Reasons why therapeutic apheresis should belong to nephrology
Por qué la aféresis terapéutica debe pertenecer a la especialidad de nefrología
Read
10063
Timeswas read the article
2597
Total PDF
7466
Total HTML
Share statistics
array:20 [ "pii" => "X2013251411052306" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2011.Jun.11002" "estado" => "S300" "fechaPublicacion" => "2011-07-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2011;31:379-81" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4612 "formatos" => array:3 [ "EPUB" => 304 "HTML" => 3717 "PDF" => 591 ] ] "Traduccion" => array:1 [ "es" => array:17 [ "pii" => "X0211699511052309" "issn" => "02116995" "doi" => "10.3265/Nefrologia.pre2011.Jun.11002" "estado" => "S300" "fechaPublicacion" => "2011-07-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia. 2011;31:379-81" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 8437 "formatos" => array:3 [ "EPUB" => 287 "HTML" => 7518 "PDF" => 632 ] ] "es" => array:10 [ "idiomaDefecto" => true "titulo" => "Por qué la aféresis terapéutica debe pertenecer a la especialidad de nefrología" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "379" "paginaFinal" => "381" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Reasons why therapeutic apheresis should belong to nephrology" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11002_108_18086_es_11002_t1.jpg" "Alto" => 520 "Ancho" => 505 "Tamanyo" => 246987 ] ] "descripcion" => array:1 [ "es" => "Procedimientos de depuración sanguínea aplicados en la aféresis terapéutica" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Anaya Fernández-Lomana" "autores" => array:1 [ 0 => array:2 [ "Iniciales" => "F." "apellidos" => "Anaya Fernández-Lomana" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "X2013251411052306" "doi" => "10.3265/Nefrologia.pre2011.Jun.11002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251411052306?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699511052309?idApp=UINPBA000064" "url" => "/02116995/0000003100000004/v0_201502091411/X0211699511052309/v0_201502091411/es/main.assets" ] ] "itemSiguiente" => array:17 [ "pii" => "X2013251411052291" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2011.Apr.10740" "estado" => "S300" "fechaPublicacion" => "2011-07-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2011;31:382-91" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 13699 "formatos" => array:3 [ "EPUB" => 311 "HTML" => 12946 "PDF" => 442 ] ] "en" => array:8 [ "idiomaDefecto" => true "titulo" => "Diagnostic criteria of antibody-mediated rejection in kidney transplants" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "382" "paginaFinal" => "391" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Criterios diagnósticos de rechazo mediado por anticuerpos en el trasplante renal" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10740_16025_19055_en_t1.jpg" "Alto" => 233 "Ancho" => 600 "Tamanyo" => 95191 ] ] "descripcion" => array:1 [ "en" => "Comparison of morphological findings between acute ABMR and ACR" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Juan Manuel Mosquera Reboredo, J.M. Mosquera Reboredo, Eduardo Vázquez Martul, E. Vázquez Martul" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Juan Manuel" "apellidos" => "Mosquera Reboredo" ] 1 => array:2 [ "Iniciales" => "J.M." "apellidos" => "Mosquera Reboredo" ] 2 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Vázquez Martul" ] 3 => array:2 [ "Iniciales" => "E." "apellidos" => "Vázquez Martul" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699511052294" "doi" => "10.3265/Nefrologia.pre2011.Apr.10740" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699511052294?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251411052291?idApp=UINPBA000064" "url" => "/20132514/0000003100000004/v0_201502091636/X2013251411052291/v0_201502091636/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Reasons why therapeutic apheresis should belong to nephrology" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "379" "paginaFinal" => "381" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "F. Anaya Fernández-Lomana" "autores" => array:1 [ 0 => array:4 [ "Iniciales" => "F." "apellidos" => "Anaya Fernández-Lomana" "email" => array:1 [ 0 => "fanayaf@senefro.