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such as erythropoietin &#40;EPO&#41;<span class="elsevierStyleSup">3</span> or calcium salts<span class="elsevierStyleSup">4</span>&#44; which adds even more difficulty and confusion to the management of these patients&#46;</p><p class="elsevierStylePara">The specialised care of pre-dialysis patients in advanced stages of CKD is unanimously considered to be a factor that benefits survival in dialysis<span class="elsevierStyleSup">5&#44;6</span>&#46; In these advanced chronic kidney disease &#40;ACKD&#41; clinics&#44; many treatments are usually carried out&#44; such as controlling blood pressure&#44; correcting over-hydration&#44; metabolic acidosis&#44; mineral and bone disorders and anaemia&#44; creating vascular access and choosing when to start dialysis&#44; etc&#46;&#44; but the importance of each of these treatments and the benefits they can bring in terms of dialysis patient survival is unknown&#46;</p><p class="elsevierStylePara">We carried out this prospective study with the objective of analysing the normal treatments for ACKD and establishing which of them are associated with greater survival in dialysis&#44; as well as their relationship with causes of death&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHOD</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">We included 591 patients with the demographic and clinical characteristics that are displayed in Table 1&#46; Inclusion criteria were as follows&#58; having begun dialysis treatment at the Hospital Infanta Cristina de Badajoz during the period between October 1999 and January 2012&#44; and having previously been monitored in the ACKD clinic of the same hospital&#46; We did not exclude any patients&#46;</p><p class="elsevierStylePara">We started haemodialysis &#40;HD&#41; in 491 patients and peritoneal dialysis &#40;PD&#41; in 100&#46; There were no pre-dialysis kidney transplantations&#46;</p><p class="elsevierStylePara">The information on the treatment that the patients were receiving was obtained by anamnesis and a review of medical records&#46;</p><p class="elsevierStylePara">The treatments used during the pre-dialysis stage that were analysed in this study were&#58; treatment with angiotensin-converting enzyme inhibitors &#40;ACEI&#41; and&#47;or angiotensin receptor blockers &#40;ARBs&#41;&#44; diuretics&#44; calcium channel blockers&#44; beta-blockers&#44; statins&#44; antiplatelet drugs&#44; xanthine oxidase inhibitors&#44; correction of metabolic acidosis with sodium bicarbonate&#44; treatment with &#40;calcium or non-calcium&#41; phosphate binders&#44; calcium salts&#44; active vitamin D &#40;calcitriol or paricalcitol&#41; and anaemia correction by EPO&#46; Furthermore&#44; we included an internal arteriovenous fistula &#40;IAVF&#41; in our treatment&#44; and this was usable at the time dialysis began&#46;</p><p class="elsevierStylePara">The covariates included to adjust survival models were&#58; age&#44; sex&#44; <span class="elsevierStyleItalic">Davies comorbidity index &#40;three subgroups&#58;&#160;</span>no comorbidity&#44; mild to moderate&#44; and severe comorbidity&#41;&#160;&#44; diagnosis of diabetes mellitus&#44; serum albumin concentrations &#40;bromocresol green&#44; Advia Chemistry&#44; Siemens Healthcare Diagnostics&#41; and C-reactive protein &#40;high sensitivity by chemiluminescence immunoassay in the solid phase&#44; Immulite&#44; Siemens&#41;&#46; As potential confounding variables&#44; we also included the glomerular filtration rate &#40;MDRD-4&#41; at the start of dialysis and the follow-up time in the ACKD clinic &#40;greater or less than 90 days&#41;&#46;</p><p class="elsevierStylePara">The lack of a functioning IAVF in patients included in this study who started HD may have been due to one of the following reasons&#58; failure &#40;thrombosis&#41;&#44; its rejection by the patient or insufficient pre-dialysis follow-up time&#46;</p><p class="elsevierStylePara">Patients were followed-up with regard to their outcomes in dialysis&#44; with death due to all causes being the only study event&#46; The follow-up period began with the first dialysis session and patients were censored &#40;non-informative censoring&#41; for the end of data collection &#40;September 2012&#41;&#44; loss to follow-up and renal transplantation&#46;</p><p class="elsevierStylePara">We also recorded the cause of death&#44; establishing five etiological groups&#58; sudden death&#44; death from cardiovascular&#44; infectious&#44; tumour and other causes&#46;</p><p class="elsevierStylePara">To analyse whether there was an association between the different pre-dialysis treatments and survival in dialysis&#44; we used Kaplan-Meier curves &#40;univariate study&#41; and Cox multivariate proportional hazards