Palliative peritoneal dialysis: Implementation of a home care programme for terminal patients treated with peritoneal dialysis (PD)
Diálisis peritoneal paliativa: implantación de un programa de atención domiciliaria a enfermos tratados con diálisis peritoneal (DP) en situación terminal
Read
10520
Timeswas read the article
2160
Total PDF
8360
Total HTML
Share statistics
array:19 [ "pii" => "X2013251415123104" "issn" => "20132514" "estado" => "S300" "fechaPublicacion" => "2015-03-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2015;35:146-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6329 "formatos" => array:3 [ "EPUB" => 334 "HTML" => 5359 "PDF" => 636 ] ] "itemSiguiente" => array:15 [ "pii" => "X2013251415123112" "issn" => "20132514" "estado" => "S300" "fechaPublicacion" => "2015-03-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2015;35:150-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5126 "formatos" => array:3 [ "EPUB" => 312 "HTML" => 4261 "PDF" => 553 ] ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "The effect of some medications given to CKD patients on vitamin D levels" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "150" "paginaFinal" => "156" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Efectos de algunos fármacos administrados a los pacientes de ERC sobre los niveles de vitamina D" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "498v35n02-90412311fig4.jpg" "Alto" => 912 "Ancho" => 1012 "Tamanyo" => 66057 ] ] "descripcion" => array:1 [ "en" => "– Relationship between therapies and baseline serum 25¿OH¿D3 levels. Patients were divided in three groups according with the concomitant therapies, and there were significant statistical differences between groups (p <0 001 patients who were not receiving renin angiotensin system ras inhibitors or allopurinol n="30)" presented lower 25 8209 oh d3 d levels than those and plus p <0 001 highest 25 8209 oh d3 levels 11 7 3 p="0.005)" were found in patients receiving ras inhibitors plus allopurinol without statins lowest 5 1 82 who only</0> </0>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Claudia Yuste, Borja Quiroga, Soledad García de Vinuesa, Maria Angeles Goicoechea, Daniel Barraca, Ursula Verdalles, Jose Luño" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Claudia" "apellidos" => "Yuste" ] 1 => array:2 [ "nombre" => "Borja" "apellidos" => "Quiroga" ] 2 => array:2 [ "nombre" => "Soledad" "apellidos" => "García de Vinuesa" ] 3 => array:2 [ "nombre" => "Maria Angeles" "apellidos" => "Goicoechea" ] 4 => array:2 [ "nombre" => "Daniel" "apellidos" => "Barraca" ] 5 => array:2 [ "nombre" => "Ursula" "apellidos" => "Verdalles" ] 6 => array:2 [ "nombre" => "Jose" "apellidos" => "Luño" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251415123112?idApp=UINPBA000064" "url" => "/20132514/0000003500000002/v0_201504231604/X2013251415123112/v0_201504231605/en/main.assets" ] "itemAnterior" => array:15 [ "pii" => "X2013251415119180" "issn" => "20132514" "estado" => "S300" "fechaPublicacion" => "2015-03-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2015;35:139-45" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6071 "formatos" => array:3 [ "EPUB" => 323 "HTML" => 5103 "PDF" => 645 ] ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Hypertension in the African American population: A succinct look at its epidemiology, pathogenesis, and therapy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "139" "paginaFinal" => "145" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hipertensión en la población afroamericana: breve examen de su epidemiología, patogénesis y terapia" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "498v35n02-90411918fig3.jpg" "Alto" => 1200 "Ancho" => 2037 "Tamanyo" => 210277 ] ] "descripcion" => array:1 [ "en" => "– Treatment of hypertension in African Americans vs Whites. a Albumin:creatinine >200 mg/g, eGFR <60 ml min 1 73 m2 left ventricular hypertrophy by electro-echocardiogram b heart failure cad peripheral arterial disease stroke tia abdominal aortic aneurysm c calcium channel antagonist d renin angiotensin or at1 receptor blocker e agents are used with compelling indications</60>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Luis M Ortega, Emad Sedki, Ali Nayer" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Luis M" "apellidos" => "Ortega" ] 1 => array:2 [ "nombre" => "Emad" "apellidos" => "Sedki" ] 2 => array:2 [ "nombre" => "Ali" "apellidos" => "Nayer" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251415119180?idApp=UINPBA000064" "url" => "/20132514/0000003500000002/v0_201504231604/X2013251415119180/v0_201504231605/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "titulo" => "Palliative peritoneal dialysis: Implementation of a home care programme for terminal patients treated with peritoneal dialysis (PD)" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "146" "paginaFinal" => "149" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Maite Rivera Gorrin, José Maite Rivera Gorrin, José Luis Teruel-Briones, Victor Burguera Vion, Lourdes Rexach, Carlos Que xTeruel-Briones, Carlos Quereda" "autores" => array:5 [ 0 => array:3 [ "nombre" => "Maite" "apellidos" => "Rivera Gorrin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "José Maite Rivera Gorrin, José Luis Teruel-Briones, Victor Burguera Vion, Lourdes Rexach, Carlos Que" "apellidos" => "xTeruel-Briones" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "nombre" => "Victor" "apellidos" => "Burguera Vion" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "nombre" => "Lourdes" "apellidos" => "Rexach" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 4 => array:3 [ "nombre" => "Carlos" "apellidos" => "Quereda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Nephrology, Hospital Ramón y Cajal [Ramón y Cajal Hospital], IRYCIS (Instituto Ramón y Cajal de Investigación Sanitaria [Ramón y Cajal Institute for Health Research]), Madrid (Spain) " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Palliative Care, Hospital Ramón y Cajal, IRYCIS, Madrid (Spain)" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diálisis peritoneal paliativa: implantación de un programa de atención domiciliaria a enfermos tratados con diálisis peritoneal (DP) en situación terminal" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction </span></p><p class="elsevierStylePara"> Terminal-stage patients on peritoneal dialysis (PD) whose pathology is life threatening in the short term have reduced functional capacities and serious difficulties in performing peritoneal exchanges or attending regular check-ups at the hospital. Under these circumstances, patients in the PD programme are often transferred to haemodialysis (HD). However, since they are conscious of their end-stage condition, some patients who had opted for PD to maintain their personal independence express their desire to die at home and remain on PD until the end. The current health care organisation in Spain does not offer this possibility. We present our experience with a home care programme for terminal patients on PD who are managed in collaboration with their primary care physician (PCP) and maintained on PD until their death.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patients and methods </span></p><p class="elsevierStylePara"> Between May 1995 and December 2013, 307 patients with PD were treated by our Department, 5 of whom required palliative care due to an irreversible pathology with a short-term fatal prognosis. We analysed their data retrospectively from the PD Unit database. All the patients had expressed their desire to die at home, so it was necessary for them to remain on PD and not be transferred to HD. Making palliative care and PD compatible with the current functional structure of our Unit did not seem an easy task, although we wanted to meet all our patients’ wishes.</p><p class="elsevierStylePara"> Therefore, we contacted their PCP to ask him/her to share in the patients’ follow-up and dialysis technique. A primary care (PC) nurse underwent a short training course (one to three days) in the PD Unit. This was necessary because, while three of the patients lived with family members who were familiar with the technique, two patients lived alone. Besides, as the nurse was going to be their closest contact, we believed it was convenient for him/her to learn the technique in order to inspire higher confidence in the patient and family members. We also trained a member of the ancillary staff of a public Long-Stay Unit (LSU) for chronic patients. This staff member trained the other members of the unit, where one patient was admitted until his death.</p><p class="elsevierStylePara"> The primary care staff drew blood samples for lab tests at the patients’ homes, and the results were reported to us by phone along with clinical patient information. Blood tests included haemogram and basic blood chemistry. No urinalysis, Kt/V or PET measurements were ordered in any of the cases. The frequency of home visits and blood tests was established by the PCP and adjusted to the needs of the patient. In this manner, no patient came back to the hospital PD Unit for a periodical medical follow-up.