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Por qué la aféresis terapéutica debe pertenecer a la especialidad de nefrología" ] ] "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" => "11002_108_19847_en_11002t1.jpg" "Alto" => 579 "Ancho" => 600 "Tamanyo" => 224303 ] ] "descripcion" => array:1 [ "en" => "Blood cleansing procedures applied to therapeutic apheresis" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Margarita Rufino et al’s<span class="elsevierStyleSup">1</span> excellent original article “Patients treated with plasmapheresis: a case review from University Hospital of the Canary Islands” has also been published in this very issue of Nefrología, reviewing a nephrology department’s experience using this technique. In the Introduction, the authors highlight that plasmapheresis has become a sub-specialty within nephrology given nephrologists’ command in using blood cleansing techniques, which is an opinion that we completely agree with. In this Editorial Comment we would like to explain why therapeutic apheresis (TA) should be integrated in our department. However, before indicating such reasons, we would like to highlight the importance that this therapeutic method currently has.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">WHY IS THERAPEUTIC APHERESIS IMPORTANT AT PRESENT?</span></p><p class="elsevierStylePara">In 1982, the American Society for Apheresis (ASFA) was founded, with a series of objectives, such as controlling the TA indications and the cost-benefit ratio for the different apheresis procedures. To that end, <span class="elsevierStyleItalic">the Journal of Clinical Apheresis</span> was published.<span class="elsevierStyleItalic"> </span>Furthermore, the International Society for Apheresis also created its own journal <span class="elsevierStyleItalic">Therapeutic Apheresis</span>, both published quarterly.</p><p class="elsevierStylePara">One of the best contributions that these organisations have made to TA, especially the American Association of Blood Banks (AABB) and the ASFA, was to create the guidelines for plasmapheresis use, classifying its indications into four categories (I-IV) in accordance with its effectiveness. These categories are updated every three years. In 2010, the ASFA presented its 5<span class="elsevierStyleSup">th</span> Edition, with a special issue.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">In the last decade, various official TA work groups have been created in various countries, with the aim of registering and controlling apheresis indications and results, i.e. Canada,<span class="elsevierStyleSup">3</span><span class="elsevierStyleSup"> </span>Switzerland,<span class="elsevierStyleSup">4</span> Japan,<span class="elsevierStyleSup">5</span> and Italy.<span class="elsevierStyleSup">6</span> In 2004, a therapeutic apheresis work group (GTAF) was founded within the Spanish Society of Nephrology (S.E.N.). It is still running, and thanks to the board of directors’ support and enthusiasm, more and more professionals are becoming members. Recently, a GTAF has been created in Argentina, which forms part of the Argentinean Society of Nephrology (S.A.N.), closely associated with the S.E.N.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ARGUMENTS FOR INTEGRATING THERAPEUTIC APHERESIS IN NEPHROLOGY</span></p><p class="elsevierStylePara">There are numerous reasons why TA should be integrated in nephrology. The basics are described below:</p><p class="elsevierStylePara">1. <span class="elsevierStyleItalic">Definition</span>. TA’s purpose is to eliminate molecules and immunocomplexes that determine an illness from the bloodstream using different blood cleansing procedures (BCP). Haemodialysis (HD) is the main BCP. Its objective is to eliminate light and medium weight molecules resulting from renal failure. The remaining BCP included in TA are used more or less selectively for various illnesses depending on the molecular characteristics or the immunocomplexes that are to be cleansed.