Letter to the Editor
Pulmonary-renal syndrome as a clinical expression of multiple myeloma
Síndrome pulmón-riñón como una expresión clínica de mieloma múltiple
Joana Gameiro
, Sofia Jorge, José António Lopes, António Gomes da Costa
Autor para correspondencia
Service of Nephrology and Renal Transplantation, Department of Medicine Centro Hospitalar Lisboa Norte, EPE Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
Leído
9905
Vecesse ha leído el artículo
3171
Total PDF
6734
Total HTML
Compartir estadísticas
array:24 [ "pii" => "S0211699516301941" "issn" => "02116995" "doi" => "10.1016/j.nefro.2016.10.020" "estado" => "S300" "fechaPublicacion" => "2017-07-01" "aid" => "300" "copyright" => "Sociedad Española de Nefrología" "copyrightAnyo" => "2016" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Nefrologia. 2017;37:445-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4382 "formatos" => array:3 [ "EPUB" => 483 "HTML" => 2990 "PDF" => 909 ] ] "itemSiguiente" => array:20 [ "pii" => "S0211699516301904" "issn" => "02116995" "doi" => "10.1016/j.nefro.2016.10.016" "estado" => "S300" "fechaPublicacion" => "2017-07-01" "aid" => "296" "copyright" => "Sociedad Española de Nefrología" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Nefrologia. 2017;37:447-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 19211 "formatos" => array:3 [ "EPUB" => 389 "HTML" => 17508 "PDF" => 1314 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Director</span>" "titulo" => "Síndrome nefrótico, anticuerpos anti-PLA2R y glomerulonefritis membranosa. ¿Es necesaria la biopsia renal?" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "447" "paginaFinal" => "449" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Nephrotic syndrome, anti-PLA2R and membranous glomerulonephritis. Is the renal biopsy necessary?" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1650 "Ancho" => 1650 "Tamanyo" => 586728 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Depósitos subendoteliales (*) y subepiteliales (flechas). ME<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1.400.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Raúl Alvarado, Ricardo Enríquez, Tania Muci, Ana Esther Sirvent, Valle Lozano Vera, Isabel Millán, Cesar González" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Raúl" "apellidos" => "Alvarado" ] 1 => array:2 [ "nombre" => "Ricardo" "apellidos" => "Enríquez" ] 2 => array:2 [ "nombre" => "Tania" "apellidos" => "Muci" ] 3 => array:2 [ "nombre" => "Ana Esther" "apellidos" => "Sirvent" ] 4 => array:2 [ "nombre" => "Valle" "apellidos" => "Lozano Vera" ] 5 => array:2 [ "nombre" => "Isabel" "apellidos" => "Millán" ] 6 => array:2 [ "nombre" => "Cesar" "apellidos" => "González" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2013251417301232" "doi" => "10.1016/j.nefroe.2016.10.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251417301232?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699516301904?idApp=UINPBA000064" "url" => "/02116995/0000003700000004/v1_201707260022/S0211699516301904/v1_201707260022/es/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0211699517300474" "issn" => "02116995" "doi" => "10.1016/j.nefro.2017.01.009" "estado" => "S300" "fechaPublicacion" => "2017-07-01" "aid" => "343" "copyright" => "Sociedad Española de Nefrología" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Nefrologia. 2017;37:443-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4565 "formatos" => array:3 [ "EPUB" => 587 "HTML" => 3074 "PDF" => 904 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Transient hyperphosphatasemia in a child with nephrolithiasis and severe prematurity" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "443" "paginaFinal" => "444" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hiperfosfatasemia transitoria en un niño con nefrolitiasis y antecedentes de prematuridad severa" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Stepan Kutilek, Daniela Formanova, Marian Senkerik, Jan Langer, Daniela Markova, Sylva Skalova" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Stepan" "apellidos" => "Kutilek" ] 1 => array:2 [ "nombre" => "Daniela" "apellidos" => "Formanova" ] 2 => array:2 [ "nombre" => "Marian" "apellidos" => "Senkerik" ] 3 => array:2 [ "nombre" => "Jan" "apellidos" => "Langer" ] 4 => array:2 [ "nombre" => "Daniela" "apellidos" => "Markova" ] 5 => array:2 [ "nombre" => "Sylva" "apellidos" => "Skalova" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699517300474?idApp=UINPBA000064" "url" => "/02116995/0000003700000004/v1_201707260022/S0211699517300474/v1_201707260022/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Pulmonary-renal