</p><p class="elsevierStylePara"> The pharmacological treatment was adjusted to the needs and situation of the patient. As a general rule, all drugs were discontinued except for erythropoietin and antihypertensive drugs. Medication for symptoms treatment (analgesia, sedatives, etc.) was left at the discretion of the PCP. The physician of the long-term unit played the same role. There was fluent and permanent telephone contact between the PD Unit, care-givers and primary care professionals until death. Below, we present the characteristics of the five patients that required palliative care in our PD Unit. In order to measure the degree of independence of the patients prior to requiring palliative care, we used the Barthel activities of daily living index.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results </span></p><p class="elsevierStylePara"> Four men and one woman were included in this programme. Mean age was 49 (range: 46 to 67) and the Charlson index was 11 ± 5.6 (range: 5 to 18). The underlying disease was: chronic glomerulonephritis (n = 2), radical nephrectomy due to bilateral renal carcinoma (n = 1), diabetic nephropathy (n = 1) and undetermined kidney disease (n = 1). Three patients were HIV positive. Two patients lived alone before reaching the end-stage condition. All were on manual PD technique and independent for activities of daily living (Barthel index 50, 75, 85, 60 and 65, respectively) and able to perform the dialysis technique themselves before experiencing the event that led to their admission to the palliative programme. Four patients were anuretic and the fifth patient had a diuresis of 200 mL/24 h. After 42.6 ± 27 months (range: 16 to 81) on PD, they developed the following nonreversible complications: two cachexia, one hepatic carcinoma with frequent hospital admissions due to encephalopathy, one metastatic squamous cell carcinoma, and one invasive bilateral renal carcinoma relapse. Four patients were treated with family-assisted PD at home until their death, and one patient was treated in a public LSU. The survival was 17 to 119 days, with a mean of 33 days. Only one patient was admitted to the Hospital for three days after initiating palliative care. Assisted PD was manual in all the cases. One or two exchanges per day were scheduled, and in specific cases a third exchange was performed when it was necessary to guarantee ultrafiltration. Four patients were managed with 2.27% glucose and only one patient received icodextrin in the long exchange. The characteristics of the patients are detailed in Table I.</p><p class="elsevierStylePara"><img alt="Table I – " src="498v35n02-90412310fig1.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion </span></p><p class="elsevierStylePara"> Palliative Care Units (PCU), which have traditionally focused on patients with terminal-stage cancer, have had to widen their field of action in recent years due to the increasing demand for assistance and palliative support by patients with chronic, progressive non-cancer pathologies.<span class="elsevierStyleSup">1-3</span></p><p class="elsevierStylePara"> At the beginning of the 21st century, palliative care extended to include other pathologies, such as chronic kidney disease, with the intention of humanising and easing the transition to death, not only for patients but also for their family members<span class="elsevierStyleSup">4,5</span>. Thus, in recent years there has been a growing interest within the nephrology community to offer palliative care to patients with chronic kidney disease. This is either because they are not eligible for dialysis and would therefore start conservative treatment, or because discontinuation of dialysis treatment is considered the best option. In this regard, there are several excellent publications where the need for multidisciplinary palliative care units for renal patients was justified and the grounds were set forth, not only in Spain but also worldwide<span class="elsevierStyleSup">6,7,8</span>.