models&#44; with the calculation of the instantaneous hazard rates &#40;hazard ratio&#41; and their 95&#37; confidence intervals&#46; Covariates in multivariate models were selected automatically&#44; using the backwards progressive conditional elimination process&#46;</p><p class="elsevierStylePara">Due to the potential confounding by indication in the inclusion of PD and HD patients&#44; who not only had age and comorbidity differences&#44; but also had differences in other characteristics that were not recorded as variables but nonetheless had a potential influence on survival&#44; such as socio-economic and cultural level or the degree of dependency&#44; the analyses were stratified according to the initial form of treatment &#40;HD or PD&#41;&#46;</p><p class="elsevierStylePara">The analysis of survival and stratification between PD and HD was in any case considered by intention-to-treat&#44; independently of the time that the patient would have remained on one or another dialysis technique&#46;</p><p class="elsevierStylePara">For comparison of continuous variables between patients who survived or died&#44; we used Student&#8217;s t-test or the Mann-Whitney test&#44; depending on the characteristics of the variable distribution&#46; The &#967;<span class="elsevierStyleSup">2</span> test was used to compare categorical variables between subgroups&#46;</p><p class="elsevierStylePara">The data were presented as a mean &#177; standard deviation or the median and interquartile ranges&#46; A <span class="elsevierStyleItalic">p </span>value less than &#46;05 was considered to be statistically significant&#46; For statistical analyses and creating graphs&#44; we used the SPSS version 15&#46;0 software &#40;SPSS&#44; Chicago&#44; USA&#41; and STATA version 11&#46;1 &#40;Stata Corporation&#44; Texas&#44; USA&#41;&#46;</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">Mortality in dialysis</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">With a median follow-up of 28 months &#40;interquartile ranges&#58; 13-50 months&#41;&#44; the total number of deaths was 191 &#40;32&#37;&#41; and estimated median survival was 82 months &#40;95&#37; confidence interval&#58; 56-108 months&#41;&#46;</p><p class="elsevierStylePara">The demographic&#44; clinical and biochemical characteristics of the patients who survived and died are displayed in Table 2&#46; As well as the factors that were very much expected to be associated with mortality such as age&#44; comorbidity and serum albumin and C-reactive protein concentrations&#44; we note the low mean follow-up time in the ACKD clinics of the patients who died &#40;Table 2&#41;&#46; We also observed significant differences in pre-dialysis treatments between those who survived and those who died&#44; which highlights the positive association between survival and ACEI&#47;ARBs&#44; beta-blockers&#44; statins&#44; sodium bicarbonate and phosphate binders&#44; and even calcium salts&#46; By contrast&#44; the association was negative for survival with diuretics and at the limit of significance with antiplatelet drugs&#46; We did not observe differences in the percentage of EPO&#44; vitamin D or xanthine oxidase inhibitor prescription between those who survived and those who did not&#46;</p><p class="elsevierStylePara">The glomerular filtration rate at which dialysis began was significantly higher in patients who died and the percentage of patients with an IAVF was significantly lower in this same subgroup &#40;Table 2&#41;&#46;</p><p class="elsevierStylePara">Patients whose initial treatment was with PD had better survival than those treated with HD &#40;Figure 1&#41;&#44; although it is important to highlight again that there were major differences between both subgroups with regard to age&#44; comorbidity and other factors that potentially influenced survival that were not recorded in this study&#44; such as socio-economic&#44; cultural and dependency levels&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Causes of death according to pre-dialysis treatments</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Figure 2 displays the causes of death grouped into five aetiological sections &#40;sudden death&#44; cardiovascular&#44; infection&#44; tumour and other causes&#41;&#44; according to the type of initial dialysis and some treatments carried out in the pre-dialysis stage&#46; Those of cardiovascular and infectious origin were the most common causes of mortality&#46;</p><p class="elsevierStylePara">The only significant difference observed was between PD and HD &#40;<span class="elsevierStyleItalic">p</span>&#61;&#46;02&#41;&#44; with there being an absence of sudden death in PD patients and on the other hand&#44; a greater proportion of death from tumours&#44; due to a lack of oncological