syndrome as a clinical expression of multiple myeloma" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">Dear Editor</span>:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "445" "paginaFinal" => "446" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Joana Gameiro, Sofia Jorge, José António Lopes, António Gomes da Costa" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Joana" "apellidos" => "Gameiro" "email" => array:1 [ 0 => "joana.estrelagameiro@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Sofia" "apellidos" => "Jorge" ] 2 => array:2 [ "nombre" => "José António" "apellidos" => "Lopes" ] 3 => array:2 [ "nombre" => "António Gomes" "apellidos" => "da Costa" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Service of Nephrology and Renal Transplantation, Department of Medicine Centro Hospitalar Lisboa Norte, EPE Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome pulmón-riñón como una expresión clínica de mieloma múltiple" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 697 "Ancho" => 960 "Tamanyo" => 57298 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray revealing bilateral diffuse opacity, predominantly in the right hemithorax.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary-renal syndrome (PRS) is defined as pulmonary and renal failure, and is caused by immunological and non-immunological diseases. Although the most frequent immunological causes for PRS are small vessel vasculitis and lupus,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> other causes have to be considered.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Here, we present the case of a 35-year-old, black, previously healthy woman referred from Cape Verde to our Department to investigate renal failure (creatinemia 2.5<span class="elsevierStyleHsp" style=""></span>mg/dL), hypertension, lower limbs edema, foamy urine, anemia (Hb 11.5<span class="elsevierStyleHsp" style=""></span>mg/dL), and bilateral arthralgias developing within the last 6 months. She had no family history of renal disease neither respiratory, neurologic or gastrointestinal symptoms nor alopecia, rash, oral ulcers, photosensitivity, hematuria or recent drug use. At admission, she was polypneic, hypertensive, aeodematous, oligoanuric, presented bilateral fine pulmonary crackles, and bilateral erythematous lesions in thighs. Laboratory revealed anemia (Hb 7.1<span class="elsevierStyleHsp" style=""></span>g/dL), leukocytosis with neutrophilia (16.670/mm3; 91.9%), elevated C-reactive protein (12.2<span class="elsevierStyleHsp" style=""></span>mg/dL), elevated erythrocyte sedimentation rate (70<span class="elsevierStyleHsp" style=""></span>mm 1st h), renal insufficiency (uremia 247<span class="elsevierStyleHsp" style=""></span>mg/dL, creatininemia 7.5<span class="elsevierStyleHsp" style=""></span>mg/dL), and of NT pro-BNP (>105<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>pg/mL). Blood gas test showed severe hypoxemia. Urinalysis showed haematuria (200/mm3) and proteinuria 300<span class="elsevierStyleHsp" style=""></span>mg/dL, without casts. Chest X-ray revealed bilateral diffuse opacities (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and chest CT suggested pulmonary hemorrhage. Ultrasonogram showed normal sized kidneys with increased echogenicity. She required mechanical ventilation and hemodialysis. Bronchofibroscopy revealed alveolar hemorrhage, and plasmapheresis was initiated.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Complementary investigation showed nephrotic range proteinuria (4.7<span class="elsevierStyleHsp" style=""></span>g/24<span class="elsevierStyleHsp" style=""></span>h). Serum protein electrophoresis showed an alpha2 spike and hypogamaglobulinemia. Serum complement was normal and serology for lupus, vasculitis and cryoglobulinemia, as well as for human immunodeficiency virus, hepatitis B and C infections were negative. Echocardiogram revealed a type II diastolic dysfunction. A renal biopsy was performed and revealed nodular glomerulosclerosis. Immunofluorescence revealed linear staining for kappa light chains along the tubular basement membrane and also in the glomerulus, allowing the diagnosis of light chain deposits disease (LCDD) (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>). Serum immunofixation revealed a kappa light chain band, and urine immunofixation revealed Bence-Jones kappa. Bone marrow biopsy and aspirate showed normocellular marrow with 10% monoclonal plasmocytosis. Therefore, multiple myeloma was diagnosed. She received chemotherapy and an autologous hematopoietic cell transplant, achieving maintained complete hematological response. At one-year of follow-up, she remains dialysis-dependent.