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            "entidad" => "Servicio de Endocrinolog&#237;a&#44; Hospital Universitario Doce de Octubre&#44; Madrid&#44; Espa&#241;a"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Servicio de Cirug&#237;a General&#44; Hospital Universitario Doce de Octubre&#44; Madrid&#44; Espa&#241;a"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Secci&#243;n de Nefrolog&#237;a&#44; Hospital General de Segovia&#44; Segovia&#44; Espa&#241;a"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Autor para correspondencia&#46;"
          ]
        ]
      ]
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    "titulosAlternativos" => array:1 [
      "en" => array:1 [
        "titulo" => "Does renal function improve after parathyroidectomy in primary hyperparathyroidism&#63;"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">El hiperparatiroidismo primario &#40;HPTP&#41; es un trastorno com&#250;n del metabolismo mineral que se debe a la secreci&#243;n excesiva de parathormona &#40;PTH&#41; por parte de una o varias gl&#225;ndulas paratiroideas&#46; La secreci&#243;n aut&#243;noma de PTH act&#250;a sobre sus &#243;rganos diana &#40;hueso y ri&#241;&#243;n&#41;&#44; y aumenta las concentraciones de calcio en el espacio extracelular<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En la visi&#243;n hist&#243;rica del HPTP se describen 2 etapas&#46; La primera&#44; cuando fue descubierta&#44; con cl&#237;nica florida de litiasis renal&#44; enfermedad &#243;sea y s&#237;ntomas de hipercalcemia franca&#46; La segunda&#44; desde hace unos 40 a&#241;os&#44; tras la aparici&#243;n de los autoanalizadores&#44; en la que se detecta ante hipercalcemias leves y ausencia de las caracter&#237;sticas cl&#237;nicas cl&#225;sicas&#46; En la actualidad podemos estar entrando en una tercera etapa&#44; en la que los pacientes presentan concentraciones s&#233;ricas de calcio total e ionizado dentro de los intervalos de normalidad y niveles de PTH persistentemente elevados&#44; constituyendo la entidad conocida como HPTP normocalc&#233;mico<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En la era del HPTP sintom&#225;tico con frecuencia los pacientes presentaban litiasis renal y complicaciones relacionadas con c&#225;lculos&#44; tales como infecciones del tracto urinario&#44; hidronefrosis y deterioro de funci&#243;n renal&#46; Actualmente son raras&#44; ya que la mayor&#237;a de los HPTP cursan asintom&#225;ticos&#59; a nivel renal pueden presentar hipercalciuria&#44; microlitiasis renal y leves disminuciones en la funci&#243;n renal<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">2&#44;3</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El ri&#241;&#243;n es un &#243;rgano diana cl&#225;sico de PTH&#44; y la relaci&#243;n que existe entre el HPTP severo y el da&#241;o renal ha sido descrita desde hace a&#241;os<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3&#8211;7</span></a>&#46; Por otra parte&#44; en el HPTP el deterioro progresivo de la funci&#243;n renal eleva de forma secundaria los niveles de PTH<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">8</span></a>&#46; Tradicionalmente se asume que la resoluci&#243;n del HPTP mediante cirug&#237;a podr&#237;a preservar la funci&#243;n renal en estos pacientes<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">4</span></a>&#46; La disminuci&#243;n del filtrado glomerular &#40;&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; se mantiene en la gu&#237;as como un criterio para la realizaci&#243;n de paratiroidectom&#237;a &#40;PTX&#41;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La influencia que la PTX tiene sobre la evoluci&#243;n de la funci&#243;n renal es controvertida&#46; La mayor&#237;a de los estudios retrospectivos que han abordado este problema no han evidenciado una mejor&#237;a en la funci&#243;n renal despu&#233;s de la PTX <a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">11&#8211;16</span></a>&#46; Por otra parte&#44; los ensayos controlados&#44; aleatorizados&#44; realizados principalmente en pacientes con HPTP asintom&#225;ticos leves