control of myeloma and leukaemia that were already related to the origin of renal failure&#46;</p><p class="elsevierStylePara">We did not observe significant differences in the cause of death between those treated and those not treated with EPO&#44; vitamin D or calcium salts&#46; The differences in the cause of death between patients who began HD with or without an IAVF were not significant either&#44; although there was a higher rate of death from infectious aetiologies in those who did not possess an IAVF&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Analysis of survival and its association with the study variables</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In the Cox stratified regression analysis according to the initial type of dialysis &#40;Table 3&#41; we observed that&#44; as well as age&#44; the comorbidity index and serum albumin&#44; pre-dialysis treatment with ACEI&#47;ARBs and the correction of acidosis with sodium bicarbonate were positively associated with survival in dialysis&#46; We also note the positive and significant association between the availability of an IAVF at the start of HD and survival&#46; By contrast&#44; higher renal function at the start of dialysis was associated with worse survival&#46;</p><p class="elsevierStylePara">Figures 3 and 4 display the dialysis survival curves of the patients who had been treated and those who had not been treated with ACEI&#47;ARBs during the pre-dialysis period&#46; Figure 5 displays the survival curves of patients who started HD with or without an IAVF&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Mortality in dialysis patients continues to be very high&#46; Some characteristics of CKD such as the growing severity of its complications as renal failure progresses&#44; as well as accumulative adverse effects&#44; some of them irreversible&#44; could help us to understand this disconcerting fact&#46; As such&#44; the monitoring and treatment of the disease in less advanced stages may have a major influence on the survival of patients who reach more advanced stages&#46;</p><p class="elsevierStylePara">This is a hypothesis that would explain better survival in dialysis of patients who were monitored and treated in ACKD clinics&#46;</p><p class="elsevierStylePara">The results of this study show that there are various pre-dialysis treatments that are significantly associated with a better outcome in dialysis patients&#44; but the only ones to remain in the models adjusted for age&#44; sex&#44; comorbidity&#44; dialysis type and other prognosis markers were treatment with ACEI&#47;ARBs&#44; metabolic acidosis correction with sodium bicarbonate and the introduction of an IAVF in those who began HD&#46; By contrast&#44; we did not observe that any of the treatments analysed in adjusted models were associated with a worse outcome or any specific cause of death&#46;</p><p class="elsevierStylePara">Due to strong confounding by indication in this study&#44; we cannot claim that there is causality between the direct therapeutic effects of these drugs and improved survival in dialysis patients&#44; even after adjustment with the confounding variables&#44; but we believe that the data provide information that could prove useful in the prediction of outcomes in dialysis patients&#46;</p><p class="elsevierStylePara">The effect of treatment with ACEI or ARBs on ACKD or dialysis patient survival is controversial&#46; These drugs may have positive effects on residual renal function&#44; vascular access and the uraemic myocardium<span class="elsevierStyleSup">7</span>&#44; which in turn may be reflected in better survival<span class="elsevierStyleSup">8</span>&#44; although other studies have not been able to demonstrate this benefit<span class="elsevierStyleSup">9</span>&#46;</p><p class="elsevierStylePara">The association between ACEI&#47;ARBs use in pre-dialysis and survival in PD and HD patients is an original result of this study&#46; A hypothesis to explain these findings may be based on a potential survival bias&#44; that is&#44; patients who required&#44; tolerated and survived treatment with ACEI&#47;ARBSs in the pre-dialysis period form a select group with a greater probability of survival in dialysis&#46; However&#44; this hypothesis seems unlikely&#44; since we also observed better pre-dialysis survival in those treated with ACEI&#47;ARBs &#40;observations not published&#41;&#46;</p><p class="elsevierStylePara">Another hypothesis to explain this delayed association may be related to a &#8220;legacy effect&#8221;&#46; This term was originally coined to describe the positive effect of good metabolic control during the initial stages of diabetes on the subsequent outcome and its complications&#46; There has also been speculation about the possibility that this