</p><p class="elsevierStylePara"> But, what if the patient is eligible for palliative care and does not want to discontinue dialysis? The decision to discontinue dialysis raises concerns. It is perceived as suicide in up to 12% of patients<span class="elsevierStyleSup">9</span>, and it may even be considered euthanasia from a family standpoint. This dilemma is partially solved through the new “palliative dialysis” concept<span class="elsevierStyleSup">10</span>, which basically involves continuing dialysis treatment but replacing the usual targets of dialysis efficiency (Kt/V, dry weight, PTH levels, etc.) with asymptomatic patient targets. Thus, palliative dialysis consists in individualising the dialysis prescription for each patient, focusing on ultrafiltration rather than on the clearance of uraemic solutes. The palliative dialysis mentioned in the literature is, in fact, palliative HD, and patients on PD who may require palliative care would be transferred to HD when they are not independent enough to make exchanges themselves.</p><p class="elsevierStylePara"> Moreover, what if patients on PD who require palliative care do not want to change their dialysis technique? That is to say, if patients have chosen home dialysis and express the explicit desire to continue said treatment when facing the end of life, should we keep them on PD or transfer them to HD? This is the situation of our patients. The first time we faced this event was in 2001. As mentioned above, our patient had a highly invasive bilateral renal carcinoma recurrence with a poor short-term prognosis. The patient had the support of family members who were trained in the technique, but he needed an individualised treatment, at home if possible, for the tumour-related symptoms. Given this circumstance and wishing to respect this request, we opted to contact the patient’s PCP. After explaining the situation, we asked the physician to share in the responsibility of monitoring the patient and dialysis technique with us. This request was immediately accepted. Our nursing staff gave the visiting nurse a short training session on the PD technique. This patient died 20 days later, without requiring office visits or hospital admission. We have repeated the experience four more times. In each case, both the patients and families have personally manifested their satisfaction to us, while we ourselves have also felt satisfied. We must highlight that patient No. 3 was admitted to a publicly-funded LSU and treated with PD until the moment of death 119 days later. In this case, a member of the LSU ancillary staff was trained at our PD Unit and was later able to teach the LSU staff.</p><p class="elsevierStylePara"> Since 1990, the Community of Madrid has progressively implemented a health care resource directed at providing palliative care services for both Specialised Care and Primary Care. Family members of treated patients and the participating staff themselves have shown a high rate of satisfaction with this high-quality care<span class="elsevierStyleSup">11</span>. In 1991 and 1992, Health Areas 4 and 11 initiated specific programmes directed towards terminal patients that were based on the collaboration between Primary and Specialized Care in order to ensure continuous care. In addition, six home care support teams<span class="elsevierStyleSup">12</span> were created in 1999, under the management of Primary Care, in order to collaborate with and support PCP when treating immobilised terminal-stage patients. Subsequently, Act 16/2003 (from May 28<span class="elsevierStyleSup">th</span>) on the Cohesion and Quality of the National Health Care Service specifically included palliative care for terminal patients, both in Primary Care and Specialised Care services. The health area of Ramón y Cajal Hospital and Gregorio Marañón Hospital was a pioneer in the implementation of specialised and continuous care programmes for terminal patients based on the collaboration and coordination between Primary Care and Specialised Care. These programmes are aimed at any and all patients at a terminal stage, including renal patients. In its 2004 report, the ESAD (<span class="elsevierStyleItalic">Equipo de Soporte de Atención Domiciliaria </span>[Home Care Support Team]) of the Community of Madrid assisted 24 terminal nephrology patients, as detailed in its report<span class="elsevierStyleSup">11</span>.