Safety and efficacy of outpatient biopsy in renal transplantation
Seguridad y eficacia de la biopsia ambulatoria en trasplante renal
Irina B. Torres-Rodrígueza, Eva Castella-Fierrob, Xavier Serres-Creixansb, Maite Salcedo-Allendec, María A. Azancot-Riveroa, Manel Perelló-Carrascosaa, Joana Sellares-Roiga, Carme Cantarell-Aixandria, Francesc Moreso-Mateosa, Daniel Serón-Micasa
a Servicio de Nefrología, Hospital Universitario Vall d'Hebron. Universidad Autónoma de Barcelona,
b Servicio de Radiología, Hospital Universitario Vall d'Hebron. Universidad Autónoma de Barcelona,
c Servicio de Anatomía Patológica, Hospital Universitario Vall d'Hebron. Universidad Autónoma de Barcelona,
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Universidad Autónoma de Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Servicio de Radiología, Hospital Universitario Vall d'Hebron. Universidad Autónoma de Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Vall d'Hebron. Universidad Autónoma de Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Seguridad y eficacia de la biopsia ambulatoria en trasplante renal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12509_16025_63733_en_t212509_i.jpg" "Alto" => 797 "Ancho" => 2142 "Tamanyo" => 388536 ] ] "descripcion" => array:1 [ "en" => "Complications associated with renal biopsy and efficiency of this in each of the groups studied" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Over the past decade, the need to meet a growing surgical waiting list for low or medium complexity processes has encouraged the development of outpatient intervention programmes, complying with efficiency and safety conditions, with a high degree of patient and professional satisfaction<span class="elsevierStyleSup">1</span>.</p><p class="elsevierStylePara">Percutaneous renal biopsy is a diagnostic procedure used since 1944 and a fundamental tool for the knowledge of renal pathology and to guide decision making in clinical practice<span class="elsevierStyleSup">2,3</span>. Traditionally, this procedure required patient hospitalisation. However, over the last two decades the performance of automatic needle biopsy guided by ultrasound has reduced procedure related serious complications (death and/or graft loss)<span class="elsevierStyleSup">4,5</span>. These changes have favoured ambulatory biopsy of native kidneys and renal allografts, making it a safe procedure in a selected population of patients<span class="elsevierStyleSup">6,7</span>.</p><p class="elsevierStylePara">The implementation of a programme of outpatient biopsies improves patients’ quality of life by minimizing their hospital stay. In addition, it results in a significant decrease in the cost of the procedure and a shorter waiting list<span class="elsevierStyleSup">1</span>.</p><p class="elsevierStylePara">For these reasons, since December 2011 we have implemented a renal transplant outpatient biopsies programme in our service. The aim of our study is to evaluate the safety and efficacy of the procedure, comparing the incidence and severity of complications with a historical cohort in which the procedure was performed with the patient hospitalised.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">PATIENTS AND METHOD</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">This is a cohort study in which the incidence and severity of complications associated with kidney biopsy performed on an inpatient basis during the period January 2007-November 2011 and December 2011-December 2013 are compared with those performed on an outpatient basis during the period December 2011-December 2013.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Biopsy procedure</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Outpatient renal biopsy is indicated in the Outpatient Consulting Offices. Its performance is contraindicated under the following circumstances: 1) anticoagulant warfarin treatment, 2) thrombocytopenia <50 000/mm<span class="elsevierStyleSup">3</span>, 3) obesity with BMI> 35 kg/m<span class="elsevierStyleSup">2</span>, 4) hypertension uncontrolled with medical treatment. In patients receiving antiplatelet medication, this was discontinued a week before and reintroduced after 72 hours if there were no complications. The patient was admitted on the same day of the procedure to the haemodialysis unit. After obtaining informed consent, a peripheral vein was channelled and samples were obtained for a complete blood count with platelet count, determination of coagulation parameters and blood bank reserves. Patients who had to be hospitalised due to contraindications for performing an outpatient biopsy were admitted the day before the procedure and discharged after 24 hours of observation. If the patient continued treatment with oral anticoagulants, these were discontinued a week before and low molecular weight heparin was given, which was discontinued 24 hours before biopsy.