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The initial presentation led us to consider an immunological cause for the pulmonary renal syndrome, despite the negative immunological results, which might occur in 10–20% of the PRS of immunological origin. The unexpected nodular glomerulosclerosis on the kidney biopsy led us to further investigate an hematological disease, because together with diabetes mellitus and smoking, light or heavy chain deposits disease is one of the main causes of nodular glomerulosclerosis. The investigation of the hematological disease was consistent with a diagnosis of multiple myeloma, according to the International Myeloma Working Group criteria.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">LCDD is a rare renal manifestation of plasma cell disorders.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> LCDD is a systemic disease with renal, cardiac, pulmonary, hepatic and gastrointestinal involvement.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3–5</span></a> Renal involvement is the most frequent and manifests as nephrotic syndrome and renal insufficiency, typically rapidly progressive. Renal biopsy typically reveals nodular glomerulosclerosis and thickening of the tubular basement membrane. In 80% of the cases it is characterized by the deposition of kappa light chains along the glomerular capillaries, nodules and the tubular basement membrane. Electron microscopy reveals granular deposits.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4,6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Although we cannot conclude on the cause of the pulmonary hemorrhage, because of the lack of pulmonary biopsy, we speculate on pulmonary tissue LC deposition, as this seems to be a case of systemic LC deposition: kidney, lung, heart, skin and articulations. This case highlights that LCDD should be kept in mind in the differential diagnosis of PRS.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 697 "Ancho" => 960 "Tamanyo" => 57298 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray revealing bilateral diffuse opacity, predominantly in the right hemithorax.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 721 "Ancho" => 960 "Tamanyo" => 155067 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Immunofluorescence for κ-light chain – diffuse linear staining of the tubular basement membranes.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 675 "Ancho" => 900 "Tamanyo" => 149286 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Immunofluorescence for κ-light chain reveals diffuse linear staining of the glomerular basement membranes.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary-renal syndromes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G.G. Brusselle" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1179/acb.2007.016" "Revista" => array:7 [ "tituloSerie" => "Acta Clin Belg" "fecha" => "2007" "volumen" => "62" "paginaInicial" => "88" "paginaFinal" => "96" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17547289" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1201971211001846" "estado" => "S300" "issn" => "12019712" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V. Rajkumar" 1 => "M. Dimopoulos" 2 => "A. Palumbo" 3 => "J. Blade" 4 => "G. Merlini" 5 => "M.V. Mateos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1474-4422(16)00115-0" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2014" "volumen" => "15" "paginaInicial" => "538" "paginaFinal" => "548" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27017470" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multiple myeloma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K. Korbet" 1 => "M. Schwartz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1681/ASN.2006020139" "Revista" => array:6 [ "tituloSerie" => "JASN" "fecha" => "2006" "volumen" => "17" "paginaInicial" => "2533" "paginaFinal" => "2545" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16885408" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Renal monoclonal immunoglobulin deposition disease: the disease spectrum" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Lin" 1 => "G.S. Markowitz" 2 => "A.M. Valeri" 3 => "N. Kambham" 4 => "W.H. Sherman" 5 => "G.B. Appel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Soc Nephrol" "fecha" => "2001" "volumen" => "12" "paginaInicial" => "1482" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11423577" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Light chain deposit disease: a frequent cause of diagnostic