The role of peritoneal dialysis in the treatment of ascites
Papel de la diálisis peritoneal en el tratamiento de la ascitis
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ROS RUIZ, E. GUTIÉRREZ VILCHES, E. GUTIÉRREZ VILCHEZ, P. FRÍAS, T. P. GARCÍA FRÍAS, M. MARTÍN VELÁZQUEZ, T. M. MARTÍN VELÁZQUEZ, L. BLANCA, L. BLANCA MARTOS, T. JIMÉNEZ, T. JIMÉNEZ SALCEDO, D. HERNÁNDEZ MARRERO" "autores" => array:12 [ 0 => array:4 [ "Iniciales" => "S." "apellidos" => "ROS RUIZ" "email" => array:1 [ 0 => "sirosru@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "E." "apellidos" => "GUTIÉRREZ VILCHES" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "E." "apellidos" => "GUTIÉRREZ VILCHEZ" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "P." 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"apellidos" => "BLANCA MARTOS" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 9 => array:3 [ "Iniciales" => "T." "apellidos" => "JIMÉNEZ" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 10 => array:3 [ "Iniciales" => "T." "apellidos" => "JIMÉNEZ SALCEDO" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 11 => array:3 [ "Iniciales" => "D." "apellidos" => "HERNÁNDEZ MARRERO" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Unidad de Nefrología, Hospital Regional Carlos Haya, Málaga, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Papel de la diálisis peritoneal en el tratamiento de la ascitis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10901_16025_23723_en_10901t1.jpg" "Alto" => 169 "Ancho" => 600 "Tamanyo" => 67733 ] ] "descripcion" => array:1 [ "en" => "Child-Pugh classification of severity of liver disease" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Liver disease, including cirrhosis, is one of the primary causes of human morbidity and mortality, and is the third leading cause among the population of adults aged 40-59 years.</p><p class="elsevierStylePara">Cirrhosis is an advanced state of progressive hepatic fibrosis characterised by altered liver structure and the formation of regenerative nodules. It is irreversible in advanced stages, and the only treatment option in these cases is liver transplant. Patients with cirrhosis are susceptible to a number of complications that determine a lower life expectancy. The most common complication is ascites. Cirrhosis and liver disease were the cause of over 25 000 deaths and 373 000 hospitalisations in the United States in 1998, according to a report by the National Centre for Health Statistics.<span class="elsevierStyleSup">1-8</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">ASCITES</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Definition</span></p><p class="elsevierStylePara">Ascites is the pathological accumulation of liquid in the peritoneal cavity, and is brought on by portal hypertension. Ascites is the primary complication in cirrhosis. Its development is the final consequence of a series of anatomical (circulatory and vascular), functional, and biochemical disorders that cause abnormal liquid retention.<span class="elsevierStyleSup">9-11</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical manifestations and diagnosis</span></p><p class="elsevierStylePara">Generally, patients discover that they have ascites by observing an increase in abdominal circumference. When the accumulated liquid volume exceeds 500ml, ascites can be observed through a physical examination in the form of shifting dullness, fluid wave, and distension.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Physiopathology</span><span class="elsevierStyleBold"></span></p><p class="elsevierStylePara">Several different theories have been proposed to explain the pathogenesis of ascites, but the most recent and widely accepted theory is that of arterial vasodilation.<span class="elsevierStyleSup">12</span> This causes reduced peripheral vascular resistance and blood pressure, increased cardiac output, and consequently, hyperdynamic circulation. The secondary effects are activation of endogenous vasoconstrictors and water and sodium retention, which causes abnormal accumulation of liquid in the peritoneum.<span class="elsevierStyleSup">13-15</span> The increased synthesis of vasodilators such as nitric oxide has been recently involved in the pathogenesis of cirrhosis.<span class="elsevierStyleSup">16,17</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Classification</span></p><p class="elsevierStylePara">A new classification system has been proposed by the International Ascites Club,<span class="elsevierStyleSup">18</span> involving the following grades:</p><p class="elsevierStylePara">Grade 1. Mild ascites only detectable by imaging tests (ultrasound).</p><p class="elsevierStylePara">Grade 2. Moderate ascites manifesting as moderate symmetrical abdominal distension.</p><p class="elsevierStylePara">Grade 3. Severe ascites, with notable abdominal distension.</p><p class="elsevierStylePara">However, the validity of this classification system has not yet been established, and the ascites classification system that ranges between 1+ and 4+ continues to be used, with 1+ being undetectable, minimal ascites, 2+ is moderate ascites, 3+ is massive but not tense, and 4+ is massive and tense.<span class="elsevierStyleSup">19</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Prognosis</span></p><p class="elsevierStylePara">The prognosis in cirrhosis varies widely due to the number of factors involved, including aetiology, severity, and the presence of complications and associated comorbidity. The most useful method for stratifying the severity of the disease, surgical risk, and the general prognosis is by using the Child-Pugh classification system (Table 1).</p><p class="elsevierStylePara">A total score of 5-6 is considered grade A (well-compensated disease); 7-9 is grade B (significant functional compromise), and 10-15 is grade C (decompensated disease). These grades correspond to patient survival rates at 1 and 2 years, respectively: grade A: 100% and 85%; B: 80% and 60%, and grade C: 45% and 35%.