same legacy effect could be achieved with the control of high blood pressure or with the use of ACEI&#47;ARBs<span class="elsevierStyleSup">11</span>&#44; which is a benefit of survival that could be maintained beyond drug interruption&#44; and it is therefore more difficult to appreciate it clinically&#46;</p><p class="elsevierStylePara">Metabolic acidosis in CKD has negative effects on the state of nutrition&#44; mineral and bone disease and inflammation&#44; and is associated with worse survival<span class="elsevierStyleSup">12</span>&#46; The correction of acidosis with sodium bicarbonate has demonstrated not only that it improves the state of nutrition&#44; but that it also has very positive effects on maintaining renal function&#46;</p><p class="elsevierStylePara">In this study&#44; the correction of acidosis with sodium bicarbonate was independently associated with better survival in dialysis&#46; However&#44; the potential confounding by indication also prevented the causality of this association from being confirmed&#46; Some confounding factors that may influence this association are the decreased tendency for acidosis of diabetic patients with CKD<span class="elsevierStyleSup">13</span>&#44; or the association between acidosis and treatment with ACEI&#47;ARBs due to type IV renal tubular acidosis or the impossibility of prescribing antacids in those who were treated for a brief period of time in the ACKD clinic&#46; All of these confounding variables were taken into account in the multivariate regression analyses &#40;diagnosis of diabetes&#44; ACEI&#47;ARB treatment and pre-dialysis follow-up time&#41;&#44; and treatment with bicarbonate maintained statistical significance&#46;</p><p class="elsevierStylePara">Starting HD with an IAVF improved vital prognosis<span class="elsevierStyleSup">14</span>&#46; According to these studies&#44; we also observed better survival in patients with a functioning IAVF at the start of HD&#44; and this association was independent of other confounding factors &#40;age&#44; sex&#44; comorbidity&#44; drugs&#44; etc&#46;&#41;</p><p class="elsevierStylePara">Although the causes of death in those who initiated HD with or without IAVF were not significantly different&#44; a greater percentage of deaths due to infection was observed&#44; perhaps in relation to the more frequent use of endovascular catheters&#46;</p><p class="elsevierStylePara">The renal function with which these patients started dialysis was another determining factor of survival&#44; but to the contrary of what was expected&#44; the association was negative&#46; In accordance with observations of other authors<span class="elsevierStyleSup">15</span>&#44; it is likely that a higher glomerular filtration rate at the start of dialysis reflects a poor general patient condition&#44; higher intolerance to uraemia&#44; especially that related to states of over-hydration and the development of heart failure&#46; It is also important to point out that when a patient from our study required the &#40;urgent&#41; non-scheduled initiation of dialysis due to any of these complications&#44; the renal function figure that was taken was that of the last scheduled test&#44; and therefore&#44; this higher glomerular filtration rate would not reflect real renal function at the time of the first dialysis session&#46;</p><p class="elsevierStylePara">This study has limitations mainly derived from the aforementioned confounding biases &#40;indication and survival&#41;&#46; Although the effect of these biases aims to correct itself by stratification and adjustment of the models with the main confounding variables&#44; we cannot rule out the possibility of other variables that we have not considered having a significant influence on the end results&#46;</p><p class="elsevierStylePara">Another limitation is that all patients studied were from the same hospital&#44; with certain treatment criteria&#44; which prevents us from guaranteeing the reproduction of the results with different treatment criteria&#46;</p><p class="elsevierStylePara">In conclusion&#44; there are differences in pre-dialysis treatments of patients who survive or die on dialysis&#46; The most significant differences in models that are stratified to the type of dialysis and to the main confounding factors are&#58; treatment with ACEI&#47;ARBs&#44; treatment with sodium bicarbonate and having a usable IAVF at the time of the first HD session&#46;</p><p class="elsevierStylePara">These results suggest a potential delayed benefit &#40;legacy effect&#41; of some treatment in pre-dialysis stages on the subsequent evolution of dialysis patients&#46; In addition&#44; starting HD without an IAVF&#44; with the resulting need for intravenous catheters&#44; could be related to worse