</p><p class="elsevierStylePara">2. <span class="elsevierStyleItalic">Blood cleansing procedures</span>. There are numerous BCP; TA is currently used for more than 80 different illnesses, corresponding to most medical specialities. All BCP use extracorporeal circulation (ECC), which is best understood by trained nephrologists. As shown in Table 1, we divided the 23 BCP into two groups: the first group shows the procedures that are used for TA in accordance with indications in ASFA’s categories I, II and P<span class="elsevierStyleSup">2</span>. The procedures indicated for chronic and acute renal failure are in the second group. For both groups, the patients’ treatment may be acute or chronic, such as HD or LDL-apheresis. No other specialty is able to provide such variety in treatment.</p><p class="elsevierStylePara">3. <span class="elsevierStyleItalic">ECC</span> All BCP included in the TA require an ECC, similar to that used in HD. The following is therefore needed: <span class="elsevierStyleItalic">a) vascular access</span> to provide an average blood flow of 100±20ml/min, which could be performed using vascular accesses similar to those used for HD, such as arteriovenous fistulae (AV) or central, temporary, or permanent catheters. There are BCP such as leukocytapheresis or granulocytapheresis which can be performed via the peripheral vein, and which need a blood flow of 50-60ml/min; <span class="elsevierStyleItalic">b) anticoagulation</span> during the apheresis process similar to HD, generally with heparin, although citrate is also used, and <span class="elsevierStyleItalic">c) different lines, filters and monitors</span> used for therapeutic apheresis, similar to the ones used for HD.</p><p class="elsevierStylePara">4. <span class="elsevierStyleItalic">Knowledge of ECC and its complications.</span><span class="elsevierStyleItalic"> </span>Being familiar with ECC techniques is essential, and only nephrology professionals are. They know the initial, maintenance and end manoeuvres for these extracorporeal procedures, and their complications. We must take into account that most complications are reversible, and such reversibility mainly depends on how early the disorder is diagnosed and treated, and therefore, on the professionals’ experience. It is essential to have this knowledge, not only for the patient’s safety but also from the financial point of view, considering that these techniques are costly.</p><p class="elsevierStylePara">5. <span class="elsevierStyleItalic">Chronic programme maintenance.</span> TA is mainly indicated as an acute treatment, but there are a series of disorders that should be treated regularly, either restrictively, as is the case for inflammatory bowel diseases with leukocyte apheresis or granulocytapheresis, every week for 5-8 weeks, or in senile macular degeneration, in which rheopheresis is performed two sessions a month, for 5-6 months. Furthermore, an unlimited chronic TA programme could be established, as is the case for the homozygous and heterozygous familiar hypercholesterolemia and for some neurological diseases, which is similar to the HD programme.  </p><p class="elsevierStylePara"><span class="elsevierStyleBold">THERAPEUTIC APHERESIS AND NEPHROLOGY IN SPAIN</span></p><p class="elsevierStylePara">TA has been incorporated by nephrology and supported by the S.E.N for many decades. Over the past 30 years, this therapeutic method has been developed interruptedly, using various BCP, proving that it is part of nephrology. Proof of such claim are some of the following scientific activities that have been established in recent years:</p><p class="elsevierStylePara">1. Forming the GTAF integrated in the S.E.N. since 2004.