no han mostrado ning&#250;n efecto de la PTX en la funci&#243;n renal<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">17&#8211;20</span></a>&#46; Por el contrario&#44; en otros estudios objetivan que la PTX influye negativamente en la funci&#243;n renal<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">21</span></a>&#44; y de manera particular en pacientes con aclaramiento de creatinina<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">22</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Aunque no se puede negar que la curaci&#243;n quir&#250;rgica de HPTP evita un mayor deterioro de la funci&#243;n renal&#44; una cuesti&#243;n importante es si la PTX en pacientes con insuficiencia renal es capaz de enlentecer el descenso del filtrado glomerular<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">4&#44;22</span></a>&#46; El objetivo de nuestro trabajo es el estudio de una amplia serie de pacientes con HPTP intervenido&#44; y analizar los cambios en la funci&#243;n renal despu&#233;s de la PTX&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material y m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Dise&#241;o y pacientes</span><p id="par0035" class="elsevierStylePara elsevierViewall">Revisamos las historias de todos los pacientes diagnosticados de HPTP que fueron intervenidos mediante PTX en nuestro centro entre los a&#241;os 1998 y 2016&#44; con un seguimiento posquir&#250;rgico superior a un a&#241;o&#46; Se trata de un estudio observacional y retrospectivo&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se recogieron datos epidemiol&#243;gicos &#40;edad&#44; sexo&#41; y de la historia cl&#237;nica de cada paciente &#40;tiempo de evoluci&#243;n del HPTP&#44; presencia de litiasis renal&#44; hipertensi&#243;n arterial&#44; s&#237;ntomas asociados y par&#225;metros bioqu&#237;micos&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Definiciones</span><p id="par0045" class="elsevierStylePara elsevierViewall">Hipercalcemia&#58; calcio s&#233;rico superior a 11&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;calcio s&#233;rico<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mg&#47;dl al rango superior de la normalidad&#41;&#46; La medida de la calcemia se corrigi&#243; por la alb&#250;mina&#58; calcio corregido &#40;mg&#47;dl&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#40;4&#44;0<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>alb&#250;mina s&#233;rica &#91;g&#47;dl&#93;&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#44;8<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Ca total &#40;mg&#47;dl&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">HPTP sintom&#225;ticos&#58; pacientes que presentaban s&#237;ntomas en relaci&#243;n con litiasis renal recidivante&#44; manifestaciones &#243;seas &#40;dolor &#243;seo&#44; articular o fracturas&#41; o s&#237;ntomas generales atribuibles al HPTP &#40;digestivos o neuromusculares&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Hipertensi&#243;n arterial&#58; se consideraron como hipertensos aquellos pacientes que recib&#237;an tratamiento hipotensor&#44; con independencia de los valores de presi&#243;n arterial registrados&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Afectaci&#243;n &#243;sea relacionada con el HPTP&#58; La densidad &#243;sea mineral se midi&#243; mediante densitometr&#237;a dual de rayos X &#40;DEXA&#41; a nivel lumbar &#40;L2-L4&#41; y femoral&#46; Se consider&#243; que ten&#237;a afectaci&#243;n &#243;sea cuando present&#243; una disminuci&#243;n de la densidad mineral &#243;sea en la DEXA &#40;T score<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#44;5<span class="elsevierStyleHsp" style=""></span>DE en columna vertebral o a nivel femoral&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se identific&#243; la indicaci&#243;n quir&#250;rgica de la PTX en pacientes asintom&#225;ticos seg&#250;n las gu&#237;as internacionales<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">9</span></a>&#46; Un paciente pod&#237;a tener m&#225;s de una indicaci&#243;n&#44; por ello se estableci&#243; un orden jer&#225;rquico para poder