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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La calcifilaxis&#44; tambi&#233;n denominada arteriolopat&#237;a ur&#233;mica calcificante &#40;CUA&#41;&#44; es una entidad poco com&#250;n&#44; aunque grave y con elevada mortalidad<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">La CUA se desarrolla en la dermis y el tejido celular subcut&#225;neo&#44; generalmente en &#225;reas de adiposidad&#46; Se caracteriza por lesiones cut&#225;neas pruriginosas o dolorosas&#44; n&#243;dulos viol&#225;ceos&#44; &#250;lceras y escaras que evolucionan a necrosis isqu&#233;mica de la piel<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a>&#46; La histolog&#237;a puede revelar calcificaci&#243;n de la media y proliferaci&#243;n de la &#237;ntima en los peque&#241;os vasos&#44; con o sin fibrosis endovascular&#44; calcificaci&#243;n extravascular y vasooclusi&#243;n tromb&#243;tica<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Aparece con mayor frecuencia en pacientes con enfermedad renal cr&#243;nica avanzada en di&#225;lisis o en pacientes trasplantados renales&#59; sin embargo&#44; se han descrito casos de calcifilaxis en sujetos con funci&#243;n renal normal&#44; recogidas en las clasificaciones como las CUA &#171;no renales&#187;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La patogenia de esta vasculopat&#237;a es compleja y no bien conocida&#44; aunque se defienden varios mecanismos para su desarrollo&#46; A los factores tradicionales del metabolismo mineral-&#243;seo &#40;hiperparatiroidismo&#44; hipercalcemia e hiperfostatemia&#41; y su elevada prevalencia en pacientes con bajo remodelado &#243;seo<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">6&#44;7</span></a>&#44; se han ido sumando a lo largo de estos a&#241;os otros factores de riesgo&#58; sexo femenino&#44; diabetes&#44; obesidad&#44; trauma local&#44; hipoalbuminemia&#44; estados de hipercoagulabilidad y exposici&#243;n a vitamina D activa&#44; quelantes c&#225;lcicos&#44; corticoesteroides y antagonistas de la vitamina K<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">8&#8211;11</span></a>&#46; Esta amalgama de factores ha generado un nuevo fenotipo de paciente que presenta lesiones de calcifilaxis alejado de la imagen cl&#225;sica de esta entidad&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A pesar del mal pron&#243;stico de esta entidad&#44; el empleo del tratamiento multidisciplinar en los &#250;ltimos a&#241;os &#40;tratamiento del dolor y de las sobreinfecciones&#44; intensificaci&#243;n de hemodi&#225;lisis&#44; bifosfonatos&#44; tiosulfato s&#243;dico&#44; quelantes no c&#225;lcicos&#44; cinacalcet&#44; vitamina K y pentoxifilina&#41; ha conseguido que la supervivencia haya aumentado en estos pacientes<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">12&#8211;14</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">El objetivo de este estudio fue analizar la epidemiolog&#237;a actual de la calcifilaxis en el &#225;rea del Hospital 12 de Octubre&#44; los factores de riesgo para su desarrollo&#44; as&#237; como la evoluci&#243;n de los pacientes en funci&#243;n del tratamiento recibido&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><p id="par0035" class="elsevierStylePara elsevierViewall">Se realiz&#243; un estudio observacional y retrospectivo de una serie de pacientes diagnosticados de calcifilaxis entre diciembre de 1999 y diciembre de 2015 en el Hospital Universitario 12 de Octubre de Madrid&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se registraron los siguientes datos&#58; sexo&#44; edad&#44; &#237;ndice de comorbilidad de Charlson&#44; situaci&#243;n al diagn&#243;stico &#40;pacientes en hemodi&#225;lisis&#44; con trasplante renal normofuncionante o sin enfermedad renal&#41;&#44; etiolog&#237;a de la insuficiencia renal cr&#243;nica &#40;IRC&#41;&#44; tiempo de tratamiento renal sustitutivo &#40;tanto hemodi&#225;lisis como trasplante renal&#41;&#44; factores de riesgo cardiovascular &#40;hipertensi&#243;n arterial&#44; diabetes mellitus&#44; obesidad&#41;&#44; s&#237;ndrome de isquemia cr&#243;nica&#44; enfermedad arterial coronaria&#44; fibrilaci&#243;n auricular&#44; presencia de virus de hepatitis C&#44; par&#225;metros del metabolismo &#243;seo &#40;PTH&#44; calcio&#44; f&#243;sforo&#44; y fosfatasa alcalina&#41;&#44; alb&#250;mina s&#233;rica&#44; tipo de afectaci&#243;n &#40;distal o proximal&#41;&#44; tratamiento habitual de los pacientes antes del desarrollo de la calcifilaxis&#44; diagn&#243;stico de calcifilaxis &#40;mediante la cl&#237;nica&#44; la realizaci&#243;n de biopsia o ambas&#41;&#44; estrategias