</p><p class="elsevierStylePara">2. Spanish Second Symposium on Therapeutic Apheresis, held in the nephrology department of the Hospital de Logroño, on 11 and 12 February 2010.</p><p class="elsevierStylePara">3. Conferences on TA.</p><p class="elsevierStylePara">World Congress of Nephrology, Milan, Italy, 22-26 May 2009.</p><p class="elsevierStylePara">16<span class="elsevierStyleSup">th </span>Argentinean Society of Nephrology Conference. Paraná City, Mar del Plata, Argentina 15 September 2009.</p><p class="elsevierStylePara">21<span class="elsevierStyleSup">th</span> Nephrology Winter Meeting. Candanchú, Spain, 7-11 April 2010.</p><p class="elsevierStylePara">31<span class="elsevierStyleSup">st</span> Spanish Conference of the Spanish Society of Internal Medicine (SEMI). Oviedo, Spain 18 November 2010.</p><p class="elsevierStylePara">Northern Nephrology Societies’ meeting. Pamplona, Spain 30 November 2010.</p><p class="elsevierStylePara">4<span class="elsevierStyleSup">th</span> Spanish Conference on Obesity and Cardio-Metabolic Risk Factors. Madrid, Spain. 4 February 2011.</p><p class="elsevierStylePara">National Conference on Therapeutic Apheresis in Argentina. Paraná City, Santa Fe and Rosario, Argentina, 18 and 19 March 2011.</p><p class="elsevierStylePara">Annual Congress of the Spanish Society of Dialysis and Transplantation (SEDYT). Granada, Spain. 11-13 May 2011.</p><p class="elsevierStylePara">4. Healthcare activities</p><p class="elsevierStylePara">In Spain, there are numerous nephrology departments that currently have a more or less active TA programme. The following should be highlighted:</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Torrecárdenas Hospital Complex,</span><span class="elsevierStyleItalic"> </span><span class="elsevierStyleItalic">Almería, Spain.</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">San Carlos Clinical Hospital,</span><span class="elsevierStyleItalic"> </span><span class="elsevierStyleItalic">Madrid, Spain.</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">University Hospital of the Canary Islands</span> whose experience is reflected in this issue’s Editorial.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Gregorio Marañón University General Hospital,</span><span class="elsevierStyleItalic"> </span>Madrid, Spain.</p><p class="elsevierStylePara">Throughout our long 29-year experience with TA, we have performed 10 050 sessions on 1157 patients, with different apheresis procedures such as plasmapheresis, immunoadsorption, direct adsorption of lipoproteins (DALI), double filtration, rheopheresis, leukocytapheresis, granulocytapheresis, hemadsorption-Pmx, molecular adsorbents recirculating system (MARS), and Prometheus for 73 different disorders across different medical specialities. The results have been excellent, with a very good tolerance and minimum complications. Treatment has been either acute or chronic, over programmed time periods.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">OBJECTIVES OF THERAPEUTIC APHERESIS INTEGRATED IN NEPHROLOGY</span></p><p class="elsevierStylePara">The following objectives can be achieved by the GTAF: <span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">1. Create a national register which features the disorders treated with the different apheresis procedures in agreement with four ASFA categories.</p><p class="elsevierStylePara">2. Regularly publish the results from this register so that they can serve as a control and guide in Spain.</p><p class="elsevierStylePara">3. Offer to conduct multicentre studies related to different techniques and clinical studies.</p><p class="elsevierStylePara">4. With S.E.N.’s support, promote this new work group as much as possible, through different communications and presentations, to inform and arouse interest in nephrology departments.</p><p class="elsevierStylePara">5. Inform health departments in the different Spanish regions and the main hospitals’ managers, to ensure that TA is recognised as an effective therapeutic method, and to request financial support so that TA can be performed without any difficulties.