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Treatment</span></p><p class="elsevierStylePara">The aim of treatment in patients with cirrhosis and ascites is to correct the underlying cause of the liver disease to the extent possible and to minimise water and sodium retention. The treatment objective is weight loss of 1kg/day (maximum), in the presence of ascites and peripheral oedema, or 0.5kg/day if the patient only has ascites. The most important component of patient treatment is the restriction of salt uptake. A diet of 800mg sodium (2g NaCl) is usually sufficient to induce a negative sodium balance and facilitate diuresis. If the sodium restriction is insufficient for increasing diuresis and inducing weight loss, diuretics must be prescribed, usually spironolactone, and a proximally acting diuretic can be added if the patient does not achieve adequate diuresis. However, 10% of patients are resistant to normal treatment measures. In these cases of resistant ascites, other therapeutic options are necessary.<span class="elsevierStyleSup">20,21</span></p><p class="elsevierStylePara">In patients with severe ascites, evacuation paracentesis is the most effective treatment. In some patients with ascites refractory to paracentesis, a latero-lateral porto-caval shunt can improve the condition, although these patients generally have very high surgical risk. The use of this technique is limited by the high frequency of complications, such as infection, disseminated intravascular coagulation, and shunt thrombosis. More recently, transjugular intrahepatic portosystemic shunts (TIPS) have provided effective control of ascites refractory to other treatments, although portal decompression upon mobilising the ascitic fluid has triggered severe hepatic encephalopathy in some patients.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">PREVALENCE OF ASCITES IN CHRONIC KIDNEY DISEASE </span></p><p class="elsevierStylePara">The incidence of ascites in advanced chronic kidney disease (CKD) varies, but tends to fall between 0.7% and 20%.<span class="elsevierStyleSup">22</span> The prevalence of CKD along with hepatic cirrhosis and ascites is not precisely established, but there is a clear increase in the frequency of the occurrence of this association due to the growing prevalence of both diseases. Chronic liver disease frequently progresses along with renal disorders that lead to CKD, even reaching levels requiring dialysis treatment.<span class="elsevierStyleSup">23</span> The optimal time for commencing dialysis in these patients is difficult to determine, since they share symptoms such as anorexia and weight loss, among others, which could be due to both uraemia and liver disease. Additionally, the over-estimation of renal glomerular filtration rates leads the physician to attribute the symptoms to the liver disease more than to uraemia.<span class="elsevierStyleSup">24</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Renal replacement therapy in patients with CKD associated with liver disease and ascites</span></p><p class="elsevierStylePara">No clinical trials have yet been carried out that accurately evaluate the impact of the different dialysis options available to patients with CKD and cirrhosis. The causes of ascites in patients on dialysis are: coexisting liver disease, coexisting cardiovascular disease, peritonitis, severe protein depletion, and idiopathic ascites. All of these situations represent a challenge to maintaining haemodynamic stability in the presence of CKD and dialysis is necessary, especially during haemodialysis sessions (HD).<span class="elsevierStyleSup">22</span></p><p class="elsevierStylePara">The primary limitation to the use of HD in cirrhotic patients is <span class="elsevierStyleItalic">intra-dialysis hypotension</span>. Patients with hepatic cirrhosis and ascites have reduced peripheral intravascular resistance. Under these circumstances, the sudden decrease in intravascular volume during the ultrafiltration (UF) process of HD frequently produces haemodynamic intolerance by exacerbating the level of hypotension. An added factor that can contribute to the instability of cirrhotic patients during HD is the increased production of nitric oxide during dialysis which has been demonstrated in patients without cirrhosis and with intra-dialysis hypotension.</p><p class="elsevierStylePara">In addition, there is also an increased risk of <span class="elsevierStyleItalic">haemorrhage</span> due to thrombocytopaenia and prolonged coagulation time, as well as gastrointestinal bleeding due to oesophageal varices or hypertensive gastropathy. The former limits the prescription of heparin during HD, but this natural elongation of coagulation times may be sufficient for avoiding trans-dialysis coagulation problems. Anticoagulation-free circuits can be used in these cases. Moreover, since no studies have evaluated the use of anticoagulants in cirrhotic patients, the exposure of patients to anticoagulants must be limited to the extent possible.</p><p class="elsevierStylePara">The assessment of dialysis <span class="elsevierStyleItalic">adequacy</span> in patients with severe ascites is under debate. Measuring the urea reduction ratio (URR) before balancing the urea levels of the large extracellular reservoir overestimates the dialysis dosage used, and so it is recommended to measure the <span class="elsevierStyleItalic">equilibrated fractional clearance index of urea</span><span class="elsevierStyleItalic"> </span>1-2 hours after dialysis in ascites patients.