establecer criterio predominante sobre los dem&#225;s&#58; litiasis renal&#44; afectaci&#243;n &#243;sea&#44; hipercalcemia&#44; edad<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50 a&#241;os y disminuci&#243;n del filtrado glomerular &#40;&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Localizaci&#243;n</span><p id="par0070" class="elsevierStylePara elsevierViewall">Se recogieron tambi&#233;n los resultados de las t&#233;cnicas de imagen procedentes de nuestros pacientes entre las que se hallaban la ecograf&#237;a paratiroidea&#44; la tomograf&#237;a computarizada c&#233;rvico-tor&#225;cica con contraste intravenoso&#44; con secciones tomogr&#225;ficas cada 5<span class="elsevierStyleHsp" style=""></span>mm y la gammagraf&#237;a paratiroidea preoperatoria con Tc99m-Sestamibi&#44; a dosis de 25<span class="elsevierStyleHsp" style=""></span>mCi&#44; mediante gammac&#225;mara planar&#46; Los registros de la gammagraf&#237;a se realizaron a los 10<span class="elsevierStyleHsp" style=""></span>min y a las 2<span class="elsevierStyleHsp" style=""></span>h postinyecci&#243;n&#44; utilizando colimador pin-hole y de agujeros paralelos&#46; Se consider&#243; patol&#243;gica la persistencia a las 2<span class="elsevierStyleHsp" style=""></span>h del trazador en las im&#225;genes registradas&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Procedimiento quir&#250;rgico</span><p id="par0075" class="elsevierStylePara elsevierViewall">Se realiz&#243; adenomectom&#237;a simple en los adenomas &#250;nicos&#46; Por otro lado&#44; se procedi&#243; a una exploraci&#243;n cervical de inicio en la afectaci&#243;n multiglandular&#44; en casos de reintervenci&#243;n por HPTP persistente&#44; cuando exist&#237;a patolog&#237;a tiroidea concomitante y en los casos con estudio de localizaci&#243;n negativo&#46; Durante la cirug&#237;a se monitoriz&#243; la PTH intacta &#40;PTHi&#41; y se consider&#243; como satisfactorio un descenso superior al 50&#37; del valor preoperatorio&#46; En los casos de hiperplasia se llev&#243; a cabo una PTX subtotal o reimplantaci&#243;n en antebrazo&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Metodolog&#237;a de las determinaciones anal&#237;ticas</span><p id="par0080" class="elsevierStylePara elsevierViewall">Las determinaciones anal&#237;ticas se realizaron mediante autoanalizador HPLC &#40;analizador ADAMS A1c&#44; HA-8160&#44; de Menarini&#41; y la PTHi mediante quimioluminiscencia &#40;Roche diagnostics GmbH&#44; Mannheim&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">El filtrado glomerular se estim&#243; seg&#250;n la ecuaci&#243;n CKD-EPI<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">23</span></a>&#44; que incluye como variables la creatinina s&#233;rica&#44; la edad&#44; el sexo y la raza&#46; La determinaci&#243;n de creatinina en suero se realiz&#243; mediante un m&#233;todo de Jaff&#233; cin&#233;tico compensado &#40;Roche Diagnostics&#41; que presenta trazabilidad frente al m&#233;todo de referencia IDMS&#46; La calciuria se determin&#243; en una muestra de la orina de 24<span class="elsevierStyleHsp" style=""></span>h&#44; y se calcul&#243; el cociente Ca&#47;creatinina urinario&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Los rangos normales de laboratorio considerados fueron&#58; calcio 8&#44;2-10&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; f&#243;sforo 2&#44;3-4&#44;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; creatinina plasm&#225;tica en varones entre 0&#44;7-1&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y en mujeres entre 0&#44;5-0&#44;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y PTHi 15&#44;0-51&#44;0<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#46; En orina la calciuria<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#237;a y el cociente Ca&#47;creatinina<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;20&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Los estudios anal&#237;ticos se realizaron en situaci&#243;n basal previa a la cirug&#237;a&#44; a la semana de la PTX &#40;1 semana-PTX&#41; y a los 12 meses de la misma &#40;12 meses-PTX&#41;&#46; En