although previous studies highlight the weight of DM as a prognostic factor&#44; it is important to have data from our area and for such a long period&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Most diabetic patients had injury in various organs and systems at the time of starting PD&#44; which determines a high comorbidity&#46; This&#44; in turn&#44; can influence their adaptation to the technique&#44; their maintenance on it and their survival&#46; With regard to adaptation&#44; it is relevant that we have achieved a sufficient level of self-care so that the patient is responsible for their dialysis&#44; even with the large number of DM patients who are blind&#46; As for continuation of the technique and survival&#44; our data shows increased mortality&#44; especially cardiovascular&#44; as other authors have also reported&#46;<span class="elsevierStyleSup">8&#44; 9</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">One of the merits of this study is that it brings together a long experience in a single centre&#44; more than 25 years&#46; This has allowed us to <a href="http&#58;&#47;&#47;www&#46;wordmagicsoft&#46;com&#47;diccionario&#47;en-es&#47;differentiate&#46;php" class="elsevierStyleCrossRefs">differentiate</a> two time periods&#44; in which progressive improvement is seen&#44; and although DM patients have a worse prognosis in both periods&#44; in post-92 an improvement is seen in survival in Non-DM and DM1 patients&#46; The worst prognosis of DM patients is often reported in the medical literature until the late nineties<span class="elsevierStyleSup">10-13</span> and more sporadically in recent years&#46;<span class="elsevierStyleSup">14-16</span> Accordingly&#44; the long-term trends described here are influenced by changes in the prescription of dialysis over time&#44; improvements in technology and greater experience in treating these patients&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Dividing the study into two phases&#44; with a time point in 1992&#44; coincides with major changes in PD technology&#44; such as the consolidation of double-bag systems and the introduction of new cyclers that have allowed an increasing number of patients in ADP&#46; A learning curve is common in almost all complex medical activities&#44; but here it is clear that this improvement in results is not limited to the first months or years of application of the technique&#44; but persists in time and can be maintained for years&#46;<span class="elsevierStyleSup">17</span> This improvement in overall performance is more evident in younger patients with Type 1 diabetes&#44; which have reduced mortality in the comparison between the two periods&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In one of the few recent studies on the evolution of DM patients on PD&#44; Fang et al&#46;<span class="elsevierStyleSup">15</span> indicate advanced age as the most important factor affecting mortality in diabetic patients&#46; Our results are along the same lines&#44; and age&#44; along with cardiovascular comorbidity are the most significant factors with regards the mortality of our patients&#46; Other authors report similar results&#44; describing how heart disease primarily affects DM2 patients&#46;<span class="elsevierStyleSup">14&#44;16</span> In our study the CV event with the greatest weight on outcome is stroke &#40;CVA&#41;&#46; Type 2 DM patients are older and have a higher prevalence of stroke&#44; and the three factors combine to worsen the prognosis of these patients&#46; Others have suggested the prognostic value of cerebrovascular disease in DM patients&#44; both in PD<span class="elsevierStyleSup">18</span> and in HD&#46;<span class="elsevierStyleSup">19</span> In a previous study by our group on survival in DM patients and the renal function with which they started PD&#44; cerebrovascular disease and heart failure also appear as the factors with greatest impact on mortality&#46;<span