</p><p class="elsevierStylePara">Another inconvenience of intermittent HD is the sharp changes in osmolarity and electrolyte levels that produce severe alterations in cerebral water levels, with consequent increased risk for developing encephalopathy. Continuous treatment with PD offers significant advantages in several different aspects to chronic hepatopathy/ascites patients, and even allows for partial and progressive draining of the ascitic fluid.<span class="elsevierStyleSup">23,24</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Transmission of hepatitis C and B viruses</span></p><p class="elsevierStylePara">The prevalence of the hepatitis B virus (HBV) in dialysis centres varies widely, between 0% and 51%, and can be 8-9 times higher than in patients on peritoneal dialysis (PD).<span class="elsevierStyleSup">25</span> Nosocomial transmission is a risk factor for HBV infection of patients on HD. In contrast with other viral infections, the viral load in the blood can be increased in seropositive patients, and the HBV can survive in an open environment, which is a fact that must be taken into account in dialysis patients, above all those undergoing HD, since these can be at risk for a nosocomial HBV infection. Although it is known that the DNA of the HBV crosses the membrane of a dialyser during high-flow dialysis, the level of ineffectiveness of the dialysate and ultrafiltration is under debate.<span class="elsevierStyleSup">26,27</span> A reduced risk of being infected by HBV has been observed in patients on PD, with a 19 times lower seroconversion rate.<span class="elsevierStyleSup">28</span></p><p class="elsevierStylePara">In comparison, liver disease caused by the hepatitis C virus (HCV) is a significant cause of morbidity and mortality in dialysis patients. Additionally, these patients have a higher risk of contracting HCV than the general population. Several different factors have been identified: the number of transfusions, the duration of CKD (some studies have shown higher probability of infection after one decade of HD), the prevalence of HCV at the dialysis unit, and previous history of organ transplant or intravenous drug abuse. As such, patients treated in HD units with a high prevalence of HCV infection have a greater risk of being infected.<span class="elsevierStyleSup">29</span></p><p class="elsevierStylePara">The type of dialysis performed also seems to influence the risk of infection by HCV, with lower rates in PD than HD. Such was the case in a study from 2009 in which all incident dialysis patients were included from the registries of 10 different countries/regions of Asia and the Pacific (Australia, New Zealand, Japan, China, Taiwan, Korea, Thailand, Hong-Kong, Malaysia, and India) between April 1995 and December 2005.<span class="elsevierStyleSup">30</span> The seroprevalence rates for HCV were generally higher in patients on HD than PD (7.9% compared to 3.0%), with similar results in seroconversion rates (incidence rate ratios of 0.33 PD vs HD; 95% confidence interval [CI]: 0.13-0.75). Regarding HBV, the available data from this study were more limited (only 7 countries were included), although the authors did observe that the result were less influenced by the type of dialysis used.<span class="elsevierStyleSup">25</span></p><p class="elsevierStylePara">In another study involving 129 anti-HCV negative patients that were undergoing chronic dialysis treatment, the seroconversion rate for patients on HD was 0.15/patient-year as compared to 0.03/patient-year in PD patients.<span class="elsevierStyleSup">28</span> In addition, the majority of the patients on PD that tested positive for anti-HCV had acquired the disease while on HD. In accordance with these results, an Israeli study observed that the prevalence of HCV infection among HD patients was 18% and only 7% among PD patients.<span class="elsevierStyleSup">31</span></p><p class="elsevierStylePara">Several different factors explain the lower risk of HCV infection among PD patients: this technique requires fewer blood transfusions and absence of vascular access points and extracorporeal blood circuits, which reduces the risk of parenteral exposure to the virus during this outpatient procedure.<span class="elsevierStyleSup">29,32</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">PERITONEAL DIALYSIS AS A RENAL REPLACEMENT THERAPY ALTERNATIVE </span>(Table 2)</p><p class="elsevierStylePara">Patients with CKD and liver disease with ascites benefit from PD through several different mechanisms: improved haemodynamic tolerance with fewer episodes of hypotension, dialysis-ascites fluid drainage and early diagnosis of infection, avoiding the use of heparin, reducing the risk of haemorrhage and anaemia, better preservation of residual renal function, complementary glucose input, and reduced risk of contracting hepatitis in the case of positive patients.<span class="elsevierStyleSup">23</span></p><p class="elsevierStylePara">However, the fear of excessive bleeding during the placement of the catheter, inadequate ultrafiltration (UF) and removal of solutes in the presence of ascites, and the increased risk of bacterial peritonitis and hypoalbuminaemia have all limited its use.<span class="elsevierStyleSup">23,24</span></p><p class="elsevierStylePara">Paracentesis is considered to be the first line of treatment for severe ascites. Given that treatment is continuous, PD is a slow and continuous method of dialysis and water loss that imitates a daily regimen of paracentesis, and provides an alternative treatment for these patients, even for prolonged periods of time. As such, cirrhotic patients with temporary or chronic renal failure could benefit from the placement of a peritoneal catheter in order to repeatedly drain the ascitic fluid at home.<span class="elsevierStyleSup">22</span> Wilcox et al<span class="elsevierStyleSup">33</span> used PD catheters successfully for this purpose, with a mean drainage of 7.6 litres in 129 minutes.