prognosis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12277&#95;16025&#95;59975&#95;en&#95;t1&#46;jpg" class="elsevierStyleCrossRefs"><img src="12277_16025_59975_en_t1.jpg" alt="Clinical characteristics and treatments received by patients included in the study"></img></a></p><p class="elsevierStylePara">Table 1&#46; Clinical characteristics and treatments received by patients included in the study</p><p class="elsevierStylePara"><a href="grande&#47;12277&#95;16025&#95;59976&#95;en&#95;t2&#46;jpg" class="elsevierStyleCrossRefs"><img src="12277_16025_59976_en_t2.jpg" alt="Clinical characteristics and treatments received by patients who survived or died during the study period "></img></a></p><p class="elsevierStylePara">Table 2&#46; Clinical characteristics and treatments received by patients who survived or died during the study period </p><p class="elsevierStylePara"><a href="grande&#47;12277&#95;16025&#95;59977&#95;en&#95;t3&#46;jpg" class="elsevierStyleCrossRefs"><img src="12277_16025_59977_en_t3.jpg" alt="Cox multivariate regression models on mortality in dialysis "></img></a></p><p class="elsevierStylePara">Table 3&#46; Cox multivariate regression models on mortality in dialysis </p><p class="elsevierStylePara"><a href="grande&#47;12277&#95;16025&#95;59978&#95;en&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="12277_16025_59978_en_f1.jpg" alt="Kaplan-Meier survival curves in patients who started haemodialysis or peritoneal dialysis&#46; "></img></a></p><p class="elsevierStylePara">Figure 1&#46; Kaplan-Meier survival curves in patients who started haemodialysis or peritoneal dialysis&#46; </p><p class="elsevierStylePara"><a href="grande&#47;12277&#95;16025&#95;59979&#95;en&#95;f2&#46;jpg" class="elsevierStyleCrossRefs"><img src="12277_16025_59979_en_f2.jpg" alt="Causes of death according to the dialysis type&#44; or some pre-dialysis treatments&#44; or the availability of an arteriovenous fistula in those who started haemodialysis&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Causes of death according to the dialysis type&#44; or some pre-dialysis treatments&#44; or the availability of an arteriovenous fistula in those who started haemodialysis&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12277&#95;16025&#95;59980&#95;en&#95;f3&#46;jpg" class="elsevierStyleCrossRefs"><img src="12277_16025_59980_en_f3.jpg" alt="Kaplan-Meier survival curves in patients who started peritoneal dialysis and were treated or not with angiotensin-converting enzyme inhibitors and&#47;or angiotensin receptor blockers&#46;"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Kaplan-Meier survival curves in patients who started peritoneal dialysis and were treated or not with angiotensin-converting enzyme inhibitors and&#47;or angiotensin receptor blockers&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12277&#95;16025&#95;59981&#95;en&#95;f4&#46;jpg" class="elsevierStyleCrossRefs"><img src="12277_16025_59981_en_f4.jpg" alt="Kaplan-Meier survival curves in patients who started haemodialysis and were treated or not with angiotensin-converting enzyme inhibitors and&#47;or angiotensin receptor blockers&#46;"></img></a></p><p class="elsevierStylePara">Figure 4&#46; Kaplan-Meier survival curves in patients who started haemodialysis and were treated or not with angiotensin-converting enzyme inhibitors and&#47;or angiotensin receptor blockers&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12277&#95;16025&#95;59982&#95;en&#95;f5&#46;jpg" class="elsevierStyleCrossRefs"><img src="12277_16025_59982_en_f5.jpg" alt="Kaplan-Meier survival curves in patients who started haemodialysis and had or did not have a functioning arteriovenous fistula&#46;"></img></a></p><p class="elsevierStylePara">Figure 5&#46; Kaplan-Meier survival curves in patients who started haemodialysis and had or did not have a functioning arteriovenous fistula&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducci&#243;n</span><span class="elsevierStyleBold">&#58;</span> El cuidado especializado de los pacientes en estadios avanzados de la enfermedad renal cr&#243;nica &#40;ERC&#41; se asocia a una mejor supervivencia en di&#225;lisis&#44; pero se desconoce qu&#233; tratamientos favorecen espec&#237;ficamente esta evoluci&#243;n&#46; <span class="elsevierStyleBold">Objetivos</span><span class="elsevierStyleBold">&#58;</span> Analizar las intervenciones terap&#233;uticas habituales en el estadio de ERC avanzada y establecer cu&#225;les de ellas se asocian a una mejor supervivencia en di&#225;lisis y su relaci&#243;n con las causas de muerte&#46; <span class="elsevierStyleBold">Material y m&#233;todos</span><span class="elsevierStyleBold">&#58;</span> Estudio de cohortes&#44; prospectivo y de observaci&#243;n&#44; que incluy&#243; a 591 pacientes que iniciaron di&#225;lisis &#40;491 