terap&#233;uticas &#40;tratamiento convencional&#8211;intensificaci&#243;n de la hemodi&#225;lisis&#44; medidas de soporte o amputaci&#243;n del miembro afecto&#8211;vs<span class="elsevierStyleItalic">&#46;</span> tratamiento <span class="elsevierStyleItalic">multitarget</span>&#8211;tratamiento convencional junto con tiosulfato s&#243;dico&#44; bifosfonatos&#44; cinacalcet&#44; quelantes no c&#225;lcicos o pentoxiflina&#41;&#44; evoluci&#243;n de las lesiones&#44; seguimiento&#44; supervivencia&#44; muerte en relaci&#243;n con la calcifilaxis &#40;para establecer esta conexi&#243;n&#44; el punto de corte se estableci&#243; en los primeros 6 meses desde el desarrollo de la calcifilaxis&#41; y otras causas de muerte&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">En el an&#225;lisis estad&#237;stico&#44; las variables cuantitativas se expresaron como media y desviaci&#243;n est&#225;ndar y rango&#44; mientras que las variables cualitativas se expresaron como n&#250;mero absoluto y porcentaje&#46; Para la comparaci&#243;n de variables cuantitativas se emple&#243; el test estad&#237;stico t de Student y para las variables cualitativas se utiliz&#243; el test de la Chi-cuadrado&#46; La evoluci&#243;n desde el diagn&#243;stico hasta el fallecimiento fue descrita mediante el m&#233;todo de Kaplan-Meier&#46; Se consideraron como estad&#237;sticamente significativos aquellos valores con una p&#160;&#60;&#160;0&#44;05&#46; El an&#225;lisis estad&#237;stico se realiz&#243; mediante el programa SPSS &#40;versi&#243;n 20 para Windows&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Datos epidemiol&#243;gicos generales</span><p id="par0050" class="elsevierStylePara elsevierViewall">Se identificaron 28 pacientes con diagn&#243;stico de calcifilaxis&#44; de los cuales el 53&#44;6&#37; eran mujeres&#44; todos de raza cauc&#225;sica&#46; La edad media fue de 67&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;8 a&#241;os &#40;38-88&#41;&#46; La <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> muestra la distribuci&#243;n de casos por a&#241;o&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Al diagn&#243;stico&#44; el 53&#44;6&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41; recib&#237;a terapia sustitutiva mediante hemodi&#225;lisis &#40;HD&#41;&#44; el 25&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#41; era portador de un trasplante renal normofuncionante &#40;Tx&#41; y un 21&#44;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41; no presentaba enfermedad renal&#58; fueron etiquetados como sujetos con &#171;funci&#243;n renal normal&#187; &#40;FRN&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Las causas m&#225;s frecuentes de IRC &#40;tanto en los pacientes en HD como en los que hab&#237;an recibido trasplante renal&#41; fueron nefroangioesclerosis &#40;22&#44;7&#37;&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;&#44; nefropat&#237;a diab&#233;tica &#40;18&#44;2&#37;&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41; y enfermedad glomerular &#40;18&#44;2&#37;&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">El tiempo medio de tratamiento renal sustitutivo &#40;incluyendo HD y trasplante renal&#41; fue de 133&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>102&#44;8 &#40;10-324&#41; meses&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Se recogieron diferentes variables respecto a la comorbilidad y al tratamiento habitual de los pacientes y las diferencias respecto a los 3<span class="elsevierStyleHsp" style=""></span>tipos de tratamiento &#40;HD&#44; TR&#44; FRN&#41; antes de que se desarrollasen las lesiones por calcifilaxis &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Es importante destacar que no hubo significaci&#243;n estad&#237;stica entre las distintas variables y el desarrollo de la calcifilaxis&#44; salvo con los esteroides &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; La toma de anticoagulantes en los pacientes que no estaban en hemodi&#225;lisis &#40;trasplantados renales y pacientes con funci&#243;n renal normal&#41; presentan una tendencia pr&#243;xima a la significaci&#243;n estad&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;07&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Formas de presentaci&#243;n</span><p id="par0075" class="elsevierStylePara elsevierViewall">En el 82&#44;1&#37; de los casos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>23&#41; las lesiones tuvieron una distribuci&#243;n distal&#44; con afectaci&#243;n proximal el 17&#44;9&#37; restante &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">El diagn&#243;stico se bas&#243; en la sospecha cl&#237;nica junto con