class="elsevierStyleSup">20</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The Type 1 and Type 2 DM patient profiles are completely different&#44; and therefore we analysed both groups separately&#46; Type 1 DM patients had similar survival rates to the Non-DM in the first 4 years of treatment&#44; as shown in Figure 1&#44; and improved survival and hospitalisation in the post-92 period&#44; which is not seen in the DM2 patients&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">We found a higher hospitalisation rate in diabetic patients&#44; especially in Type 2 diabetics&#44; although some studies do not report differences in hospitalisation between DM and Non-DM on PD&#46;<span class="elsevierStyleSup">14</span> We have previously discussed how technical advances can have lead to the improved results for the second period&#46; One recent study&#44; with a similar design which divides a long-term monitoring in two periods of time&#44; explained how technological advances in PD may influence the results&#46;<span class="elsevierStyleSup">21</span> A significant percentage of DM patients underwent kidney transplantation&#44; although due to their higher comorbidity&#44; it was a lower number than Non-DM&#46; The transfer to HD due to failure or fatigue of the technique is&#44; however&#44; same for the DM and Non-DM patients&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">This study has several limitations&#46; On one hand&#44; a long evolution involves the incorporation of changes and improvements in treatment&#44; but the prognosis for DM is maintained in both periods&#46; On the other hand&#44; as it is a single-centre study&#44; we cannot ensure that results can be generalised&#46; This is a retrospective study with asymmetry in the size of the groups&#44; which limits the survival analysis&#46; However&#44; we have included all patients who have gone through the PD programme&#44; data has been reviewed and a correct analysis was carried out&#46; Therefore&#44; this study provides a good description of PD treatment in the real world&#44; away from the constraints of clinical trials&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In conclusion&#44; in the 25 year monitoring&#44; diabetic patients had worse clinical status at the start of PD and had a poorer outcome in overall results such as hospitalisation and patient survival&#46; The leading cause of death is a cardiovascular event&#44; and it is possible that the vascular damage present before the start of the PD affects these results&#46; Therefore&#44; DM patients require special attention from the CKD early stages&#46; The programme experience and developments in PD may be responsible for the better results with Type 1 DM patients in the second half of the period&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Thanks to Dr J&#46; Portol&#233;s for his comments and advice on the statistical treatment of the study&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10553&#95;16025&#95;10789&#95;en&#95;10553&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10553_16025_10789_en_10553_f1.jpg" alt="Survival of Patients with Type 1 Diabetes &#40;DM1&#41;&#44; Type 2 &#40;DM2&#41; and Non-Diabetic &#40;ND&#41; in Peritoneal Dialysis &#40;PD&#41; "></img></a></p><p class="elsevierStylePara">Figure 1&#46; Survival of Patients with Type 1 Diabetes &#40;DM1&#41;&#44; Type 2 &#40;DM2&#41; and Non-Diabetic &#40;ND&#41; in Peritoneal Dialysis &#40;PD&#41; </p><p class="elsevierStylePara"><a href="grande&#47;10553&#95;16025&#95;10790&#95;en&#95;10553&#95;f2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10553_16025_10790_en_10553_f2.jpg" alt="Comparison of the Survival of Non-Diabetic Patients in the Two Study Periods "></img></a></p><p class="elsevierStylePara">Figure 2&#46; Comparison of the Survival of Non-Diabetic Patients in the Two Study Periods </p><p class="elsevierStylePara"><a href="grande&#47;10553&#95;16025&#95;10793&#95;en&#95;10553&#95;f3&#46;jpg" class="elsevierStyleCrossRefs"><img