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Placement of the peritoneal catheter</span></p><p class="elsevierStylePara">The peritoneal catheter can be inserted percutaneously or surgically. Neither bleeding complications nor intestinal perforations have been reported to occur more often in this type of patient.<span class="elsevierStyleSup">22</span></p><p class="elsevierStylePara">Marcus et al<span class="elsevierStyleSup">36</span> described five patients with prolonged coagulation times who underwent percutaneous catheter placement with no bleeding complications.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Peritoneal transport and adequacy</span></p><p class="elsevierStylePara">Patients with ascites have been observed to develop increased diffusion of urea, creatinine, phosphorous, and CO<span class="elsevierStyleInf">2</span> molecules through the peritoneal membrane, as well as increased UF capacity. The increase in UF is not correlated with glucose absorption (D/D0) after 4 hours, or with the concentration of sodium in the dialysis effluent (PD Na), probably due to the production of ascites. The increased UF capacity makes the use of hypertonic solutions especially important.<span class="elsevierStyleSup">22,24</span></p><p class="elsevierStylePara">Durand et al<span class="elsevierStyleSup">37</span> described the functional behaviour of the peritoneum in four patients, observing an initial increase in UF capacity and high solute clearance. Selgas et al<span class="elsevierStyleSup">22</span><span class="elsevierStyleSup"> </span>and Durand et al<span class="elsevierStyleSup">37</span> described a higher UF capacity in cirrhotic patients than in non-cirrhotic patients.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Nutritional status and peritoneal protein loss</span></p><p class="elsevierStylePara">One of the problems associated with the loss of proteins through the effluent produced in these patients is the risk of malnutrition. However, in the study of cirrhotic patients and ascites treated with PD described by Selgas et al,<span class="elsevierStyleSup">22</span> these authors observed an initial loss of proteins in the peritoneal membrane at the start of dialysis treatment as high as 30g per day, but this loss later decreased to a mean of 7-15g/day. This effect was observed during the first three months of dialysis treatment; later, the reduced protein loss was correlated with increased serum albumin levels and the patient’s recovered body weight.<span class="elsevierStyleSup">22</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Peritonitis</span></p><p class="elsevierStylePara">There are some discrepancies regarding the higher rate of peritonitis associated with cirrhotic patients with ascites compared to the rate of peritonitis in patients without cirrhosis. Chow et al<span class="elsevierStyleSup">38</span> found no differences in the incidence of episodes of peritonitis between patients with HBV and cirrhosis and those without cirrhosis (1 episode/19 patient-months in the group with cirrhosis compared to 1 episode/20.5 patient-months). Similarly, De Vecchi et al<span class="elsevierStyleSup">39</span> observed a similar incidence of peritonitis in cirrhotic and non-cirrhotic patients treated with PD (1 episode/39 patient-months compared to 1 episode/22 patient-months, NS). However, Selgas et al observed a higher incidence of peritonitis in patients with cirrhosis treated with PD than in non-cirrhotic patients (1 episode/9 patient-months compared to 1 episode/24 patient-months). The aetiology associated with peritonitis in patients with cirrhosis treated with PD varies. De Vecchi et al<span class="elsevierStyleSup">39</span> observed that the majority of the isolated microorganisms were gram-positive, primarily <span class="elsevierStyleItalic">Staphylococcus </span>(14 episodes), and only two episodes were caused by gram-negative bacteria. This result differs from other studies in which the more frequent cause was gram-negative bacteria.<span class="elsevierStyleSup">22</span></p><p class="elsevierStylePara">Given that spontaneous bacterial peritonitis (SBP), the pathology most frequently associated with ascites, is primarily caused by gram-negative bacteria, it is difficult to differentiate the infectious episodes that are due to the dialysis technique used from those secondary to the liver disease itself. In any case, continuous visualisation of the peritoneal liquid through a daily drain allows for an earlier diagnosis based on the turbidity of the dialysate and avoids the need for paracentesis in the case of suspected SBP. Additionally, having access to a peritoneal catheter, these patients could benefit from the intraperitoneal administration of antibiotics for the treatment of peritonitis.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Survival of the cirrhotic patient on peritoneal dialysis</span></p><p class="elsevierStylePara">In the study carried out by Marcus et al<span class="elsevierStyleSup">36</span> involving 9 patients with hepatic cirrhosis on PD, five survived longer than 18 months, two for two years, one for four years, and another for eight years. Bajo et al<span class="elsevierStyleSup">40</span> described six patients with cirrhosis and ascites treated with PD, and with a follow-up period of 8-66 months and good control. Three patients died due to causes unrelated to the technique used. Durand et al<span class="elsevierStyleSup">37</span> described four patients, three of which survived longer than 2 years.</p><p class="elsevierStylePara">The most recent and largest study was that performed by De Vecchi et al<span class="elsevierStyleSup">39</span> involving 21 cirrhotic patients on PD, and comparing them with a historical cohort of patients on PD and without cirrhosis. Of the 21 patients, 11 had been on PD for more than one year and 8 patients more than 2 years. There were no differences in mortality as compared to the PD group without cirrhosis.