lo referente a la creatinina s&#233;rica&#44; no se objetivaron modificaciones significativas desde el momento del diagn&#243;stico del HPTP hasta la determinaci&#243;n basal&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">An&#225;lisis estad&#237;stico</span><p id="par0100" class="elsevierStylePara elsevierViewall">El an&#225;lisis estad&#237;stico se realiz&#243; usando el programa SPSS &#40;IBM SPSS Statistics<span class="elsevierStyleSup">&#174;</span> 20&#41;&#46; La normalidad de las variables se analiz&#243; mediante el test de Kolmogorov-Smirnov&#46; Las variables categ&#243;ricas fueron expresadas como frecuencias &#40;&#37;&#41; y las variables continuas como medias y desviaci&#243;n est&#225;ndar en caso de presentar distribuci&#243;n normal&#44; o medianas &#40;p25-p75&#41; si no cumplen esa caracter&#237;stica&#46; Para valorar la asociaci&#243;n entre los distintos tipos de HPTP y las variables categ&#243;ricas se emple&#243; el test de la Chi-cuadrado&#46; En el caso de variables continuas param&#233;tricas se utiliz&#243; la t de Student&#46; En el caso de variables continuas no param&#233;tricas se emple&#243; el test de Mann-Whitney para las muestras independientes o el test de Wilcoxon para muestras pareadas&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Resultados</span><p id="par0105" class="elsevierStylePara elsevierViewall">A un total de 297 pacientes con HPTP se les realiz&#243; PTX&#46; La incidencia de PTX fue de 39&#47;mill&#243;n de habitantes&#47;a&#241;o&#46; La edad media de los pacientes fue de 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 a&#241;os&#46; La relaci&#243;n mujer&#47;var&#243;n fue de 4&#44;1&#47;1&#44; los varones ten&#237;an una menor edad en el momento de la PTX&#46; El tiempo medio desde el diagn&#243;stico hasta la realizaci&#243;n de la cirug&#237;a fue de 14&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 meses&#46; La hipertensi&#243;n arterial se detect&#243; en un total de 126 pacientes &#40;42&#37;&#41;&#46; El HPTP fue asintom&#225;tico en 194 pacientes &#40;65&#44;3&#37;&#41;&#46; El resto de las caracter&#237;sticas cl&#237;nicas y anal&#237;ticas se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">En cuanto al diagn&#243;stico de localizaci&#243;n&#44; la gammagraf&#237;a sestamibi fue el mejor m&#233;todo para la localizaci&#243;n de la afectaci&#243;n glandular&#59; se realiz&#243; en 289 pacientes y fue diagn&#243;stica en 266 &#40;92&#37;&#41;&#46; La ecograf&#237;a cervical se llev&#243; a cabo en 269 pacientes y en 189 &#40;70&#37;&#41; fue positiva&#46; La tomograf&#237;a computarizada tuvo unos resultados parecidos&#44; resultando positiva en 52 &#40;68&#37;&#41; de 76 pacientes en los que se efectu&#243; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; Con el estudio gammagr&#225;fico se encontraron 22 falsos negativos&#46; De ellos en 11 el diagn&#243;stico se realiz&#243; con ecograf&#237;a&#44; y en 9 con la tomograf&#237;a computarizada&#59; en 2 pacientes no se dispon&#237;a de im&#225;genes de localizaci&#243;n previa a la cirug&#237;a&#46; Respecto de las indicaciones de PTX&#44; en el 34&#44;7&#37; de los pacientes fue por HPTP sintom&#225;tico&#46; De los asintom&#225;ticos&#44; la hipercalcemia &#40;Ca<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; fue la causa m&#225;s frecuente &#40;27&#37;&#41;&#44; seguido de la litiasis renal &#40;13&#37;&#41;&#44; de la afectaci&#243;n &#243;sea &#40;12&#37;&#41; y de una edad menor de 50 a&#241;os &#40;11&#37;&#41;&#46; En 280 casos &#40;94&#44;3&#37;&#41; la histolog&#237;a de la pieza quir&#250;rgica era compatible con adenoma paratiroideo &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">La evoluci&#243;n anal&#237;tica tras la PTX mostr&#243; una disminuci&#243;n significativa del calcio&#44; de la PTHi y de la calciuria&#44; con aumento del f&#243;sforo a la en la primera semana&#44; que se mantienen a lo largo del tiempo&#46; La creatinina s&#233;rica aument&#243; y el filtrado glomerular descendi&#243; en la primera semana tras la cirug&#237;a&#44; con valores similares a los 12 meses de la PTX &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Dividimos a los pacientes en 2 grupos en relaci&#243;n con el filtrado glomerular basal &#40;mayor o menor de 60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#46; Los pacientes con filtrado<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min ten&#237;an m&#225;s edad &#40;70<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12 vs&#46; 59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 a&#241;os&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y con mayor frecuencia eran hipertensos &#40;72 vs&#46; 39&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Encontramos que la elevaci&#243;n en la creatinina y el descenso del filtrado glomerular a los 12 meses de la PTX tuvieron significaci&#243;n estad&#237;stica en los casos con aclaramiento de creatinina<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#59; tambi&#233;n los pacientes con filtrado glomerular<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min deterioraron la funci&#243;n renal al a&#241;o de la PTX&#44; aunque no alcanz&#243; significaci&#243;n estad&#237;stica &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discusi&#243;n</span><p id="par0125" class="elsevierStylePara elsevierViewall">El HPTP es un trastorno frecuente&#44; su prevalencia var&#237;a en diferentes an&#225;lisis seg&#250;n la forma de detecci&#243;n y la poblaci&#243;n estudiada&#46; Los estudios poblacionales de cribado&#44; que inclu&#237;an la medici&#243;n de calcio s&#233;rico&#44; ayudaron a definir la epidemiolog&#237;a del HPTP&#46; La incidencia se ha modificado en las &#250;ltimas d&#233;cadas&#59; en EE&#46; UU&#46; la incidencia anual de HPTP en 1974 fue de 78 casos&#47;mill&#243;n&#47;a&#241;o y un a&#241;o despu&#233;s&#44; tras la medici&#243;n de calcio s&#233;rico de forma rutinaria&#44; se elev&#243; a 277 casos&#47;mill&#243;n&#47;a&#241;o&#46; De 1983 a 1992&#44; a pesar del uso m&#225;s amplio y continuo de la medici&#243;n de calcio&#44; la incidencia disminuye a 208 casos&#47;mill&#243;n&#47;a&#241;o<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">24</span></a>&#46; En Europa la situaci&#243;n es similar&#44; en la actualidad se estima entre 100-150 casos&#47;mill&#243;n&#47;a&#241;o<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">25</span></a>&#46; En Espa&#241;a en un estudio reciente estima una incidencia de HPTP de 99&#44;5 casos&#47;mill&#243;n&#47;a&#241;o<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Existen pocos estudios que analicen la incidencia de PTX en la poblaci&#243;n general&#44; y estos se remontan a estudios anteriores al a&#241;o 2000&#59; en EE&#46; UU&#46; se estima en 44&#47;mill&#243;n&#47;a&#241;o y en Suecia 50-100&#47;mill&#243;n&#47;a&#241;o<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">24</span></a>&#44; en nuestra serie fue de 38 casos por mill&#243;n de poblaci&#243;n y a&#241;o&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">El HPTP es m&#225;s frecuente en mujeres&#44; en nuestro estudio fue del 80&#44;5&#37; &#40;tasa M&#47;V 4&#44;1&#47;1&#41; con una incidencia ligeramente superior a lo referido en la literatura&#44; que se estima alrededor del 75&#37;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">27&#8211;29</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Las t&#233;cnicas de localizaci&#243;n de referencia son la gammagraf&#237;a paratiroidea con Tc99m-sestamibi &#40;asociado o no a SPECT&#41; y la ecograf&#237;a cervical&#46; La gammagraf&#237;a conTc99m-sestamibi presenta una sensibilidad entre el 74-90&#37; seg&#250;n las diferentes series<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">10&#44;30</span></a>&#59; en nuestra serie fue del 92&#37;&#46; La rentabilidad de la ecograf&#237;a cervical depende de la pericia del explorador&#44; su rentabilidad es variable entre el 70-87&#37;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">31</span></a>&#44; en nuestro estudio fue diagn&#243;stica en el 70&#37; de los pacientes&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Las manifestaciones cl&#237;nicas del HPTP han cambiado a lo largo de los