src="10553_16025_10793_en_10553_f3.jpg" alt="Comparison of the Survival of Type 1 Diabetic &#40;DM1&#41; Patients in the Two Study Periods "></img></a></p><p class="elsevierStylePara">Figure 3&#46; Comparison of the Survival of Type 1 Diabetic &#40;DM1&#41; Patients in the Two Study Periods </p><p class="elsevierStylePara"><a href="grande&#47;10553&#95;16025&#95;10795&#95;en&#95;10553&#95;f4&#46;jpg" class="elsevierStyleCrossRefs"><img src="10553_16025_10795_en_10553_f4.jpg" alt="Comparison of the Survival of Type 2 Diabetic &#40;DM2&#41; Patients in the Two Study Periods "></img></a></p><p class="elsevierStylePara">Figure 4&#46; Comparison of the Survival of Type 2 Diabetic &#40;DM2&#41; Patients in the Two Study Periods </p><p class="elsevierStylePara"><a href="10553&#95;108&#95;10786&#95;en&#95;w4777105871110553&#95;t1&#95;&#95;en&#46;ppt" class="elsevierStyleCrossRefs">10553&#95;108&#95;10786&#95;en&#95;w4777105871110553&#95;t1&#95;&#95;en&#46;ppt</a></p><p class="elsevierStylePara">Table 1&#46; Characteristics of diabetic and non-diabetic patients on PD and risk factors upon initiation of PD</p><p class="elsevierStylePara"><a href="10553&#95;108&#95;10787&#95;en&#95;w4777105871010553&#95;t2&#95;en&#46;ppt" class="elsevierStyleCrossRefs">10553&#95;108&#95;10787&#95;en&#95;w4777105871010553&#95;t2&#95;en&#46;ppt</a></p><p class="elsevierStylePara">Table 2&#46; Causes of Hospitalisation and PD Discontinuation in Diabetic and Non-Diabetic Patients</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Aims</span>&#58; To describe PD outcomes over 25 years in a single centre&#44; comparing hospitalisation rate&#44; technique withdrawal&#44; and survival between diabetic &#40;DM&#41; and non-diabetic &#40;NonDM&#41; patients&#46; Differences between type 1 &#40;DM1&#41; and type 2 &#40;DM2&#41; diabetics were also analysed&#46; <span class="elsevierStyleBold">Patients and methods&#58;</span> One hundred and eighteen DM patients &#40;52 year old average&#44; 74 men&#44; 44 female&#41; and 117 Non-DM &#40;53 year old average&#44; 64 men&#44; 53 female&#41;&#44; with at least 2 months on PD&#44; 25&#177;20 &#40;2-109&#41; and 29&#46;4&#177;27 &#40;2-159&#41; months respectively&#44; were included&#46; Diabetics were divided in 66 DM1 and 52 DM2&#46; The survival and hospitalisation study was also analysed in two different time periods&#58; before 1992 &#40;1981-1992&#41; and after 1992 &#40;1993-2005&#41;&#46; <span class="elsevierStyleBold">Results&#58;</span><span class="elsevierStyleBold"> </span>93&#37; Non-DM and 75&#37; DM were self-sufficient to manage the PD technique &#40;P&#60;&#46;001&#41; as well as 65&#37; of 44 blind patients&#46; 28&#37; of Non-DM and 15&#37; of DM received a renal allograft &#40;P&#60;&#46;001&#41;&#46; There was no difference in transfer to haemodialysis&#46; 18&#46;6&#37; of DM and 4&#46;3&#37; of Non-DM patients presented &#62;4 comorbid factors on starting PD &#40;P&#60;&#46;001&#41;&#46; Hospitalisation &#40;admissions&#47;year&#41; was higher in DM than in Non-DM patients &#40;3&#46;4 vs 1&#46;8&#44; P&#60;&#46;01&#41; and also hospitalisation length &#40;46 vs 22 days&#47;year&#44; P&#61;&#46;01&#41;&#44; without differences between DM1 and DM2&#46; Admissions due to cardiovascular events&#44; infections&#44; technical problems and peritonitis were more frequent in DM2 than in Non-DM and DM1 patients &#40;P&#60;&#46;05&#41;&#46; <span class="elsevierStyleBold">However&#44; DM2&#160;patients admitted to hospital for peritonitis did not spend more days in hospital than Non-DM or DM1 patients&#46;</span><span class="elsevierStyleBold"> </span>Mortality was 48&#37; in DM and 22&#37; in Non-DM &#40;P&#60;&#46;001&#41;&#46; Survival adjusted for comorbidity was higher in Non-DM &#40;P&#60;&#46;001&#41;&#46; Cerebrovascular disease was the highest risk factor for mortality in DM&#46; Mortality was higher in DM2 than in DM1 and Non-DM&#40;P&#60;&#46;001&#41;&#46; Age &#40;HR 1&#46;052&#44; P&#61;&#46;001&#41;&#44; DM2 &#40;HR 1&#46;96&#44; P&#60;&#46;01&#41; and cerebrovascular disease &#40;HR 4&#46;01&#44; P&#60;&#46;001&#41; were the most important risk factors&#46; In the post-1992 period&#44; the hospitalisation rate and survival improved in DM1 and Non-DM patients&#46; <span class="elsevierStyleBold">Conclusions&#58;</span> DM patients more often require outside assistance to perform PD and have more comorbidity&#44; lower survival&#44; and higher admissions than Non-DM&#44; but there is no difference in HD discontinuation&#46; Age and cardiovascular comorbidity are the factors involved in mortality&#46; Technological advances and cumulative center experience may achieve dialysis outcome improvements in diabetic patients&#46;</p> <p class="elsevierStylePara">¿</p>"
      ]
      "es" => array:1 [
        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold"> <span class="elsevierStyleBold">Objetivos&#58;</span> Describir la experiencia de 25 a&#241;os de tratamiento con di&#225;lisis peritoneal &#40;DP&#41; en un solo centro&#44; comparando la hospitalizaci&#243;n&#44; abandono de la t&#233;cnica y supervivencia entre pacientes diab&#233;ticos &#40;DM&#41; y no diab&#233;ticos &#40;NoDM&#41; y analizando las diferencias entre diab&#233;ticos tipo 1 &#40;DM 1&#41; y tipo 2 &#40;DM 2&#41;&#46; <span class="elsevierStyleBold">Material y m&#233;todos&#58;</span> Se incluyen 118 DM &#40;52 a&#241;os&#44; 74 hombres y 44 mujeres&#41; con&#44; al menos&#44; 2 meses de permanencia en DP y media de 25 &#177; 20 meses &#40;2-109&#41;&#44; divididos en 66 con DM 1 &#40;45 a&#241;os&#41; y 52 con DM 2 &#40;65 a&#241;os&#41; y 117 NoDM &#40;53 a&#241;os&#44; 64 hombres y 53 mujeres&#41;&#44; con un tiempo en DP de 29&#44;4 &#177; 27 meses &#40;2-159&#41;&#46; Por el largo per&#237;odo estudiado&#44; en el an&#225;lisis de hospitalizaci&#243;n y de supervivencia se eval&#250;a&#44; adem&#225;s&#44; el seguimiento en dos per&#237;odos&#58; 1981 a 1992 &#40;pre-92&#41; y 1993 a 2005 &#40;post-92&#41;&#46; <span class="elsevierStyleBold">Resultados&#58;</span> El 93&#37; de los NoDM y el 75&#37; de los DM fueron autosuficientes para realizar DP &#40;p &#60;0&#44;001&#41; y tambi&#233;n el 65&#37; de 44 pacientes ciegos&#46; Han sido sometidos a trasplante el 28&#37; NoDM frente al 15&#37; DM &#40;p &#60;0&#46;001&#41; y no hay diferencia en la transferencia a HD&#46; El 18&#44;6&#37; de los DM frente al 4&#44;3&#37; de los NoDM &#40;p &#60;0&#46;001&#41; presentan cuatro o m&#225;s factores com&#243;rbidos al iniciar DP&#46; La hospitalizaci&#243;n &#40;ingresos&#47;a&#241;o&#41; fue mayor en DM &#40;3&#44;4 frente a 1&#44;8&#41; que en NoDM &#40;p &#60;0&#44;01&#41; y tambi&#233;n los d&#237;as&#47;a&#241;o &#40;46 frente a 22&#59; p &#60;0&#44;01&#41;&#44; sin que exista diferencia entre DM 1 y DM 2&#46; Los ingresos por causas cardiovasculares&#44; infecciones&#44; problemas t&#233;cnicos e infecci&#243;n peritoneal fueron m&#225;s frecuentes en DM 2 &#40;p &#60;0&#44;05&#41; que en NoDM y DM 1&#44; pero no los d&#237;as de ingreso por peritonitis&#46; El 48&#37; de los DM y el 22&#37; de los NoDM fallecen &#40;p &#60;0&#44;001&#41;&#46; La supervivencia ajustada a factores de comorbilidad es mayor en NoDM &#40;p &#60;0&#44;001&#41;&#44; con la enfermedad cerebrovascular como factor mayor de impacto en la mortalidad de DM&#46; La mortalidad es mayor en DM 2 que en DM 1 y NoDM &#40;p &#60;0&#44;001&#41;&#46; La edad &#40;HR 1&#44;052&#59; p &#60;0&#44;001&#41;&#44; la condici&#243;n de DM 2 &#40;HR 1&#44;96&#59; p &#60;0&#44;01&#41; y la enfermedad cerebrovascular &#40;HR 4&#44;01&#59; p &#60;0&#44;001&#41; son los m&#225;s importantes factores de riesgo&#46; En el per&#237;odo post-92 mejora de manera importante la tasa de hospitalizaci&#243;n y la supervivencia de pacientes NoDM y&#44; sobre todo&#44; de DM 1&#46; <span class="elsevierStyleBold">Conclusi&#243;n&#58;</span> Los pacientes con DM precisan m&#225;s frecuentemente ayuda para realizar la DP y presentan m&#225;s comorbilidad&#44; menor supervivencia y mayor hospitalizaci&#243;n que los pacientes NoDM&#44; mientras que es comparable la tasa de abandono de la t&#233;cnica&#46; La edad y las complicaciones cardiovasculares &#40;sobre todo cerebrales&#41; son los factores implicados en la mayor mortalidad&#46; Los avances tecnol&#243;gicos y la mayor experiencia de los centros pueden mejorar las expectativas de los DM en di&#225;lisis&#46;</span></p>"