difficulty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Hall" 1 => "D. Peat" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Nephrol Dial Transpl" "fecha" => "2001" "volumen" => "16" "paginaInicial" => "1939" "paginaFinal" => "1941" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Light chain deposition disease involving the airways: diagnosis by fibreoptic bronchoscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Colombat" 1 => "V. Gounant" 2 => "H. Mal" 3 => "P. Callard" 4 => "B. Milleron" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00134406" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2007" "volumen" => "29" "paginaInicial" => "1057" "paginaFinal" => "1060" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17470625" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack291662" "titulo" => "Acknowledgements" "texto" => "<p id="par0035" class="elsevierStylePara elsevierViewall">The authors would like to acknowledge Helena Viana, MD and Fernanda Carvalho, MD, who were responsible for the kidney biopsy results and supplied the images.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/02116995/0000003700000004/v1_201707260022/S0211699516301941/v1_201707260022/en/main.assets" "Apartado" => array:4 [ "identificador" => "48186" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Cartas al Director" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/02116995/0000003700000004/v1_201707260022/S0211699516301941/v1_201707260022/en/main.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699516301941?idApp=UINPBA000064" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 10 | 6 | 16 |
| 2024 Octubre | 51 | 43 | 94 |
| 2024 Septiembre | 65 | 35 | 100 |
| 2024 Agosto | 72 | 67 | 139 |
| 2024 Julio | 46 | 25 | 71 |
| 2024 Junio | 64 | 47 | 111 |
| 2024 Mayo | 79 | 35 | 114 |
| 2024 Abril | 58 | 40 | 98 |
| 2024 Marzo | 48 | 33 | 81 |
| 2024 Febrero | 36 | 35 | 71 |
| 2024 Enero | 56 | 20 | 76 |
| 2023 Diciembre | 37 | 30 | 67 |
| 2023 Noviembre | 72 | 29 | 101 |
| 2023 Octubre | 51 | 36 | 87 |
| 2023 Septiembre | 39 | 27 | 66 |
| 2023 Agosto | 39 | 30 | 69 |
| 2023 Julio | 55 | 24 | 79 |
| 2023 Junio | 57 | 21 | 78 |
| 2023 Mayo | 74 | 29 | 103 |
| 2023 Abril | 46 | 26 | 72 |
| 2023 Marzo | 73 | 26 | 99 |
| 2023 Febrero | 54 | 29 | 83 |
| 2023 Enero | 50 | 36 | 86 |
| 2022 Diciembre | 89 | 49 | 138 |
| 2022 Noviembre | 77 | 56 | 133 |
| 2022 Octubre | 70 | 80 | 150 |
| 2022 Septiembre | 59 | 42 | 101 |
| 2022 Agosto | 43 | 47 | 90 |
| 2022 Julio | 53 | 63 | 116 |
| 2022 Junio | 84 | 45 | 129 |
| 2022 Mayo | 71 | 39 | 110 |
| 2022 Abril | 71 | 69 | 140 |
| 2022 Marzo | 68 | 60 | 128 |
| 2022 Febrero | 39 | 46 | 85 |
| 2022 Enero | 49 | 41 | 90 |
| 2021 Diciembre | 48 | 54 | 102 |
| 2021 Noviembre | 48 | 49 | 97 |
| 2021 Octubre | 72 | 47 | 119 |
| 2021 Septiembre | 58 | 47 | 105 |
| 2021 Agosto | 79 | 54 | 133 |
| 2021 Julio | 81 | 33 | 114 |
| 2021 Junio | 82 | 39 | 121 |
| 2021 Mayo | 100 | 69 | 169 |
| 2021 Abril | 204 | 104 | 308 |
| 2021 Marzo | 114 | 32 | 146 |
| 2021 Febrero | 99 | 48 | 147 |
| 2021 Enero | 83 | 32 | 115 |
| 2020 Diciembre | 50 | 25 | 75 |
| 2020 Noviembre | 74 | 24 | 98 |
| 2020 Octubre | 45 | 31 | 76 |
| 2020 Septiembre | 52 | 33 | 85 |
| 2020 Agosto | 55 | 33 | 88 |
| 2020 Julio | 69 | 23 | 92 |
| 2020 Junio | 103 | 26 | 129 |
| 2020 Mayo | 80 | 32 | 112 |
| 2020 Abril | 56 | 22 | 78 |
| 2020 Marzo | 66 | 27 | 93 |
| 2020 Febrero | 51 | 33 | 84 |
| 2020 Enero | 73 | 28 | 101 |
| 2019 Diciembre | 60 | 34 | 94 |
| 2019 Noviembre | 49 | 32 | 81 |
| 2019 Octubre | 27 | 23 | 50 |
| 2019 Septiembre | 67 | 24 | 91 |
| 2019 Agosto | 43 | 27 | 70 |
| 2019 Julio | 42 | 22 | 64 |
| 2019 Junio | 36 | 34 | 70 |
| 2019 Mayo | 24 | 35 | 59 |
| 2019 Abril | 89 | 51 | 140 |
| 2019 Marzo | 69 | 24 | 93 |
| 2019 Febrero | 42 | 27 | 69 |
| 2019 Enero | 38 | 28 | 66 |
| 2018 Diciembre | 114 | 57 | 171 |
| 2018 Noviembre | 214 | 49 | 263 |
| 2018 Octubre | 123 | 24 | 147 |
| 2018 Septiembre | 94 | 19 | 113 |
| 2018 Agosto | 82 | 26 | 108 |
| 2018 Julio | 59 | 24 | 83 |
| 2018 Junio | 77 | 24 | 101 |
| 2018 Mayo | 85 | 21 | 106 |
| 2018 Abril | 86 | 10 | 96 |
| 2018 Marzo | 114 | 15 | 129 |
| 2018 Febrero | 82 | 8 | 90 |
| 2018 Enero | 76 | 11 | 87 |
| 2017 Diciembre | 89 | 18 | 107 |
| 2017 Noviembre | 69 | 18 | 87 |
| 2017 Octubre | 69 | 12 | 81 |
| 2017 Septiembre | 115 | 23 | 138 |
| 2017 Agosto | 147 | 22 | 169 |
| 2017 Julio | 95 | 14 | 109 |
| 2017 Junio | 77 | 18 | 95 |
| 2017 Mayo | 87 | 7 | 94 |
| 2017 Abril | 89 | 25 | 114 |
| 2017 Marzo | 105 | 12 | 117 |
| 2017 Febrero | 70 | 18 | 88 |
| 2017 Enero | 83 | 24 | 107 |
Mostrar todo