</p><p class="elsevierStylePara">In summary, the treatment of patients with CKD and chronic liver disease with ascites is a complex undertaking due to several different associated issues, including ascites and other complications derived from liver disease. Given the elevated morbidity and mortality rates derived from cirrhosis, special care must be taken when indicating and starting RRT in this population, especially with regard to the potential risks associated with HD. PD provides a viable alternative with several potential benefits, such as improved haemodynamic stability and reduced risk of bleeding. The theoretically higher risk of peritonitis has not been clearly shown by the medical literature, and publications tend to show a similar rate of peritonitis between patients undergoing PD with and without cirrhosis. Additionally, PD can facilitate proper solute clearance while allowing for relief from ascites symptoms. As such, in spite of the scarce clinical observations yet published, PD can be considered as a viable and effective dialysis technique for this group of patients.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">KEY CONCEPTS</span></p><p class="elsevierStylePara">1. The prevalence of coexisting chronic kidney disease and hepatic cirrhosis is increasing due to the growing prevalence of both diseases.</p><p class="elsevierStylePara">2. A tight follow-up regimen is necessary in these patients in order to determine when to start dialysis based on the difficulty in determining the exact glomerular filtration rate and the presence of similar symptoms.</p><p class="elsevierStylePara">3. The spontaneous tendency towards arterial hypotension, haemodynamic instability, and increased risk of bleeding in cirrhotic patients make haemodialysis a difficult task.</p><p class="elsevierStylePara">4. Since periodic evacuation paracentesis is the treatment of choice for cirrhotic patients with ascites, the continuous and slow drainage of peritoneal liquid through peritoneal dialysis is similar to the normal treatment given to these patients, even on a long-term basis.</p><p class="elsevierStylePara">5. The fear of increased risk of peritonitis with peritoneal dialysis has not been clearly supported or rejected, and fewer bleeding complications and better haemodynamic tolerance have been observed, as well as decreased transmission of hepatitis B and C, when compared to haemodialysis.</p><p class="elsevierStylePara">6. As such, peritoneal dialysis should be considered as a viable and effective dialysis alternative for this group of patients.</p><p class="elsevierStylePara"><a href="grande/10901_16025_23723_en_10901t1.jpg" class="elsevierStyleCrossRefs"><img src="10901_16025_23723_en_10901t1.jpg" alt="Child-Pugh classification of severity of liver disease"></img></a></p><p class="elsevierStylePara">Table 1. Child-Pugh classification of severity of liver disease</p><p class="elsevierStylePara"><a href="grande/10901_108_23724_en_10901t2.jpg" class="elsevierStyleCrossRefs"><img src="10901_108_23724_en_10901t2.jpg" alt="Advantages and disadvantages of peritoneal dialysis in patients with chronic kidney disease and liver disease"></img></a></p><p class="elsevierStylePara">Table 2. Advantages and disadvantages of peritoneal dialysis in patients with chronic kidney disease and liver disease</p><p class="elsevierStylePara"><a href="grande/10901_16025_23725_en_10901t3.jpg" class="elsevierStyleCrossRefs"><img src="10901_16025_23725_en_10901t3.jpg" alt="Summary of cirrhotic patients on peritoneal dialysis"></img></a></p><p class="elsevierStylePara">Table 3. Summary of cirrhotic patients on peritoneal dialysis</p>" "pdfFichero" => "P1-E528-S3203-A10901-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439327" "palabras" => array:1 [ 0 => "Diálisis peritoneal" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439329" "palabras" => array:1 [ 0 => "Ascitis" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439331" "palabras" => array:1 [ 0 => "Enfermedad hepática" ] ] ] "en" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439328" "palabras" => array:1 [ 0 => "Peritoneal dialysis" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439330" "palabras" => array:1 [ 0 => "Ascites" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439332" "palabras" => array:1 [ 0 => "Liver disease" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "<p class="elsevierStylePara">La cirrosis representa un estadio avanzado de la fibrosis hepática y conlleva a una alta morbimortalidad cuya complicación más frecuente es la ascitis. Una minoría de pacientes con cirrosis avanzada tiene «ascitis refractaria» y no responden al tratamiento convencional. La paracentesis evacuadoras de repetición se consideran el tratamiento de elección en estos casos. Una gran parte de estos pacientes presentan asociada una enfermedad renal crónica (ERC), que puede precisar de tratamiento renal sustitutivo (TRS). Debido a las complicaciones asociadas a la enfermedad hepática de alteraciones de la coagulación y tendencia espontánea a la hipotensión arterial plantea problemas de cara al TRS, especialmente derivados de la hemodiálisis (HD). En este sentido la diálisis peritoneal (DP) ofrece varias ventajas respecto a la HD en pacientes con cirrosis, con o sin ascitis debido a su mejor tolerancia hemodinámica por ser un técnica continua y lenta, con baja tasa de complicaciones infecciosas y hemorrágicas.