a&#241;os&#44; actualmente en pa&#237;ses desarrollados cursan asintom&#225;ticos el 80&#37; de los pacientes<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">10&#44;32</span></a>&#46; El 65&#37; de nuestros pacientes sometidos a PTX estaban asintom&#225;ticos&#44; pero hemos de tener en cuenta que se trata de una poblaci&#243;n seleccionada&#44; que cumpl&#237;a criterios para la cirug&#237;a de paratiroides&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">La PTX es el tratamiento definitivo y conduce a la curaci&#243;n total del HPTP&#46; Se sigue de normalizaci&#243;n de la calcemia&#44; la disminuci&#243;n del riesgo de litiasis y el aumento de la masa &#243;sea&#44; con una disminuci&#243;n del riesgo de fracturas&#46; El efecto sobre los s&#237;ntomas cardiovasculares y neurocognitivos es controvertido&#46; La tasa de curaci&#243;n es superior al 95&#37;&#44; con escasa complicaciones y baja morbimortalidad<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">33</span></a>&#46; Otro aspecto importante es que la cirug&#237;a reduce costes en el HPTP&#59; de tal manera que cuando se realiza al inicio del diagn&#243;stico es 2&#44;5 veces m&#225;s rentable que en aquellos casos en que se realiza tras un per&#237;odo de seguimiento con tratamiento m&#233;dico&#44; y 1&#44;5 veces m&#225;s rentable sobre los pacientes que solamente siguen tratamiento m&#233;dico<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">34</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">En las 3 &#250;ltimas ediciones sobre el consenso del manejo del HPTP asintom&#225;tico se incluye a la insuficiencia renal &#40;filtrado glomerular<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41; entre los criterios quir&#250;rgicos<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">En las formas leves de HPTP&#44; los estudios observacionales no son muy consistentes&#44; es decir&#44; no hay evidencia definitiva de que el HPTP asintom&#225;tico&#47;leve tenga un impacto negativo en la funci&#243;n renal<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">18&#44;32&#44;35&#44;36</span></a>&#46; El PEARS es un estudio prospectivo reciente que compara a 1&#46;424 pacientes con HPTP con 7&#46;120 controles&#44; y encuentran que los individuos con HPTP tienen un riesgo de presentar insuficiencia renal a los 10 a&#241;os 13&#44;83 veces superior a los controles<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">36</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">A pesar de que la disminuci&#243;n del filtrado glomerular es indicaci&#243;n de PTX<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">9</span></a>&#44; apenas hay estudios que demuestren el efecto beneficioso de la PTX sobre la funci&#243;n renal&#46; Cuando buscamos en la literatura evidencia de que la PTX puede cambiar el curso hacia la insuficiencia renal&#44; encontramos que la mayor&#237;a de los trabajos retrospectivos no mostraron ning&#250;n cambio en la funci&#243;n renal &#40;tanto si se estima con creatinina s&#233;rica&#44; aclaramiento de creatinina o tasa de filtraci&#243;n glomerular&#41;&#44; durante per&#237;odos de seguimiento que van desde 6 meses a 11 a&#241;os<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">11&#44;37&#44;38</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">En 2 trabajos recientes dise&#241;ados para valorar el efecto de la PTX encuentran un empeoramiento de la funci&#243;n renal tras la PTX<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">21&#44;22</span></a>&#46; En el estudio de Egan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">21</span></a> estudian la evoluci&#243;n de la funci&#243;n renal en 62 pacientes&#44; y objetivan que la creatinina se eleva desde el postoperatorio &#40;1&#44;09 vs&#46; 1&#44;15<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; y el filtrado glomerular disminuye de 78 a 73<span class="elsevierStyleHsp" style=""></span>ml&#47;min a las 8-12 semanas&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Tassone et al&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">22</span></a> analizan la evoluci&#243;n de la funci&#243;n renal