realizaci&#243;n de biopsia en 22 pacientes &#40;78&#44;6&#37;&#41;&#44; que &#250;nicamente fue cl&#237;nico en los 6 restantes &#40;21&#44;4&#37;&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a> se muestran algunas im&#225;genes representativas de las lesiones por calcifilaxis&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Par&#225;metros bioqu&#237;micos</span><p id="par0085" class="elsevierStylePara elsevierViewall">Se recogieron valores del metabolismo &#243;seo y alb&#250;mina s&#233;rica al diagn&#243;stico&#44; los cuales quedan reflejados en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46; Cabe destacar que no hubo diferencias significativas entre grupos&#44; excepto al comparar los valores de PTH entre pacientes en HD vs&#46; FRN &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41; y entre pacientes trasplantados vs&#46; FRN &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;&#46; En cuanto a la albuminemia&#44; en pacientes con IRC tambi&#233;n se observaron cifras por debajo del l&#237;mite de la normalidad&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Tratamiento</span><p id="par0090" class="elsevierStylePara elsevierViewall">En cuanto a las opciones terap&#233;uticas&#44; el 71&#44;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&#41; recibi&#243; un tratamiento combinado &#40;<span class="elsevierStyleItalic">multitarget</span>&#41;&#44; mientras que el 28&#44;6&#37; restante &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41; recibi&#243; tratamiento convencional&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Centr&#225;ndonos en el tratamiento combinado&#44; en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> se exponen todas las opciones terap&#233;uticas que se emplearon &#40;por grupos y en total&#41;&#46; Cabe destacar que respecto al tratamiento <span class="elsevierStyleItalic">multitarge</span>t se observaron diferencias significativas entre los distintos grupos&#46; Las sesiones de hemodi&#225;lisis se realizaron con ba&#241;os bajos en calcio&#59; los bifosfonatos empleados fueron ibandronato o alendronato y los quelantes no c&#225;lcicos fueron sevel&#225;mero o lantano&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Evoluci&#243;n y mortalidad</span><p id="par0100" class="elsevierStylePara elsevierViewall">El seguimiento de los pacientes se realiz&#243; durante una media de 26&#44;29 meses &#40;1-192&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">La resoluci&#243;n de las lesiones se produjo en el 60&#44;7&#37; de los pacientes &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#41;&#44; mientras que en el 39&#44;3&#37; restante &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41; estas no desaparecieron&#46; Respecto a la mortalidad&#44; el 39&#44;3&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41; falleci&#243; por la propia calcifilaxis&#58; el 40&#37; de los pacientes en HD &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#47;15&#41; y el 71&#44;4&#37; de los trasplantados &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#47;7&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">La principal causa de mortalidad fue infecciosa &#40;64&#37;&#41;&#44; seguida de la cardiovascular &#40;27&#44;2&#37;&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Se realiz&#243; un an&#225;lisis de los diferentes factores de riesgo en relaci&#243;n con la mortalidad relacionada con la calcifilaxis &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#59; fueron estad&#237;sticamente significativas la presencia de IRC &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41; y la distribuci&#243;n central de las lesiones &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Se analizaron las diferencias de las principales variables del metabolismo mineral-&#243;seo en funci&#243;n de la presencia o no de IRC y de la mortalidad relacionada con la calcifilaxis &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#44; y se encontr&#243; una significaci&#243;n estad&#237;stica entre esta &#250;ltima&#44; el hiperparatiroidismo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41; y la hiperfosforemia &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Por otra parte&#44; se analiz&#243; la supervivencia en relaci&#243;n con la muerte por calcifilaxis en funci&#243;n de los grupos diagn&#243;sticos &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46; Al cabo de 12 meses&#44; el 56&#37; de los pacientes en HD&#44; el 23&#37; de los trasplantados renales y el 100&#37; de los pacientes con FRN permanec&#237;an vivos&#46; Al cabo de 24 meses&#44; el 56&#37; de los pacientes en HD&#44; el 100&#37; de los