</p><p class="elsevierStylePara">In patients with a glomerular filtration rate <30ml/min/1.73 m<span class="elsevierStyleSup">2</span> estimated by CKD-EPI formula (Chronic Kidney Disease Epidemiology Collaboration) and/or who have a known coagulation disorder, desmopressin was administered at 0.3mg/kg one hour before the procedure. In addition, all patients received 5mg diazepam orally 30 minutes before the procedure and atropine 0.5mg subcutaneously at the time of the biopsy.</p><p class="elsevierStylePara">Renal biopsy was performed by the radiologist using an automatic 16-gauge needle (BARD<span class="elsevierStyleSup">® </span>MONOPTY<span class="elsevierStyleSup">®</span>) under real-time ultrasound guidance and routinely two cores are obtained for study by light and immunofluorescence microscopy. In addition, in all follow-up biopsies a third core for molecular biological studies was obtained. In a group of 42 biopsies performed during the period 2007-2011, an additional core for molecular biology<span class="elsevierStyleSup">8</span> was also obtained. After the procedure, the patient remained at rest for 6 hours while diuresis and blood pressure were checked, and a control blood count was performed after 4 hours. If no immediate complications were detected, the patient is discharged, with a recommendation of relative rest for 72 hours.</p><p class="elsevierStylePara">If immediate complications are observed such as subcapsular haematoma with no active bleeding during post-biopsy ultrasound and/or there is post-puncture renal macroscopic haematuria, observation time is extended or hospitalisation is indicated according to severity of symptoms.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Assessment of complications</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">After biopsy the following complications were evaluated: a) major complications: gross haematuria, haematoma and/or arterio-venous fistula, requiring blood transfusion or interventional treatment; b) minor complications: self-limited gross haematuria and/or subcapsular haematoma without haemodynamic complications.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistical analysis</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Results are expressed as frequencies for qualitative variables and as mean ± standard deviation for continuous variables. Comparison between groups is performed with the Χ<span class="elsevierStyleSup">2</span> test for qualitative variables and analysis of variance for comparison of means with the Scheffe post hoc test for individual comparisons between groups. All analyses are two sided and a <span class="elsevierStyleItalic">P</span> value of <.05 is considered to be significant.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patients</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">During the study period, 385 renal graft biopsies were performed. In the period between January 2007 and November 2011, 124 biopsies were performed on an hospitalisation basis. In the period between December 2011 and December 2013 a total of 261 biopsies, of which 219 (84%) were on an outpatient basis were performed. During this same period, biopsies on an hospitalisation basis were performed in 42 cases (16%) for the following reasons: Biopsies are indicated in hospitalised patients either due to delayed graft function or to acute impairment of renal function (n = 31), b) patient hospitalisation is programmed because there is a contraindication for an outpatient biopsy (n = 11), as shown in Figure 1. Contraindications for ambulatory biopsies are the following: treatment with systemic anticoagulants (n=2), obesity (n=2), thrombocytopenia (n=3), inadequate social and/or family environment for ensuring patient monitoring 24 hours post-biopsy (n=3) and insular residence (n=1).</p><p class="elsevierStylePara">Table 1 shows the demographic and clinical characteristics of the three groups of patients. Differences in renal function and proteinuria between groups are related to the indication for biopsy. It is noteworthy that in the group of outpatient biopsies 53% were indicated due to graft dysfunction and 47% were follow-up biopsies at 3 or 12 months after transplantation.