</p>" ] "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleItalic">Cirrhosis represents a late stage of hepatic fibrosis and leads to high morbidity and mortality, and the most frequent complication is ascites. Only a few patients with advanced cirrhosis have 'refractory ascites' and do not respond to conventional treatment. Repeated paracentesis for evacuation is considered the treatment of choice in these cases. A large proportion of these patients have associated chronic kidney disease (CKD), which may require renal replacement therapy (RRT). Due to the complications associated with liver disease with coagulation disorders and tendencies towards spontaneous hypotension, there are significant problems associated to RRT, especially haemodialysis (HD). On the contrary, peritoneal dialysis (PD) offers several advantages over HD in cirrhotic patients (with or without ascites) thanks to better haemodynamic tolerance, as it is a continuous and slow technique. Furthermore, PD has a low rate of infection and bleeding.</span></p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10901_16025_23723_en_10901t1.jpg" "Alto" => 169 "Ancho" => 600 "Tamanyo" => 67733 ] ] "descripcion" => array:1 [ "en" => "Child-Pugh classification of severity of liver disease" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10901_108_23724_en_10901t2.jpg" "Alto" => 193 "Ancho" => 600 "Tamanyo" => 100106 ] ] "descripcion" => array:1 [ "en" => "Advantages and disadvantages of peritoneal dialysis in patients with chronic kidney disease and liver disease" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10901_16025_23725_en_10901t3.jpg" "Alto" => 453 "Ancho" => 600 "Tamanyo" => 166413 ] ] "descripcion" => array:1 [ "en" => "Summary of cirrhotic patients on peritoneal dialysis" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Jang JW. Current status of liver diseases in Korea: Liver cirrosis. Korean J Hepatol 2009;15(6)(Suppl):40-9." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "D¿Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: A meta-analytic review. Hepatology 1995;22:332-54. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7601427" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Floras JS, Legault L, Morali M, Hara K, Blendis LM. Increased sympathetic outflow in cirrhosis and ascites: Direct evidence from intraneural recordings. Ann Intern Med 1991;114:373-80. <a href="http://www.ncbi.nlm.nih.gov/pubmed/1992879" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ginés P, Arroyo V, Quintero E. Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites: Results of a randomized study. Gastroenterology 1987;93:234-41. <a href="http://www.ncbi.nlm.nih.gov/pubmed/3297907" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ochs A. The transjugular intrahepatic portoystemic stent-shunt procedure for refractory ascites. N Engl J Med 1995;332:1192-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7700312" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Pinto PC, Amerian J, Reynolds TB. Large-volume paracentesis in nonedematous patients with tense ascites: Its effect on intravascular volume. Hepatology 1988;8:207-10. <a href="http://www.ncbi.nlm.nih.gov/pubmed/3356400" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Conn H, Atterbury C. Cirrhosis: Diseases of the liber, 7th edition. In: Schiff L, Schiff E (eds.). Philadelphia: Lippencott Company; 1993. p. 875." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Runyon BA. Care of patients with ascites. N Engl J Med 1994;330:337-42. <a href="http://www.ncbi.nlm.nih.gov/pubmed/8277955" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ginés P, Quintero E, Arroyo V. Compensated cirrhosis: natural history and prognostic factors. Hepatology 1987;7:122-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/3804191" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Runyon BA. AASLD Practice Guidelines Comitee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology 2009;49:2087-107. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19475696" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lieberman FL, Denison EK, Reynolds TB. The relationship of plasma volume, portal hypertension, ascites, and renal sodium retention in cirrhosis: The overflow theory of ascites formation. Ann NY Acad Sci 1970;170:292-5." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Schrier RW, Arroyo V, Bernardi M, Epstein M, Henriksen JH, Rodés J. Peripheral arterial vasodilation, hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology 1988;8:1151-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/2971015" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Asbert M, Ginés A, Ginés P, Jiménez W, Claria J, Saló J, et al. Circulating levels of endothelin in cirrhosis. Gastroenterology 1993;104:1485-91. <a href="http://www.ncbi.nlm.nih.gov/pubmed/8482460" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Wensing G, Lotterer E, Link I, Hahn EG, Fleig WE. Urinary sodium balance in patients with cirrhosis: relationship to quantitative parameters of liver function. Hepatology 1997;26:1149-55. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9362355" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Arroyo V, Clària J, Salo J, Jiménez W. Antidiuretic hormone and the pathogenesis of water retention in cirrosis with ascites. Semin Liver Dis 1994;14:44-58. <a href="http://www.ncbi.nlm.nih.gov/pubmed/8016662" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ros J, Jiménez W, Lamas S. Nitric oxide production in arterial vessels of cirrhotic rats with ascites: role of endogenous nitric oxide. Hepatology 1992;15:343-60." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Clària J, Jiménez W, Ros J, Rigol M, Angeli P, Arroyo V, et al. Pathogenesis of arterial hypotension in cirrhotic rats with ascites: role of endogenous nitric oxide. Hepatology 1992;15:343-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/1735539" 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" => "Moore KP, Wong F, Ginés P,\u{A0}\u{A0}Bernardi M, Ochs A, Salerno F, et al. The management of ascites in cirrhosis: report on the consensus conference of the international Ascites Club. Hepatology 2003;38:258-66." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Stanley MM, Ochi S, Lee KK, Nemchausky BA, Greenlee HB, Allen JI, et al. Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. Veterans Administration Cooperative Study on Treatment of alcoholic cirrhosis with ascites. N Engl J Med 1989;321:1632-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/2586565" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Runyon BA. Historical aspects of treatment of patients with cirrhosis and ascites. Semin Liver Dis 1997;17:163-73. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9308122" 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" => "García-Pagán JC, Salmerón JM, Feu F,\u{A0}\u{A0}Luca A, Ginés P, Pizcueta P,\u{A0}et al. Effects of low-sodium diet and spironolactone on portal pressure in patients with compensated cirrhosis. Hepatology 1994;19:1095-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/8175131" 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" => "Selgas R, Bajo MA, Del Peso G, Sánchez-Villanueva R, González E, Romero S, et al. Peritoneal dialysis in the comprehensive management of end-stage renal disease patients with liver cirrosis and ascites: practical aspects and review of the literatura. Perit Dial Int 2008;28:118-22. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18332443" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 22 => array:3 [ "identificador" => "bib23" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "23.\u{A0}Chaudhary K,\u{A0}Khanna R. Renal replacement therapy in end-stage renal disease patients with chronic liver disease and ascites: role of peritoneal dialysis. Perit Dial Int 2007;28:113-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18332442" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 23 => array:3 [ "identificador" => "bib24" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Howard CS,\u{A0}Teitelbaum I. Renal replacement therapy in patients with chronic liver disease. Semin Dial 2005;18(3):212-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15934968" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 24 => array:3 [ "identificador" => "bib25" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Johnson DW, Dent H, Yao Q, Trasanesu A, Huang C. Frequencies of hepatitis B and C infections among haemodialysis and peritoneal dialysis patients in Asian-Pacific countries: analysis of registry data. Nephrol Dial Transplant 2009;24:1598-603. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19096083" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 25 => array:3 [ "identificador" => "bib26" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Andrew R, Hariharan S, Saha V. Biochemical evaluation of ultrafiltrate in dialysis-dependent HBsAG-positive patients. Nephron 1988;49:88. <a href="http://www.ncbi.nlm.nih.gov/pubmed/3380225" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 26 => array:3 [ "identificador" => "bib27" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Kroes AC, Van Bommel EF, Niesters HG, Weimar W. Hepatitis B viral DNA detectable in dialysate. Nephron 1994;67:369. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7936036" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 27 => array:3 [ "identificador" => "bib28" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Cendoroglo Neto M, Draibe SA, Silva AE. Incidence of and risk factors for hepatitis B virus and hepatitis C virus infection among haemodialysis and CAPD patients: evidence for environmental transmission. Nephrol Dial Transplant 1995;10:240-65." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 28 => array:3 [ "identificador" => "bib29" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Sun J, Yu R, Zhu B, Wu J, Larsen S. Hepatitis C infection and related factors in hemodialysis patients in China: systematic review and meta-analysis. Ren Fail 2009;31(7):610-2." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 29 => array:3 [ "identificador" => "bib30" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Puttinger H, Vychytil A. Hepatitis B and C in peritoneal dialysis patients. Semin Nephrol 2002;22(4):351-60. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12118400" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 30 => array:3 [ "identificador" => "bib31" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Weinstein T, Tur-Kaspa R, Chagnac A, Korzets A, Ori Y, Zevin D, et al. Hepatitis C infection in dialysis patients in Israel. Isr Med Assoc 2001;3:174-7." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 31 => array:3 [ "identificador" => "bib32" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Natoy SN, Pereira BJ. Hepatitis C virus in chronic dialysis patients. Minerva Urol Nephrol 2005;57(83):175-97." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 32 => array:3 [ "identificador" => "bib33" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "33.\u{A0}Wilcox CM, Woods BL,\u{A0}Mixon HT. Prospective evaluation of a peritoneal dialysis catheter system for large volume paracentesis. Am Coll Gastroenterol 1992;87(10):1443-6." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 33 => array:3 [ "identificador" => "bib34" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "34.\u{A0}Poulos AM, Howard L, Eisele G,\u{A0}Rodgers JB. Peritoneal dialysis therapy for patients with liver and renal failure with ascites. Am Coll\u{A0}Gastroenterol 1993; 88(1):109-12." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 34 => array:3 [ "identificador" => "bib35" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Wilkinson SP, Weston MJ, Parsons V, Williams R. Dialysis in the treatment of renal failure in patients with liver disease. Clin Nephrol 1977;8(1):287-92. <a href="http://www.ncbi.nlm.nih.gov/pubmed/884909" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 35 => array:3 [ "identificador" => "bib36" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Marcus RG, Messana J, Swartz R. Peritoneal dialysis in end-stage renal disease patients with preexisting chronic liver disease and ascites. Am J Med 1992;93:35-40. <a href="http://www.ncbi.nlm.nih.gov/pubmed/1626571" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 36 => array:3 [ "identificador" => "bib37" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Durand PY, Freida P, Chanliau J. Long-term follow-up in cirrhotic patients with chronic renal failure undergoing CAPD. Perit Dial Int 1993;13(Suppl 1):47." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 37 => array:3 [ "identificador" => "bib38" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Chow KM, Szeto CC, Wu AKL, Leung CB. Continuous ambulatory peritoneal dialysis in patients with hepatitis B liver disease. Perit Dial Int 2006;26:213-17." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 38 => array:3 [ "identificador" => "bib39" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "De Vecchi AF, Colucci P, Salerno F, Scalamogna A,\u{A0}Ponticelli C. Outcome of peritoneal dialysis in cirrhotic patients with chronic renal failure. Am J Kid Dis 2002;40(1):161-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12087574" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 39 => array:3 [ "identificador" => "bib40" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Bajo MA, Selgas R. CAPD for treatment of ESRD patients with ascites secondary to liver cirrhosis. Adv Perit Dial 1994;10:73-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7999868" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003100000006/v0_201502091623/X2013251411000278/v0_201502091623/en/main.assets" "Apartado" => array:4 [ "identificador" => "35445" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Short Reviews" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003100000006/v0_201502091623/X2013251411000278/v0_201502091623/en/P1-E528-S3203-A10901-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251411000278?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 26 | 28 | 54 |
| 2024 October | 174 | 183 | 357 |
| 2024 September | 160 | 159 | 319 |
| 2024 August | 172 | 168 | 340 |
| 2024 July | 143 | 174 | 317 |
| 2024 June | 145 | 182 | 327 |
| 2024 May | 159 | 180 | 339 |
| 2024 April | 143 | 135 | 278 |
| 2024 March | 129 | 80 | 209 |
| 2024 February | 114 | 73 | 187 |
| 2024 January | 114 | 94 | 208 |
| 2023 December | 98 | 92 | 190 |
| 2023 November | 124 | 79 | 203 |
| 2023 October | 148 | 98 | 246 |
| 2023 September | 142 | 114 | 256 |
| 2023 August | 129 | 44 | 173 |
| 2023 July | 209 | 76 | 285 |
| 2023 June | 165 | 86 | 251 |
| 2023 May | 124 | 79 | 203 |
| 2023 April | 128 | 53 | 181 |
| 2023 March | 101 | 54 | 155 |
| 2023 February | 90 | 52 | 142 |
| 2023 January | 88 | 43 | 131 |
| 2022 December | 83 | 54 | 137 |
| 2022 November | 102 | 62 | 164 |
| 2022 October | 112 | 52 | 164 |
| 2022 September | 124 | 36 | 160 |
| 2022 August | 117 | 69 | 186 |
| 2022 July | 95 | 57 | 152 |
| 2022 June | 86 | 65 | 151 |
| 2022 May | 109 | 55 | 164 |
| 2022 April | 92 | 73 | 165 |
| 2022 March | 166 | 80 | 246 |
| 2022 February | 106 | 70 | 176 |
| 2022 January | 81 | 48 | 129 |
| 2021 December | 92 | 64 | 156 |
| 2021 November | 81 | 63 | 144 |
| 2021 October | 117 | 51 | 168 |
| 2021 September | 121 | 51 | 172 |
| 2021 August | 121 | 55 | 176 |
| 2021 July | 164 | 38 | 202 |
| 2021 June | 112 | 50 | 162 |
| 2021 May | 155 | 48 | 203 |
| 2021 April | 317 | 46 | 363 |
| 2021 March | 157 | 65 | 222 |
| 2021 February | 127 | 37 | 164 |
| 2021 January | 125 | 34 | 159 |
| 2020 December | 114 | 28 | 142 |
| 2020 November | 125 | 39 | 164 |
| 2020 October | 53 | 23 | 76 |
| 2020 September | 76 | 13 | 89 |
| 2020 August | 77 | 24 | 101 |
| 2020 July | 110 | 28 | 138 |
| 2020 June | 91 | 39 | 130 |
| 2020 May | 78 | 27 | 105 |
| 2020 April | 94 | 51 | 145 |
| 2020 March | 120 | 19 | 139 |
| 2020 February | 105 | 45 | 150 |
| 2020 January | 154 | 49 | 203 |
| 2019 December | 105 | 39 | 144 |
| 2019 November | 105 | 48 | 153 |
| 2019 October | 94 | 40 | 134 |
| 2019 September | 112 | 43 | 155 |
| 2019 August | 108 | 27 | 135 |
| 2019 July | 551 | 50 | 601 |
| 2019 June | 193 | 78 | 271 |
| 2019 May | 207 | 25 | 232 |
| 2019 April | 205 | 34 | 239 |
| 2019 March | 160 | 28 | 188 |
| 2019 February | 83 | 34 | 117 |
| 2019 January | 141 | 24 | 165 |
| 2018 December | 276 | 50 | 326 |
| 2018 November | 204 | 41 | 245 |
| 2018 October | 233 | 26 | 259 |
| 2018 September | 267 | 31 | 298 |
| 2018 August | 172 | 22 | 194 |
| 2018 July | 158 | 17 | 175 |
| 2018 June | 126 | 12 | 138 |
| 2018 May | 163 | 15 | 178 |
| 2018 April | 121 | 12 | 133 |
| 2018 March | 174 | 16 | 190 |
| 2018 February | 141 | 8 | 149 |
| 2018 January | 138 | 8 | 146 |
| 2017 December | 151 | 11 | 162 |
| 2017 November | 162 | 7 | 169 |
| 2017 October | 143 | 10 | 153 |
| 2017 September | 143 | 8 | 151 |
| 2017 August | 149 | 7 | 156 |
| 2017 July | 190 | 20 | 210 |
| 2017 June | 176 | 12 | 188 |
| 2017 May | 200 | 16 | 216 |
| 2017 April | 150 | 18 | 168 |
| 2017 March | 163 | 7 | 170 |
| 2017 February | 195 | 19 | 214 |
| 2017 January | 153 | 22 | 175 |
| 2016 December | 153 | 6 | 159 |
| 2016 November | 171 | 22 | 193 |
| 2016 October | 215 | 10 | 225 |
| 2016 September | 255 | 14 | 269 |
| 2016 August | 486 | 22 | 508 |
| 2016 July | 275 | 23 | 298 |
| 2016 June | 190 | 0 | 190 |
| 2016 May | 170 | 0 | 170 |
| 2016 April | 168 | 0 | 168 |
| 2016 March | 143 | 0 | 143 |
| 2016 February | 144 | 0 | 144 |
| 2016 January | 133 | 0 | 133 |
| 2015 December | 155 | 0 | 155 |
| 2015 November | 105 | 0 | 105 |
| 2015 October | 126 | 0 | 126 |
| 2015 September | 116 | 0 | 116 |
| 2015 August | 103 | 0 | 103 |
| 2015 July | 123 | 0 | 123 |
| 2015 June | 67 | 0 | 67 |
| 2015 May | 83 | 0 | 83 |
| 2015 April | 15 | 0 | 15 |
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