pacientes con FRN y el 23&#37; de los trasplantados renales permanec&#237;an vivos&#44; respectivamente &#40;log rank 6&#44;88&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;032&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0130" class="elsevierStylePara elsevierViewall">La calcifilaxis es una entidad poco frecuente generalmente asociada a IRC&#44; con una prevalencia entre el 1 y el 4&#37; en los pacientes en di&#225;lisis<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;15</span></a>&#46; En nuestra serie&#44; fueron diagnosticados 28 pacientes en un periodo de 16 a&#241;os&#44; lo cual invita a pensar que&#44; a pesar de su baja incidencia&#44; debe tenerse en cuenta en el diagn&#243;stico diferencial&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">En contra de lo esperable&#44; el perfil del paciente ha cambiado&#58; la calcifilaxis no es exclusiva de sujetos con IRC en di&#225;lisis&#44; sino que tambi&#233;n se da en trasplantados renales con funci&#243;n normal del injerto e incluso en pacientes sin enfermedad renal<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">16&#44;17</span></a> &#40;en nuestro estudio&#44; hasta el 21&#44;4&#37; presentaba funci&#243;n renal normal&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">En general es m&#225;s prevalente en mujeres obesas<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a>&#44; como se pudo apreciar en nuestra serie de casos&#46; La mayor&#237;a de los pacientes presentaba factores de riesgo cardiovascular &#40;hipertensi&#243;n arterial&#44; diabetes mellitus&#44; obesidad&#41;&#44; enfermedad coronaria y s&#237;ndrome de isquemia cr&#243;nica&#44; lo cual conduce a la hipoperfusi&#243;n de los tejidos<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">8&#44;10&#44;18</span></a>&#46; Estos factores est&#225;n desplazando a los protagonistas cl&#225;sicos de la calcifilaxis&#44; como son los atribuidos al metabolismo mineral-&#243;seo<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">19&#44;20</span></a>&#46; Un ejemplo de lo expuesto anteriormente lo encontramos en nuestra serie&#44; en la que solo se evidenci&#243; hiperparatiroidismo&#44; hiperfosforemia y calcio normal en los pacientes con IRC&#44; Sin embargo&#44; toman protagonismo otros factores de riesgo&#44; como pueden ser los esteroides &#40;en el grupo de trasplantados renales&#44; el 100&#37; consum&#237;a dichos f&#225;rmacos&#41; como causantes de la aparici&#243;n de esta entidad&#46; Este hallazgo es de suma importancia y de gran inter&#233;s cl&#237;nico para reconsiderar la indicaci&#243;n de estos tratamientos en pacientes de alto riesgo&#46; Con todas estas apreciaciones&#44; podemos dibujar un nuevo fenotipo del paciente con calcifilaxis al que debemos prestar especial inter&#233;s&#58; un sujeto con insuficiencia renal &#40;paciente en di&#225;lisis o trasplantado renal&#41; con importante comorbilidad&#44; entre la que destaca un acusado perfil cardiovascular &#40;hipertenso&#44; diab&#233;tico y con enfermedad vascular perif&#233;rica&#41;&#44; en tratamiento con anticoagulantes orales y con hipoalbuminemia debido a inflamaci&#243;n cr&#243;nica o malnutrici&#243;n<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#44;8</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">En todos los casos&#44; las lesiones cut&#225;neas presentaron evoluci&#243;n t&#243;rpida y fueron muy sugestivas de calcifilaxis&#44; que se pudo comprobar con biopsia en el 78&#44;6&#37; de los casos&#44; Incluso&#44; en algunos pacientes&#44; se realizaron radiograf&#237;as en las que se pudo apreciar la calcificaci&#243;n de los vasos&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Un aspecto fundamental que ha cobrado extraordinaria importancia en el mundo de la calcifilaxis es el uso de un tratamiento combinado o <span class="elsevierStyleItalic">multitarget</span>&#46; Existe una fuerte evidencia que confirma la mejora de las lesiones cut&#225;neas y el aumento de la supervivencia cuando se emplea este<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">13&#44;21&#44;22</span></a>&#46; Aunque no existe una terapia estandarizada&#44; se recomienda suspender los quelantes c&#225;lcicos&#44; los anticoagulantes orales &#40;pasando a heparina de bajo peso molecular&#41; y la vitamina D&#44; as&#237; como aumentar la frecuencia de las di&#225;lisis &#40;en los casos necesarios&#41; a 5-6 sesiones semanales con ba&#241;o bajo en calcio<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">23</span></a>&#44; Adem&#225;s&#44; se pueden utilizar f&#225;rmacos como los quelantes no c&#225;lcicos<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">24&#8211;26</span></a> &#40;por