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Post-biopsy complications</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">During the period between January 2007 and November 2011 one major complication (0.8%) was recorded in a patient requiring puncture embolisation of the epigastric artery with intra-abdominal bleeding and hypotension. Minor complications were three bruises without haemodynamic complications and without transfusion requirements and one patient suffered a self-limiting gross haematuria (3.2%).</p><p class="elsevierStylePara">During the period between December 2011 and December 2013, 219 patients that underwent biopsy on an outpatient basis with 6 (2.7%) minor complications were recorded (2 self-limiting haematurias and 4 subcapsular haematomas without haemodynamic complications). One patient with self-limiting haematuria and two patients with subcapsular haematomas were discharged 6 hours after the biopsy. One patient with gross haematuria and 2 patients with perirenal hematoma were hospitalised. Patients were discharged at 24 hours and one patient with perirenal hematoma after 48 hours, as his home was 200km from the hospital.</p><p class="elsevierStylePara">Of the 42 hospitalised patients who underwent biopsy during 2011-2013 one major complication was seen (2.4%) that required embolisation for abdominal wall bleeding with haemodynamic complications and 3 patients (7.1%) suffered minor complications: uncomplicated subcapsular hematoma (n=2) and self-limited haematuria (n=1). Table 2 summarises the complications of the three patient groups.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Number of cores obtained and sample adequacy</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The number of cores obtained in the outpatient biopsies was significantly higher than in hospitalised patients, since in follow-up biopsies an additional core for molecular biology was obtained. Although in the core obtained for light microscopy the number of glomeruli was significantly lower in the outpatient biopsies, this difference did not attain statistical significance when the adequacy of the sample was evaluated according to Banff criteria<span class="elsevierStyleSup">9</span>, as shown in Table 2.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Renal allograft biopsy is a useful method for understanding and characterising what happens to the graft and provides guidance for therapeutic interventions. The introduction of ultrasound-guided automatic needle puncture has made biopsing allografts, for either diagnostic reasons or during follow-up, a safe procedure<span class="elsevierStyleSup">3,6</span>.</p><p class="elsevierStylePara">In our study, in which we retrospectively evaluated complications associated with graft biopsies in hospitalised patients (periods 2007-2011 and 2011-2013) and outpatients (2011-2013), it has been demonstrated that there are no differences in the incidence of complications between the two periods of time and that the rate of serious complications was less than 1%, as described in other series of biopsies. There were no cases of death or loss of transplant<span class="elsevierStyleSup">5,6,10</span>.</p><p class="elsevierStylePara">The safety of outpatient procedures has been evaluated in retrospective studies of different series of renal allograft biopsies performed in adult and paediatric recipients. In one of the most comprehensive reviews in 1670 biopsies, Schwarz et al. showed that graft biopsy performed as an outpatient procedure is safe and that there are no differences in the complication rate regardless of indication (clinical or follow-up). In addition, according to other authors, using a 16 G gauge needle it is possible to obtain the same safety profile and improved sample adequacy for histological evaluation<span class="elsevierStyleSup">6</span>. Despite the absence of homogeneity between centres on the criteria for contraindication of outpatient procedures and patient observation time after performance of biopsies to monitor complications, the results obtained in different series (Table 3 ) suggest that a window period of between 4 and 8 hours post-biopsy during which evaluation of vital signs and urine monitoring, with or without analytical and/or ultrasound control, is enough to observe any procedure associated bleeding complication<span class="elsevierStyleSup">6,7,11,12</span>.