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">REFERENCES</span></p><p class="elsevierStylePara">Reference Journals: <span class="elsevierStyleItalic">Therapeutic Apheresis and Dialysis </span>and <span class="elsevierStyleItalic">Journal of Clinical Apheresis</span>.</p><p class="elsevierStylePara">Most Spanish nephrologists have the book <span class="elsevierStyleItalic">Aferesis Terapéutica</span><span class="elsevierStyleSup">7</span> which describes the basis, indications, procedures and TA management in a simplified way. It can be a great help for nephrologists that are interested in becoming familiar with this therapeutic method.</p><p class="elsevierStylePara">The S.E.N. Grupo Editorial Nefrología will publish the <span class="elsevierStyleItalic">Manual de la Aferesis Terapéutica Basado en la Evidencia</span> which we have written based on the <span class="elsevierStyleItalic">Guidelines on the</span><span class="elsevierStyleItalic">Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Apheresis Applications Committee of the American Society for Apheresis</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleSup"> </span>and our own experience. We believe that it will be extremely useful and serve as a continual aid in TA clinical practice.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">COMMENTS</span></p><p class="elsevierStylePara">Our opinion is that the arguments shown are solid enough to support that TA should undoubtedly belong to nephrology. Nobody would be able to perform this technique like nephrology doctors and staff.</p><p class="elsevierStylePara"><a href="grande/11002_108_19847_en_11002t1.jpg" class="elsevierStyleCrossRefs"><img src="11002_108_19847_en_11002t1.jpg" alt="Blood cleansing procedures applied to therapeutic apheresis"></img></a></p><p class="elsevierStylePara">Table 1. Blood cleansing procedures applied to therapeutic apheresis</p>" "pdfFichero" => "P1-E523-S3003-A11002-EN.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11002_108_19847_en_11002t1.jpg" "Alto" => 579 "Ancho" => 600 "Tamanyo" => 224303 ] ] "descripcion" => array:1 [ "en" => "Blood cleansing procedures applied to therapeutic apheresis" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Margarita Rufino J, Escamilla JB, Álvarez D, García S, Losada M, Hernández D, et al.\u{A0}Experiencia del Hospital Universitario de Canarias de pacientes tratados con plasmaféresis. Nefrologia 2011;31(4):415-34. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21738245" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "2.\u{A0}Szczepiorkowsk ZM,\u{A0}Winters JL,\u{A0}Bandarenko N,\u{A0}Kim HC,\u{A0}Linenberger ML,\u{A0}Marques MB, et al.\u{A0}Guidelines on the Use of Therapeutic Apheresis in Clinical Practice¿Evidence-Based Approach from the Apheresis Applications Committee of the American Society for Apheresis. Journal of Clinical Apheresis 2010;25:83-177. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20568098" 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" => "Rock G,\u{A0}Sutton CR. The Canadian apheresis registry. Transfus Apheresis Sci 2003;29(2):167-77." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Norda R, Stegmavr BG. Swedish Apheresis Group. Therapeutic apheresis in Sweden: update of epidemiology and adverse. Transfus Apheresis Sci 2003;29(2):159-66." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Kawamura A. Therapeutic apheresis in Japan. Ther Apher Dial 2003;7(6):497. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15018233" 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" => "De Silvestro G, Marson P, Russo GE.\u{A0}National survey of apheresis activity in Italy (2000). Transfus Apheresis Sci 2004;30(1):61-71." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Anaya F. Aféresis terapéutica. Madrid: Ediciones Norma-Capitel; 2005." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003100000004/v0_201502091636/X2013251411052306/v0_201502091636/en/main.assets" "Apartado" => array:4 [ "identificador" => "35428" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorial Comments" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003100000004/v0_201502091636/X2013251411052306/v0_201502091636/en/P1-E523-S3003-A11002-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251411052306?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 7 | 12 |