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            1 => array:3 [
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                  ]
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                    0 => null
                  ]
                ]
              ]
            ]
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                  "contribucion" => array:1 [
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                  ]
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                    0 => null
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
              "etiqueta" => "15"
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                0 => array:3 [
                  "referenciaCompleta" => "Miguel A, García-Ramón R, Pérez-Contreras J, et al. Comorbidity and mortality in peritoneal dialysis: a comparative study of type 1 and type 2 diabetes versus nondiabetic patients. Peritoneal dialysis and diabetes. Nephron 2002;90:290-6."
                  "contribucion" => array:1 [
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              ]
            ]
            15 => array:3 [
              "identificador" => "bib16"
              "etiqueta" => "16"
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                0 => array:3 [
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                  "contribucion" => array:1 [
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                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "16 Portolés J, Corchete E, López-Sánchez P, Coronel F, Ocaña J, Ortiz A, y GCDP. Los pacientes diabéticos tipo 2 presentan peor evolución que los no diabéticos en diálisis peritoneal a expensas de su comorbilidad cardiovascular. Nefrologia 2009;29:336-42. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19668306" 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" => "Piraino B, Minev E, Bernardini J, Bender FH. Does experience with PD matter? Perit Dial Int 2009;29:256-61. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19458292" 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" => "Miguel Carrasco A, García Ramón R, Gómez Roldán C, et al. Morbimortalidad en los pacientes diabéticos con IRC en diálisis peritoneal. En: Coronel F (ed.). Diálisis peritoneal y diabetes. Barcelona: Editorial Médica JIMS, S.L., 1999;13-8."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib20"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Mattana J, Effiong C, Gooneratne R, Singhal PC. Risk of fatal cerebrovascular accident in patients on peritoneal dialysis versus hemodialysis. J Am Soc Nephrol 1997;8:1342-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9259364" 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" => "Coronel F, Cigarrán S, Herrero JA. Early initiation of peritoneal dialysis in diabetic patients. Scand J Urol Nephrol 2009;43:148-53. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19085460" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib22"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Moraes TP, Pecoits-Filho R, Ribeiro SC, et al. Peritoneal dialysis in Brazil: Twenty-five years of experience in a single center. Perit Dial Int 2009;29:492-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19776039" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
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Article information
ISSN: 20132514
Original language: English
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