</p><p class="elsevierStylePara">The successful implementation of a low or medium complexity outpatient procedure programme is based on reduction of waiting time, as well as achieving efficiency and safety. In addition, it is of benefit to the patient, who perceives better quality of life and degree of care, to professionals as it simplifies the clinical process, and to the institution, as it increases process efficiency and reduces hospitalisation costs. It requires coordination between different specialties and a high degree of protocolisation of the clinical process applicable to a low-risk group of similar patients. All of this allows a minimum time of observation and a low rate of hospitalisation due to complications<span class="elsevierStyleSup">7,13</span>.</p><p class="elsevierStylePara">According to our experience, we have to highlight that since the implementation of outpatient biopsies only one major complication occurred in 261 (0.38%) procedures; this was in a patient who was already hospitalised and who was biopsied for acute graft dysfunction. During this same period, we should note that 95% of biopsies indicated in consulting offices were performed as outpatient procedures. None of these patients suffered a major complication. Two patients with subcapsular hematoma and one with gross haematuria were hospitalised due to minor complications detected during the monitoring period (6 hours), representing a hospitalisation rate of 1.37%, similar to that observed in other series (Table 3). In patients without complications during the monitoring period no late complications were observed.</p><p class="elsevierStylePara">The most frequent indications for biopsy in patients hospitalised during 2011-2013 were delayed graft function and acute dysfunction. Only 11 of 230 patients (5 %) in which biopsies were indicated in the external consulting offices were hospitalised due to clinical or social/family contraindications.</p><p class="elsevierStylePara">Of the 219 biopsies performed on an outpatient basis, a total of 102 (47%) were follow-up biopsies. In these cases a third core for molecular biology studies was obtained, and it is for this reason that the average number of cores in outpatients was significantly higher. Despite obtaining an additional core in these low-risk patients, no increase in complications was observed.</p><p class="elsevierStylePara">However, the number of renal tissue samples defined as marginal and adequate for diagnosis was slightly lower in outpatients, although this difference did not reach statistical significance and was not clinically relevant, since in all cases it was possible to perform a diagnosis.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Ambulatory renal allograft biopsies are a safe procedure when applied to a low-risk subgroup of patients, improving their quality of life, decreasing the waiting list and reducing hospitalisation costs.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">Receive Scholarships: IB Torres received a predoctoral fellowship from the Institut de Recerca Vall d'Hebron (VHIR). Azancot MA has received a FIS predoctoral fellowship (FI11/0246). This study received support from the Carlos III Institute (grants PI10/2496, PIE13/00027) of the Renal Research Network (REDinREN 12/0021/0013) and a grant from the Spanish Society of Transplant-Novartis.</p><p class="elsevierStylePara">We acknowledge the cooperation of the nursing staff of the Haemodialysis Unit of the Vall d'Hebron Hospital who have helped care for the patients.</p><p class="elsevierStylePara"><a href="grande/12509_16025_63733_en_t212509_i.jpg" class="elsevierStyleCrossRefs"><img src="12509_16025_63733_en_t212509_i.jpg" alt="Complications associated with renal biopsy and efficiency of this in each of the groups studied"></img></a></p><p class="elsevierStylePara">Table 2. Complications associated with renal biopsy and efficiency of this in each of the groups studied</p><p class="elsevierStylePara"><a href="grande/12509_16025_63734_en_t312509_i.jpg" class="elsevierStyleCrossRefs"><img src="12509_16025_63734_en_t312509_i.jpg" alt="Percentage of complications, observation time and complications subsequent to the observation period, hospitalisation rate and sample adequacy in different series of outpatient renal allograft biopsies. "></img></a></p><p class="elsevierStylePara">Table 3. Percentage of complications, observation time and complications subsequent to the observation period, hospitalisation rate and sample adequacy in different series of outpatient renal allograft biopsies. </p><p class="elsevierStylePara"><a href="grande/12509_16025_63735_en_f112509_i.jpg" class="elsevierStyleCrossRefs"><img src="12509_16025_63735_en_f112509_i.jpg" alt="Flowchart