ejemplo&#44; el sevel&#225;mero&#44; que inhibe las calcificaciones ect&#243;picas y reduce el colesterol&#41;&#44; el cinacalcet<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">27&#44;28</span></a> &#40;reduce la PTH&#44; el calcio y el f&#243;sforo en pacientes en di&#225;lisis con hiperparatiroidismo secundario&#41;&#44; el tiosulfato s&#243;dico<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a> &#40;antioxidante y antiinflamatorio que moviliza los dep&#243;sitos c&#225;lcicos de los vasos&#41; y los bifosfonatos<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">30&#44;31</span></a> &#40;inhibidores de la formaci&#243;n de calcificaciones ect&#243;picas con efecto antiinflamatorio&#41;&#46; Debemos considerar la administraci&#243;n de vitamina K en los casos de deficiencia<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">32</span></a>&#46; Existe controversia respecto al empleo de c&#225;mara hiperb&#225;rica<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a> &#40;podr&#237;a ser beneficiosa en lesiones distales&#41; y de la paratiroidectom&#237;a en los casos de hiperparatiroidismo severo&#44; ya que no parecen mejorar el pron&#243;stico en estos pacientes<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">El pron&#243;stico de esta enfermedad es nefasto&#44; pues presenta una mortalidad de hasta el 60-80&#37;&#44; con la sepsis relacionada con calcifilaxis como la causa m&#225;s frecuente<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2&#44;4</span></a>&#44; como ocurri&#243; en el 64&#37; de nuestros pacientes&#46; En concreto&#44; las lesiones proximales tienen una mortalidad mayor que las distales &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">9</span></a>&#46; En esta serie&#44; los principales factores de riesgo para la mortalidad relacionada con la calcifilaxis fueron la presencia de IRC &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41; y la hipoalbuminemia &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Adem&#225;s&#44; es importante se&#241;alar que los pacientes con funci&#243;n renal normal presentan un pron&#243;stico vital excelente con relaci&#243;n a la calcifilaxis &#40;ninguno de ellos falleci&#243; por este motivo&#41;&#44; frente a los pacientes con IRC &#40;especialmente los trasplantados renales&#41;&#44; los cuales tienen una probabilidad de fallecimiento muy elevada a los pocos meses &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;032&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Es un estudio con importantes limitaciones&#44; es retrospectivo&#44; unic&#233;ntrico y con un n&#250;mero reducido de casos&#44; sin la realizaci&#243;n de un an&#225;lisis comparativo con un grupo control de sujetos sin calcifilaxis&#44; pero refleja la realidad que ocurre en la actualidad en los diferentes centros de Nefrolog&#237;a&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; aunque la calcifilaxis es una entidad poco frecuente&#44; tiene una elevada mortalidad&#46; El perfil del paciente ha cambiado&#58; no es exclusiva de situaciones ur&#233;micas&#44; tambi&#233;n ocurre en pacientes con trasplante renal normofuncionante o en sujetos sin enfermedad renal&#46; Los factores de riesgo cardiovascular &#40;diabetes&#44; obesidad&#44; enfermedad vascular perif&#233;rica&#44; anticoagulaci&#243;n con antagonistas de la vitamina K&#44; esteroides&#41; desplazan a los cl&#225;sicos del metabolismo mineral-&#243;seo&#46; Se deber&#237;a establecer un &#171;score de riesgo&#187; para diagn&#243;stico precoz&#44; as&#237; como un tratamiento est&#225;ndar&#46; Es necesario realizar estudios multic&#233;ntricos que permitan unificar el tratamiento en esta entidad&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicto de intereses</span><p id="par0175" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La arteriolopat&#237;a ur&#233;mica calcificante &#40;CUA&#41;&#44; tambi&#233;n llamada calcifilaxis&#44; es un trastorno vascular poco frecuente pero potencialmente mortal que afecta casi exclusivamente a pacientes con insuficiencia renal cr&#243;nica&#46; El objetivo de este estudio fue analizar los diferentes factores de riesgo para el desarrollo de CUA y su posterior evoluci&#243;n seg&#250;n la terapia recibida&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo que recoge aquellos pacientes con diagn&#243;stico de CUA desde diciembre de 1999 hasta diciembre de 2015&#46; Se analizaron diferentes factores de riesgo&#44; evoluci&#243;n y diferentes opciones terap&#233;uticas&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 28 pacientes &#40;53&#44;6&#37; mujeres&#41; con una edad media de 