</p><p class="elsevierStylePara"> Assisted peritoneal dialysis, performed by either qualified staff or a family member, is a good solution for patients on PD at a terminal stage without the need to transfer them to HD<span class="elsevierStyleSup">13</span>. The traditional model of assisted PD <span class="elsevierStyleItalic">is</span> based on using a cycler at night with a dry day, which makes the dialysis technique compatible with the daily life of the caregiver and avoids over-burdening him/her. This modality was not applied in our patients since all of them received manual PD treatment and there was no training with cyclers. What we propose for terminal patients on PD is, in fact, <span class="elsevierStyleItalic">Palliative Peritoneal Dialysis</span>, which we define as PD therapy that, on the one hand, can keep the patient free of symptoms such as dyspnoea and, on the other hand, makes the patient feel cared for (dialysed) until the end, without overwhelming the main caregiver.</p><p class="elsevierStylePara"> In our experience, this has been possible through manual peritoneal dialysis with 1 or 2 glucose exchanges every 24 hours. In patients in whom blood volume control is a priority, a long icodextrin day exchange combined with a glucose night exchange could be the recommended pattern.</p><p class="elsevierStylePara"> To summarise, PD may be continued until the end of life of patients at a terminal stage, without transferring them to HD and without overburdening the caregiver. In our experience, the support of primary care professionals was essential to provide these patients with proper, individualised treatment and to comply with the Patient Autonomy Law<span class="elsevierStyleSup">14</span>. Selfless support provided by the primary care staff allowed patients to continue PD treatment and to receive home care without the need to be transferred to HD, thus respecting their desire to die at home. Assisted Palliative PD is well accepted by family members and does not involve a severe burden during the short survival of said patients. Decision-making in patients with an end-stage condition must be shared, while taking into consideration the patient’s clinical situation, prognosis, quality of life and desires. In cases where PD discontinuation may increase the anxiety and distress of the patient and family, we believe that palliative peritoneal dialysis is a good solution.</p><hr></hr><p class="elsevierStylePara"> Sent for Review: 8 July 2014 <br></br> Accepted on: 21 Oct. 2014</p><p class="elsevierStylePara"><a href="http://dx.doi.org/10.3265/Nefrologia.pre2014.Oct.12669" class="elsevierStyleCrossRefs">http://dx.doi.org/10.3265/Nefrologia.pre2014.Oct.12669</a></p><p class="elsevierStylePara"> * <span class="elsevierStyleItalic">Corresponding author</span>.<br></br> Maite Rivera Gorrin, <br></br> Nefrología, Hospital Ramón y Cajal, <br></br> IRYCIS, Madrid, España. <span class="elsevierStyleItalic"><br></br> E-mail:</span></p>" "pdfFichero" => "498v35n02a90412310pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec503481" "palabras" => array:4 [ 0 => "Diálisis peritoneal paliativa" 1 => "Cuidados paliativos renales" 2 => "Diálisis peritoneal" 3 => "Diálisis domiciliaria" ] ] ] "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec503482" "palabras" => array:4 [ 0 => "Palliative peritoneal dialysis" 1 => "Renal palliative care and organisation" 2 => "Peritoneal dialysis" 3 => "Home dialysis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"> Los pacientes en Diálisis peritoneal (DP) en situación terminal suelen ser transferidos a hemodiálisis ya que son incapaces de realizarse la técnica dialítica a consecuencia de que sus capacidades funcionales están disminuidas. Presentamos nuestra experiencia con 5 pacientes en DP con patología que amenazaba su vida a corto plazo, cuyo tratamiento fue compartido por las unidades de atención primaria y fueron mantenidos en una modalidad de DP adaptada a sus circunstancias a la que hemos denominado Diálisis Peritoneal Paliativa.</p>" ] "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"> Terminal-stage patients on peritoneal dialysis (PD) are often transferred to haemodialysis as they are unable to perform the dialysis technique themselves since their functional capacities are reduced. We present our experience with five patients on PD with a short-term life-threatening condition, whose treatment was shared by primary care units and who were treated with a PD modality adapted to their circumstances, which we call Palliative Peritoneal Dialysis.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl1" "etiqueta" => "Table" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "498v35n02-90412310fig1.jpg" "imagenAlto" => 470 "imagenAncho" => 2112 "imagenTamanyo" => 104272 ] ] ] ] ] "descripcion" => array:1 [ "en" => "I –" ] ] ] "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" => "Aproximación a los Cuidados Paliativos en las enfermedades avanzadas no malignas. An Med Intern. 