| 2024 October | 56 | 42 | 98 |
| 2024 September | 56 | 48 | 104 |
| 2024 August | 74 | 74 | 148 |
| 2024 July | 45 | 39 | 84 |
| 2024 June | 83 | 45 | 128 |
| 2024 May | 84 | 41 | 125 |
| 2024 April | 84 | 42 | 126 |
| 2024 March | 101 | 28 | 129 |
| 2024 February | 40 | 40 | 80 |
| 2024 January | 81 | 30 | 111 |
| 2023 December | 44 | 29 | 73 |
| 2023 November | 69 | 33 | 102 |
| 2023 October | 97 | 43 | 140 |
| 2023 September | 92 | 43 | 135 |
| 2023 August | 64 | 38 | 102 |
| 2023 July | 70 | 47 | 117 |
| 2023 June | 42 | 31 | 73 |
| 2023 May | 56 | 33 | 89 |
| 2023 April | 41 | 13 | 54 |
| 2023 March | 55 | 40 | 95 |
| 2023 February | 60 | 25 | 85 |
| 2023 January | 56 | 32 | 88 |
| 2022 December | 74 | 34 | 108 |
| 2022 November | 58 | 36 | 94 |
| 2022 October | 66 | 49 | 115 |
| 2022 September | 63 | 36 | 99 |
| 2022 August | 57 | 56 | 113 |
| 2022 July | 40 | 57 | 97 |
| 2022 June | 53 | 52 | 105 |
| 2022 May | 66 | 25 | 91 |
| 2022 April | 71 | 60 | 131 |
| 2022 March | 72 | 50 | 122 |
| 2022 February | 65 | 51 | 116 |
| 2022 January | 94 | 29 | 123 |
| 2021 December | 88 | 32 | 120 |
| 2021 November | 88 | 41 | 129 |
| 2021 October | 81 | 36 | 117 |
| 2021 September | 39 | 49 | 88 |
| 2021 August | 51 | 58 | 109 |
| 2021 July | 53 | 32 | 85 |
| 2021 June | 65 | 33 | 98 |
| 2021 May | 75 | 43 | 118 |
| 2021 April | 191 | 57 | 248 |
| 2021 March | 89 | 43 | 132 |
| 2021 February | 98 | 26 | 124 |
| 2021 January | 42 | 20 | 62 |
| 2020 December | 53 | 25 | 78 |
| 2020 November | 36 | 7 | 43 |
| 2020 October | 49 | 20 | 69 |
| 2020 September | 37 | 8 | 45 |
| 2020 August | 53 | 10 | 63 |
| 2020 July | 52 | 16 | 68 |
| 2020 June | 74 | 24 | 98 |
| 2020 May | 66 | 7 | 73 |
| 2020 April | 55 | 20 | 75 |
| 2020 March | 50 | 14 | 64 |
| 2020 February | 58 | 21 | 79 |
| 2020 January | 63 | 20 | 83 |
| 2019 December | 52 | 17 | 69 |
| 2019 November | 58 | 22 | 80 |
| 2019 October | 61 | 14 | 75 |
| 2019 September | 42 | 20 | 62 |
| 2019 August | 31 | 12 | 43 |
| 2019 July | 55 | 25 | 80 |
| 2019 June | 37 | 15 | 52 |
| 2019 May | 41 | 9 | 50 |
| 2019 April | 85 | 34 | 119 |
| 2019 March | 36 | 15 | 51 |
| 2019 February | 26 | 12 | 38 |
| 2019 January | 36 | 20 | 56 |
| 2018 December | 84 | 44 | 128 |
| 2018 November | 99 | 21 | 120 |
| 2018 October | 95 | 12 | 107 |
| 2018 September | 91 | 20 | 111 |
| 2018 August | 50 | 11 | 61 |
| 2018 July | 66 | 10 | 76 |
| 2018 June | 66 | 12 | 78 |
| 2018 May | 39 | 10 | 49 |
| 2018 April | 36 | 10 | 46 |
| 2018 March | 47 | 9 | 56 |
| 2018 February | 44 | 9 | 53 |
| 2018 January | 36 | 11 | 47 |
| 2017 December | 52 | 9 | 61 |
| 2017 November | 38 | 7 | 45 |
| 2017 October | 33 | 13 | 46 |
| 2017 September | 36 | 9 | 45 |
| 2017 August | 24 | 7 | 31 |
| 2017 July | 29 | 5 | 34 |
| 2017 June | 49 | 10 | 59 |
| 2017 May | 40 | 8 | 48 |
| 2017 April | 36 | 11 | 47 |
| 2017 March | 30 | 15 | 45 |
| 2017 February | 23 | 7 | 30 |
| 2017 January | 22 | 6 | 28 |
| 2016 December | 68 | 8 | 76 |
| 2016 November | 85 | 10 | 95 |
| 2016 October | 99 | 9 | 108 |
| 2016 September | 154 | 10 | 164 |
| 2016 August | 216 | 9 | 225 |
| 2016 July | 157 | 10 | 167 |
| 2016 June | 121 | 0 | 121 |
| 2016 May | 89 | 0 | 89 |
| 2016 April | 67 | 0 | 67 |
| 2016 March | 75 | 0 | 75 |
| 2016 February | 89 | 0 | 89 |
| 2016 January | 111 | 0 | 111 |
| 2015 December | 106 | 0 | 106 |
| 2015 November | 64 | 0 | 64 |
| 2015 October | 85 | 0 | 85 |
| 2015 September | 83 | 0 | 83 |
| 2015 August | 70 | 0 | 70 |
| 2015 July | 73 | 0 | 73 |
| 2015 June | 35 | 0 | 35 |
| 2015 May | 49 | 0 | 49 |
| 2015 April | 5 | 0 | 5 |
Show all