67&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;8 a&#241;os &#40;38-88&#41;&#46; En el momento del diagn&#243;stico&#44; el 53&#44;6&#37; estaba en hemodi&#225;lisis&#44; un 25&#37; eran pacientes con un trasplante renal y el 21&#44;4&#37; presentaba funci&#243;n renal normal&#46; En los pacientes trasplantados&#44; el consumo de esteroides &#40;100&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; fue el principal factor de riesgo&#46; La resoluci&#243;n de lesiones cut&#225;neas se produjo en el 60&#44;7&#37; &#40;especialmente en los que recibieron tratamiento <span class="elsevierStyleItalic">multitarget</span>&#41;&#46; La supervivencia de los pacientes a los 12<span class="elsevierStyleHsp" style=""></span>meses fue de 29&#44; 57 y 100&#37; en los pacientes trasplantados&#44; hemodi&#225;lisis y con funci&#243;n renal normal respectivamente &#40;log-rank 6&#44;88&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;032&#41;&#46; La presencia de insuficiencia renal cr&#243;nica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41; e hipoalbuminemia &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41; fueron los principales factores de riesgo de mortalidad CUA&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Aunque la incidencia de la CUA sigue siendo baja&#44; su mortalidad es muy elevada&#44; por lo que debe prestarse especial atenci&#243;n a la presentaci&#243;n de la CUA en los trasplantados renales y en las formas &#171;no renales&#187;&#46; Los anticoagulantes orales y los esteroides aparecen como principales factores de riesgo&#46; La CUA es un reto&#58; necesitamos un registro de nuestros pacientes y establecer una terapia est&#225;ndar&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Calcific uraemic arteriolopathy &#40;CUA&#41;&#44; also called calciphylaxis&#44; is a rare but potentially fatal vascular disorder that almost exclusively affects patients with chronic renal failure&#46; The objective of this study was to analyse various risk factors for developing CUA and its subsequent clinical course according to the treatment received&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A retrospective study that included patients diagnosed with CUA from December 1999 to December 2015&#46; Various risk factors&#44; clinical course and treatment options were analysed&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 28 patients &#40;53&#46;6&#37; females&#41; with a mean age of 67&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;8 &#40;38&#8211;88&#41; years were included&#46; At the time of diagnosis&#44; 53&#46;6&#37; were on haemodialysis&#44; 25&#37; were kidney transplant patients and 21&#46;4&#37; had normal renal function&#46; The use of steroids &#40;100&#37;&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41; was the main risk factor in renal transplant patients&#46; Skin lesions resolved in 60&#46;7&#37; &#40;especially in those receiving multitargeted therapy&#41;&#46; Patient survival at 12 months was 29&#37; in transplant patients&#44; 57&#37; in haemodialysis patients and 100&#37; in normal renal function patients &#40;log-rank 6&#46;88&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;032&#41;&#46; Chronic renal failure &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;03&#41; and hypoalbuminaemia &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;02&#41; were the main risk factor for CUA mortality&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Although the incidence of CUA remains low&#44; CUA mortality is very high&#44; Special attention to its occurrence in kidney transplant patients and &#171;non-renal&#187; CUA forms is required&#46; Oral anticoagulants and steroids appear to be the main risk factors&#44; CUA is a challenge&#59; a registry of patients and determining standard therapy are required&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;42&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;28&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;33&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;39&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">SIC n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;42&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;57&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;28&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;33&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;32&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;28&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;17&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;14&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;33&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Esteroides