2008;25:187-91. " "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Aproximación a los Cuidados Paliativos en las enfermedades avanzadas no malignas." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Navarro Sanz R" 1 => "López Almazán C." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "An Med Intern. " "fecha" => "2008" "volumen" => "25" "paginaInicial" => "187" "paginaFinal" => "91" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Specialist palliative care in non-malignant disease. Palliative Med. 1998;12:417-27. " "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Specialist palliative care in non-malignant disease." "idioma" => "it" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Addington-Hall J" 1 => "Fakhoury W" 2 => "McCarthy M." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Palliative Med. " "fecha" => "1998" "volumen" => "12" "paginaInicial" => "417" "paginaFinal" => "27" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Precisión de los criterios definitorios de pacientes con enfermedades médicas no neoplásicas en fase terminal. Proyecto PALIAR. Rev Esp Geriatr Gerontolol. 2010;45:203-12. " "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Precisión de los criterios definitorios de pacientes con enfermedades médicas no neoplásicas en fase terminal. Proyecto PALIAR." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Bernabeu-Wittel M" 1 => "Ruiz-Cantero A" 2 => "Murcia-Zaragoza J" 3 => "Hernández-Quiles C" 4 => "Barón-Franco B" 5 => "Ramos-Cantos C" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Esp Geriatr Gerontolol. " "fecha" => "2010" "volumen" => "45" "paginaInicial" => "203" "paginaFinal" => "12" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Cuidados de soporte renal y cuidados paliativos renales: revisión y propuesta en terapia renal sustitutiva. Nefrología 2012;32:20-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22294001" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Cuidados de soporte renal y cuidados paliativos renales: revisión y propuesta en terapia renal sustitutiva." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Leiva-Santos JP" 1 => "Sánchez-Hernández R." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Nefrología 2012" "volumen" => "32" "paginaInicial" => "20" "paginaFinal" => "7" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Cancer pain relief and palliative care. Technical Report Series 804. Geneva: Worl Health Organisation; 1990. " "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Cancer pain relief and palliative care." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "World Health Organisation." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Technical Report Series 804. " "fecha" => "Geneva" "volumen" => "Worl Health Organisation" "paginaInicial" => "1990" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Cuidado paliativo en el paciente con enfermedad renal crónica avanzado (grado 5) no susceptible de tratamiento dialítico Nefrologia. 2008;28 Suppl 3:129-36. " "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Cuidado paliativo en el paciente con enfermedad renal crónica avanzado (grado 5) no susceptible de tratamiento dialítico Nefrologia." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Tejedor A" 1 => "de las Cuevas Bou X." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "2008" "volumen" => "28 Suppl 3" "paginaInicial" => "129" "paginaFinal" => "36" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Experiencia de dos años. Nefrologia. 2014;34:611-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/25259816" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Experiencia de dos años." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Teruel JL" 1 => "Rexach L" 2 => "Burguera V" 3 => "Gomis A" 4 => "Rodríguez-Mendiola N" 5 => "Díaz A" 6 => "et al Programa de atención domiciliaria a pacientes con enfermedad renal crónica avanzada." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3265/Nefrologia.pre2014.Jun.12595" "Revista" => array:6 [ "tituloSerie" => "Nefrologia. " "fecha" => "2014" "volumen" => "34" "paginaInicial" => "611" "paginaFinal" => "6" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25259816" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Pathways to palliative care for patients with chronic kidney disease. J Ren Care. 2014;40:64-73. <a href="http://www.ncbi.nlm.nih.gov/pubmed/24438676" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Pathways to palliative care for patients with chronic kidney disease." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Bull R" 1 => "Youl L" 2 => "Robertson IK" 3 => "Mace R" 4 => "Challenor S" 5 => "Fassett RG." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jorc.12049" "Revista" => array:6 [ "tituloSerie" => "J Ren Care. " "fecha" => "2014" "volumen" => "40" "paginaInicial" => "64" "paginaFinal" => "73" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24438676" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Depression and suicidal ideation in patients who discontinue the life-support treatment of dialysis. Psychosom Med. 2002; 64:889-96. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12461194" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Depression and suicidal ideation in patients who discontinue the life-support treatment of dialysis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Cohen LM" 1 => "Dobscha SK" 2 => "Hails KC" 3 => "Pekow PS" 4 => "Chochinov HM." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Psychosom Med. " "fecha" => "2002" "volumen" => "64" "paginaInicial" => "889" "paginaFinal" => "96" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12461194" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Palliative dialysis: A change of perspective. J Clin Med Res. 2014;6:234-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/24883146" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Palliative dialysis: A change of perspective." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Romano TG" 1 => "Palomba H." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.14740/jocmr1773w" "Revista" => array:6 [ "tituloSerie" => "J Clin Med Res. " "fecha" => "2014" "volumen" => "6" "paginaInicial" => "234" "paginaFinal" => "8" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24883146" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Plan Integral de cuidados paliativos de la Comunidad de Madrid 2005-2008. Consejería de Sanidad y Consumo. Disponible en: http://www.madrid.org/cs/Satellite? blobcol=urldata&blobheader=application%2Fpdf&blobheadern ame1=Content-disposition&blobheadername2=cadena&blobh eadervalue1=filename%3DPlan+de+cuidados+paliativos.pdf& blobheadervalue2=language%3Des%26site%3DPortalSalud&bl obkey=id&blobtable=MungoBlobs&blobwhere=1220370009287 &ssbinary=true. " "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Plan Integral de cuidados paliativos de la Comunidad de Madrid 2005-2008. Consejería de Sanidad y Consumo. Disponible en: http://www.madrid." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Lamela M." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "tituloSerie" => "org/cs/Satellite? blobcol=urldata&blobheader=application%2Fpdf&blobheadern ame1=Content-disposition&blobheadername2=cadena&blobh eadervalue1=filename%3DPlan+de+cuidados+paliativos. " ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Programa de Atención Domiciliaria con Equipo de Soporte (ESAD). Instituto Nacional de Salud 1999. Disponible en: www.ingesa.msssi.gob.es/estadEstudios/ documPublica/.../atDomiciliaria.p.. " "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Programa de Atención Domiciliaria con Equipo de Soporte (ESAD). Instituto Nacional de Salud 1999. Disponible en: www.ingesa.msssi.gob.es/estadEstudios/ documPublica/.../atDomiciliaria.p." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Dodero de Solano J" 1 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => null ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Is assisted peritoneal dialysis associated with technique survival when competing events are considered? Clin J Am Soc Nephrol. 2012;7:612-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22344506" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Is assisted peritoneal dialysis associated with technique survival when competing events are considered? Clin J Am Soc Nephrol." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Lobbedez T" 1 => "Verger C" 2 => "Ryckelynck JP" 3 => "Fabre E" 4 => "Evans D." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "2012" "volumen" => "7" "paginaInicial" => "612" "paginaFinal" => "8" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib51" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Androgen glucuronides, instead of testosterone, as the new markers of androgenic activity in women." "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Androgen glucuronides, instead of testosterone, as the new markers of androgenic activity in women." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "BOE Ley" 1 => "Labrie F" 2 => "Bélanger A" 3 => "Bélanger P" 4 => "et-al." ] ] ] ] ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003500000002/v0_201504231604/X2013251415123104/v0_201504231605/en/main.assets" "Apartado" => array:4 [ "identificador" => "38708" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Originals" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003500000002/v0_201504231604/X2013251415123104/v0_201504231605/en/498v35n02a90412310pdf001.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251415123104?idApp=UINPBA000064" ]
Article information
ISSN: 20132514Original language: English
The statistics are updated each day
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 4 | 12 |
| 2024 October | 50 | 31 | 81 |
| 2024 September | 44 | 29 | 73 |
| 2024 August | 68 | 49 | 117 |
| 2024 July | 48 | 22 | 70 |
| 2024 June | 78 | 42 | 120 |
| 2024 May | 66 | 32 | 98 |
| 2024 April | 47 | 35 | 82 |
| 2024 March | 45 | 25 | 70 |
| 2024 February | 39 | 39 | 78 |
| 2024 January | 46 | 23 | 69 |
| 2023 December | 35 | 22 | 57 |
| 2023 November | 54 | 28 | 82 |
| 2023 October | 59 | 27 | 86 |
| 2023 September | 73 | 28 | 101 |
| 2023 August | 96 | 34 | 130 |
| 2023 July | 45 | 40 | 85 |
| 2023 June | 66 | 23 | 89 |
| 2023 May | 51 | 26 | 77 |
| 2023 April | 45 | 8 | 53 |
| 2023 March | 56 | 20 | 76 |
| 2023 February | 45 | 15 | 60 |
| 2023 January | 49 | 34 | 83 |
| 2022 December | 59 | 24 | 83 |
| 2022 November | 74 | 38 | 112 |
| 2022 October | 51 | 30 | 81 |
| 2022 September | 71 | 29 | 100 |
| 2022 August | 74 | 48 | 122 |
| 2022 July | 52 | 40 | 92 |
| 2022 June | 55 | 25 | 80 |
| 2022 May | 41 | 25 | 66 |
| 2022 April | 42 | 42 | 84 |
| 2022 March | 69 | 34 | 103 |
| 2022 February | 64 | 33 | 97 |
| 2022 January | 51 | 37 | 88 |
| 2021 December | 39 | 31 | 70 |
| 2021 November | 41 | 28 | 69 |
| 2021 October | 64 | 33 | 97 |
| 2021 September | 48 | 42 | 90 |
| 2021 August | 41 | 31 | 72 |
| 2021 July | 46 | 29 | 75 |
| 2021 June | 38 | 22 | 60 |
| 2021 May | 63 | 42 | 105 |
| 2021 April | 104 | 33 | 137 |
| 2021 March | 73 | 26 | 99 |
| 2021 February | 62 | 11 | 73 |
| 2021 January | 46 | 24 | 70 |
| 2020 December | 30 | 12 | 42 |
| 2020 November | 38 | 13 | 51 |
| 2020 October | 23 | 12 | 35 |
| 2020 September | 37 | 7 | 44 |
| 2020 August | 38 | 11 | 49 |
| 2020 July | 45 | 11 | 56 |
| 2020 June | 43 | 7 | 50 |
| 2020 May | 47 | 11 | 58 |
| 2020 April | 56 | 25 | 81 |
| 2020 March | 38 | 15 | 53 |
| 2020 February | 43 | 20 | 63 |
| 2020 January | 49 | 20 | 69 |
| 2019 December | 65 | 24 | 89 |
| 2019 November | 61 | 22 | 83 |
| 2019 October | 53 | 18 | 71 |
| 2019 September | 53 | 16 | 69 |
| 2019 August | 40 | 19 | 59 |
| 2019 July | 37 | 28 | 65 |
| 2019 June | 43 | 24 | 67 |
| 2019 May | 47 | 17 | 64 |
| 2019 April | 99 | 19 | 118 |
| 2019 March | 39 | 15 | 54 |
| 2019 February | 14 | 14 | 28 |
| 2019 January | 31 | 20 | 51 |
| 2018 December | 85 | 39 | 124 |
| 2018 November | 99 | 15 | 114 |
| 2018 October | 83 | 20 | 103 |
| 2018 September | 64 | 14 | 78 |
| 2018 August | 49 | 16 | 65 |
| 2018 July | 58 | 15 | 73 |
| 2018 June | 44 | 14 | 58 |
| 2018 May | 56 | 13 | 69 |
| 2018 April | 59 | 8 | 67 |
| 2018 March | 28 | 7 | 35 |
| 2018 February | 48 | 5 | 53 |
| 2018 January | 35 | 10 | 45 |
| 2017 December | 40 | 5 | 45 |
| 2017 November | 53 | 14 | 67 |
| 2017 October | 34 | 5 | 39 |
| 2017 September | 49 | 4 | 53 |
| 2017 August | 39 | 8 | 47 |
| 2017 July | 32 | 11 | 43 |
| 2017 June | 42 | 9 | 51 |
| 2017 May | 50 | 10 | 60 |
| 2017 April | 49 | 4 | 53 |
| 2017 March | 44 | 6 | 50 |
| 2017 February | 41 | 5 | 46 |
| 2017 January | 24 | 10 | 34 |
| 2016 December | 116 | 22 | 138 |
| 2016 November | 109 | 10 | 119 |
| 2016 October | 122 | 13 | 135 |
| 2016 September | 150 | 8 | 158 |
| 2016 August | 214 | 0 | 214 |
| 2016 July | 230 | 0 | 230 |
| 2016 June | 190 | 0 | 190 |
| 2016 May | 145 | 0 | 145 |
| 2016 April | 127 | 0 | 127 |
| 2016 March | 123 | 0 | 123 |
| 2016 February | 217 | 0 | 217 |
| 2016 January | 169 | 0 | 169 |
| 2015 December | 173 | 1 | 174 |
| 2015 November | 135 | 1 | 136 |
| 2015 October | 147 | 5 | 152 |
| 2015 September | 223 | 10 | 233 |
| 2015 August | 174 | 5 | 179 |
| 2015 July | 234 | 0 | 234 |
| 2015 June | 139 | 0 | 139 |
| 2015 May | 319 | 25 | 344 |
| 2015 April | 49 | 0 | 49 |
Show all