of biopsies performed during 2007-2013"></img></a></p><p class="elsevierStylePara">Figure 1. Flowchart of biopsies performed during 2007-2013</p><p class="elsevierStylePara"><a href="grande/12509_16025_63736_en_t112509_i.jpg" class="elsevierStyleCrossRefs"><img src="12509_16025_63736_en_t112509_i.jpg" alt="Demographic variables, indication for biopsy and laboratory data at the time of biopsy"></img></a></p><p class="elsevierStylePara">Table 1. Demographic variables, indication for biopsy and laboratory data at the time of biopsy</p>" "pdfFichero" => "P1-E577-S4785-A12509-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec436965" "palabras" => array:1 [ 0 => "Trasplante renal" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec436967" "palabras" => array:1 [ 0 => "Seguridad" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec436969" "palabras" => array:1 [ 0 => "Biopsia renal ambulatoria" ] ] ] "en" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec436966" "palabras" => array:1 [ 0 => "Renal transplantation" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec436968" "palabras" => array:1 [ 0 => "Safety" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec436970" "palabras" => array:1 [ 0 => "Outpatient renal graft" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Background:</span> In many centers patients are hospitalised to perform a renal allograft biopsy. <span class="elsevierStyleBold">Aim: </span>To evaluate the safety and efficacy of outpatient renal allograft biopsies. <span class="elsevierStyleBold">Methods: </span>Since December 2011 we perform renal allograft biopsies as an outpatient procedure. Exclusion criteria for performing an outpatient biopsy included: 1.) anticoagulant treatment, 2.) thrombocytopenia <50,000/mm<span class="elsevierStyleSup">3</span>, 3.) body mass index >35kg/m<span class="elsevierStyleSup">2</span> and 4.) uncontrolled hypertension. The number and severity of complications were compared with an historical cohort of 124 biopsies done between 2007 and 2011 when all patients were hospitalised for the procedure and with 42 patients biopsied during hospitalisation between 2011 and 2013. <span class="elsevierStyleBold">Results:</span> Between 2011 and 2013, 210 (95%) out of 230 biopsies indicated in the outclinic were performed as an outpatient procedure (95%). The incidence of major complications (bleeding requiring blood transfusion and/or embolisation) was 0.8% between 2007 and 2011 and 2.4% in biopsies between 2011 and 2013 in hospitalised patients (p=0.475). No major complications were observed in the outpatient biopsy group. Minor complications (hematuria, hematoma or fistula not requiring transfusion or embolisation) were also not different between groups (3.2%, 7.1% and 2.7%; respectively). Sample size adequacy according to the Banff criteria was not different among groups (p=0.052). <span class="elsevierStyleBold">Conclusion: </span>Ambulatory renal allograft biopsy is a safe and efficient procedure.</p>" ] "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Antecedentes:</span> La biopsia del aloinjerto renal se realiza habitualmente con el paciente hospitalizado. <span class="elsevierStyleBold">Objetivo:</span> Evaluar la seguridad y eficacia de un programa de biopsias ambulatorio en receptores de trasplante renal. <span class="elsevierStyleBold">Métodos:</span> En diciembre de 2011 se inició un programa ambulatorio de biopsias en trasplante renal. Se contraindica la biopsia ambulatoria en los casos siguientes: 1) tratamiento anticoagulante, 2) trombocitopenia < 50 000/mm<span class="elsevierStyleSup">3</span>, 3) índice de masa corporal > 35 kg/m<span class="elsevierStyleSup">2</span>, 4) hipertensión arterial no controlada. Se compara la seguridad y eficacia de las biopsias realizadas bajo hospitalización en el período 2007-2011 (n = 124) con las biopsias ambulatorias realizadas durante el período 2011-2013 (n = 219) y las realizadas en este mismo período bajo hospitalización (n = 42). <span class="elsevierStyleBold">Resultados:</span> Entre diciembre de 2011 y diciembre de 2013 se han indicado 230 biopsias desde la consulta externa y se han realizado 219 (95 %) en régimen ambulatorio. La incidencia de complicaciones mayores (necesidad de transfusión y/o embolización) ha sido de 0,8 % para el período 2007-2011 y de 2,4 % para las realizadas bajo hospitalización del período 2011-2013 (p = 0,475). No se observaron complicaciones mayores en el grupo de pacientes con biopsias realizadas de forma ambulatoria. La tasa de complicaciones menores (hematuria macroscópica, hematoma o fístula que no requirieron transfusión ni embolización) no ha sido distinta entre los grupos (3,2 %, 7,1 % y 2,7 %, respectivamente). La adecuación de la muestra obtenida según los criterios de Banff no ha sido distinta entre los grupos (p = 0,052). <span class="elsevierStyleBold">Conclusión:</span> La realización ambulatoria de la biopsia de injerto renal es un procedimiento seguro y eficaz.