hemodi&#225;lisis y 100 di&#225;lisis peritoneal&#41;&#44; que hab&#237;an sido controlados previamente en la consulta de ERC&#46; Las intervenciones terap&#233;uticas analizadas fueron&#58; tratamientos antihipertensivos&#44; estatinas&#44; antiagregantes plaquetarios&#44; inhibidores de la xantina-oxidasa&#44; correcci&#243;n de la acidosis metab&#243;lica&#44; tratamiento con captores de f&#243;sforo &#40;c&#225;lcicos o no&#41;&#44; vitamina D &#40;calcitriol o paricalcitol&#41;&#44; eritropoyetina y disponibilidad de f&#237;stula arterio-venosa interna &#40;FAVI&#41;&#46; La asociaci&#243;n independiente de cada uno de estos tratamiento con la mortalidad en di&#225;lisis fue analizada mediante modelos de regresi&#243;n de Cox con ajuste a edad&#44; sexo&#44; tiempo de seguimiento predi&#225;lisis&#44; funci&#243;n renal al inicio de di&#225;lisis&#44; comorbilidad&#44; albumina s&#233;rica y prote&#237;na C reactiva&#44; y con estratificaci&#243;n al tipo de di&#225;lisis&#46; <span class="elsevierStyleBold">Resultados</span><span class="elsevierStyleBold">&#58;</span> Con una mediana de seguimiento de 28 meses&#44; la cifra total de fallecidos fue de 191 &#40;32&#160;&#37;&#41;&#46; En los modelos multivariantes se observ&#243; que&#44; adem&#225;s de la edad&#44; el &#237;ndice de comorbilidad y la alb&#250;mina s&#233;rica&#44; el tratamiento predi&#225;lisis con inhibidores de la enzima de conversi&#243;n y&#47;o antagonistas de los receptores de la angiotensina&#44; la correcci&#243;n de la acidosis con bicarbonato s&#243;dico y la FAVI al inicio de la hemodi&#225;lisis se asociaron de forma significativa con una mejor supervivencia en di&#225;lisis&#46; No se observaron diferencias en las causas de muerte entre los diferentes tratamientos analizados&#46; <span class="elsevierStyleBold">Conclusi&#243;n</span><span class="elsevierStyleBold">&#58;</span> Estos resultados sugieren un posible beneficio diferido de algunos tratamientos en estadios predi&#225;lisis sobre la evoluci&#243;n en di&#225;lisis&#46; Adem&#225;s&#44; el inicio de hemodi&#225;lisis sin una FAVI&#44; y por tanto la necesidad de utilizaci&#243;n de cat&#233;teres endovenosos&#44; empeora el pron&#243;stico de estos pacientes&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction&#58;</span> Specialised care of patients in advanced stages of chronic kidney disease &#40;CKD&#41; is associated with better survival in dialysis&#44; but it is not known which treatments specifically favour this outcome&#46; <span class="elsevierStyleBold">Objectives&#58; </span>To analyse normal treatment in advanced stages of CKD and establish which treatments are associated with better survival in dialysis as well as their relationship with causes of death&#46; <span class="elsevierStyleBold">Material and method&#58; </span>Cohort&#44; prospective observational study of 591 patients who started dialysis &#40;491 haemodialysis and 100 peritoneal dialysis&#41;&#44; who had previously been monitored in the CKD clinic&#46; The treatments analysed were&#58; antihypertensive treatments&#44; statins&#44; antiplatelet drugs&#44; xanthine oxidase inhibitors&#44; correction of metabolic acidosis&#44; treatment with &#40;calcium or non-calcium&#41; phosphate binders&#44; vitamin D &#40;calcitriol or paricalcitol&#41;&#44; erythropoietin and the availability of an internal arteriovenous fistula &#40;IAVF&#41;&#46; The independent association of each of these treatments with mortality in dialysis was analysed using Cox regression models adjusted for age&#44; sex&#44; pre-dialysis monitoring time&#44; renal function at the start of dialysis&#44; comorbidity&#44; serum albumin and C-reactive protein&#44; and with stratification of the type of dialysis&#46; <span class="elsevierStyleBold">Results&#58; </span>With a median follow-up period of 28 months&#44; the total number of patients who died was 191 &#40;32&#37;&#41;&#46; In the multivariate models&#44; we observed that&#44; in addition to age&#44; the comorbidity index&#44; serum albumin&#44; pre-dialysis treatment with angiotensin-converting-enzyme inhibitors and&#47;or angiotensin receptor blockers&#44; correction of acidosis with sodium bicarbonate and IAVF at the start of haemodialysis were significantly associated with better survival in dialysis&#46; We did not observe differences in causes of death between the different treatments analysed&#46; <span class="elsevierStyleBold">Conclusion&#58; </span>These results suggest a potential delayed benefit of some treatments in pre-dialysis stages on the outcome of dialysis&#46; Furthermore&#44; beginning dialysis without an IAVF&#44; resulting in the need for intravenous catheters&#44; worsens prognosis in these patients&#46;</p>"
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