n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;100&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;16&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;35&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vitamina D activa n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;28&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;33&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intensificaci&#243;n HD n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;57&#44;1&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tiosulfato s&#243;dico n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;85&#44;7&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;16&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;60&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bifosfonatos n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;71&#44;4&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;16&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;66&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cinacalcet n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;42&#44;9&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;42&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;32&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vitamina K n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;16&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;21&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;14&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;21&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Amputaci&#243;n n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;7&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;14&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;7&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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            0 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 HD vs&#46; FRN&#46;</p>"
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            1 => array:3 [
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 Tx vs&#46; FRN&#46;</p>"
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          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Opciones terap&#233;uticas empleadas</p>"
        ]
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        "etiqueta" => "Tabla 4"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">ACO&#58; anticoagulaci&#243;n oral&#59; CCI&#58; &#237;ndice de comorbilidad de Charlson&#59; DM&#58; diabetes mellitus&#59; FA&#58; fibrilaci&#243;n auricular&#59; HTA&#58; hipertensi&#243;n arterial&#59; IRC&#58; insuficiencia renal cr&#243;nica&#59; SIC&#58; s&#237;ndrome isquemia cr&#243;nica&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Factores&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#62;70 a&#241;os&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;47&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;47&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IRC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;64&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HTA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;81&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;82&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;45&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;47&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obesidad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;45&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;41&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SIC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;54&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;58&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">EAC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;36&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;41&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;27&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;35&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ACO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;63&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;70&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;77&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;36&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;5&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tratamiento multitarget&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;81&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;64&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;31&nbsp;\t\t\t\t\t\t\n
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