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12509_16025_63733_en_t212509_i.jpg" "Alto" => 797 "Ancho" => 2142 "Tamanyo" => 388536 ] ] "descripcion" => array:1 [ "en" => "Complications associated with renal biopsy and efficiency of this in each of the groups studied" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12509_16025_63734_en_t312509_i.jpg" "Alto" => 1289 "Ancho" => 2173 "Tamanyo" => 616084 ] ] "descripcion" => array:1 [ "en" => "Percentage of complications, observation time and complications subsequent to the observation period, hospitalisation rate and sample adequacy in different series of outpatient renal allograft biopsies." ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12509_16025_63735_en_f112509_i.jpg" "Alto" => 1333 "Ancho" => 2110 "Tamanyo" => 404132 ] ] "descripcion" => array:1 [ "en" => "Flowchart of biopsies performed during 2007-2013" ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12509_16025_63736_en_t112509_i.jpg" "Alto" => 839 "Ancho" => 2160 "Tamanyo" => 554359 ] ] "descripcion" => array:1 [ "en" => "Demographic variables, indication for biopsy and laboratory data at the time of biopsy" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Romero Simo M, Aguayo Albasini JL. 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| Year/Month | Html | Total | |
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| 2024 November | 4 | 7 | 11 |
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| 2023 December | 40 | 20 | 60 |
| 2023 November | 44 | 35 | 79 |
| 2023 October | 50 | 34 | 84 |
| 2023 September | 54 | 32 | 86 |
| 2023 August | 78 | 23 | 101 |
| 2023 July | 101 | 34 | 135 |
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| 2023 May | 119 | 40 | 159 |
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| 2021 April | 201 | 66 | 267 |
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| 2021 February | 96 | 19 | 115 |
| 2021 January | 78 | 32 | 110 |
| 2020 December | 56 | 24 | 80 |
| 2020 November | 27 | 19 | 46 |
| 2020 October | 41 | 21 | 62 |
| 2020 September | 35 | 11 | 46 |
| 2020 August | 49 | 14 | 63 |
| 2020 July | 40 | 12 | 52 |
| 2020 June | 39 | 24 | 63 |
| 2020 May | 57 | 19 | 76 |
| 2020 April | 30 | 20 | 50 |
| 2020 March | 47 | 17 | 64 |
| 2020 February | 69 | 20 | 89 |
| 2020 January | 51 | 29 | 80 |
| 2019 December | 66 | 27 | 93 |
| 2019 November | 48 | 28 | 76 |
| 2019 October | 35 | 18 | 53 |
| 2019 September | 38 | 16 | 54 |
| 2019 August | 50 | 22 | 72 |
| 2019 July | 46 | 25 | 71 |
| 2019 June | 56 | 25 | 81 |
| 2019 May | 71 | 18 | 89 |
| 2019 April | 118 | 36 | 154 |
| 2019 March | 77 | 22 | 99 |
| 2019 February | 28 | 20 | 48 |
| 2019 January | 59 | 28 | 87 |
| 2018 December | 131 | 39 | 170 |
| 2018 November | 209 | 27 | 236 |
| 2018 October | 155 | 26 | 181 |
| 2018 September | 182 | 15 | 197 |
| 2018 August | 121 | 17 | 138 |
| 2018 July | 76 | 13 | 89 |
| 2018 June | 83 | 21 | 104 |
| 2018 May | 89 | 10 | 99 |
| 2018 April | 83 | 13 | 96 |
| 2018 March | 55 | 14 | 69 |
| 2018 February | 76 | 7 | 83 |
| 2018 January | 72 | 9 | 81 |
| 2017 December | 72 | 9 | 81 |
| 2017 November | 94 | 13 | 107 |
| 2017 October | 59 | 11 | 70 |
| 2017 September | 64 | 14 | 78 |
| 2017 August | 57 | 8 | 65 |
| 2017 July | 66 | 15 | 81 |
| 2017 June | 86 | 12 | 98 |
| 2017 May | 106 | 9 | 115 |
| 2017 April | 59 | 9 | 68 |
| 2017 March | 81 | 26 | 107 |
| 2017 February | 185 | 12 | 197 |
| 2017 January | 63 | 14 | 77 |
| 2016 December | 113 | 11 | 124 |
| 2016 November | 146 | 13 | 159 |
| 2016 October | 241 | 15 | 256 |
| 2016 September | 378 | 5 | 383 |
| 2016 August | 386 | 6 | 392 |
| 2016 July | 261 | 15 | 276 |
| 2016 June | 194 | 0 | 194 |
| 2016 May | 175 | 0 | 175 |
| 2016 April | 177 | 0 | 177 |
| 2016 March | 139 | 0 | 139 |
| 2016 February | 136 | 0 | 136 |
| 2016 January | 143 | 0 | 143 |
| 2015 December | 145 | 0 | 145 |
| 2015 November | 97 | 0 | 97 |
| 2015 October | 122 | 0 | 122 |
| 2015 September | 124 | 0 | 124 |
| 2015 August | 107 | 0 | 107 |
| 2015 July | 104 | 0 | 104 |
| 2015 June | 67 | 0 | 67 |
| 2015 May | 96 | 0 | 96 |
| 2015 April | 16 | 0 | 16 |
Show all