a los 6 meses de la PTX en 109 pacientes &#40;14 con aclaramiento<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#46; La creatinina s&#233;rica se increment&#243; significativamente en los pacientes con aclaramiento de creatinina<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;0&#44;82 vs&#46; 0&#44;87<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#59; tambi&#233;n empeor&#243; la creatinina s&#233;rica en los 14 pacientes que presentaban disminuci&#243;n del filtrado glomerular &#40;1&#44;32 vs&#46; 1&#44;41<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;5&#41; aunque sin alcanzar la significaci&#243;n estad&#237;stica&#46; De los estudios publicados&#44; nuestra serie es la que incluye a un mayor n&#250;mero de pacientes&#44; y los resultados son superponibles&#46; La funci&#243;n renal empeora en todos los pacientes&#44; desde la primera semana y se mantiene al a&#241;o de la cirug&#237;a&#46; Este empeoramiento es particularmente llamativo en pacientes con funci&#243;n renal previa normal&#46; Tambi&#233;n los pacientes con aclaramiento de creatinina<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min presentaron un empeoramiento de la funci&#243;n renal&#44; aunque este no alcanz&#243; significaci&#243;n estad&#237;stica&#44; probablemente por el tama&#241;o muestral&#46; Nuestros pacientes con insuficiencia renal ten&#237;an una edad mayor y mayor prevalencia de hipertensi&#243;n arterial&#44; por lo que probablemente estos factores no justifican dicho empeoramiento&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">En un estudio realizado en pacientes con trasplante renal&#44; a los 6 meses de la PTX presentaron un deterioro significativo de la creatinina s&#233;rica&#44; compar&#225;ndolos con un grupo control de similares caracter&#237;sticas<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">39</span></a>&#46; Los pacientes intervenidos ten&#237;an insuficiencia renal &#40;aclaramiento medio de 47<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; y el grupo control no ten&#237;a elevaci&#243;n de la PTHi&#46; Los autores lo atribuyen a un efecto hemodin&#225;mico mediado por la disminuci&#243;n de los niveles de PTH&#44; pero no se explican que el deterioro se mantenga m&#225;s all&#225; de los primeros meses&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">En nuestro trabajo se incluy&#243; un gran n&#250;mero de pacientes&#44; pero debido a la naturaleza observacional retrospectiva del estudio no podemos establecer una relaci&#243;n directa de causa y efecto entre la funci&#243;n renal y la PTX&#46; Otra limitaci&#243;n del estudio es el m&#233;todo utilizado en la estimaci&#243;n del filtrado glomerular mediante CKD-EPI que&#44; aunque infraestima menos que el MDRD en pacientes con filtrados superiores a 60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; no es una medida exacta del mismo<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">40</span></a>&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Solo podemos plantear la hip&#243;tesis de que los pacientes sin insuficiencia renal mostraron una disminuci&#243;n de la funci&#243;n renal despu&#233;s de PTX&#44; posiblemente no debido a factores relacionados con el HPTP&#46; En este sentido&#44; el mecanismo que podr&#237;a explicarlo ser&#237;a que la PTH tiene un efecto vasodilatador preglomerular&#59; otra explicaci&#243;n ser&#237;a el efecto hipertensivo de la hipercalcemia&#44; aunque solamente explicar&#237;a un deterioro agudo y no mantenido en el tiempo<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">41</span></a>&#46; Otro mecanismo propuesto es que la PTH aumenta la secreci&#243;n tubular de creatinina por incremento de la permeabilidad a nivel del t&#250;bulo proximal<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">42</span></a>&#44; y as&#237; la normalizaci&#243;n de la PTH elevar&#237;a los niveles de creatinina s&#233;rica&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Aunque un filtrado glomerular<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min es criterio de cirug&#237;a&#44; se necesitan estudios prospectivos sobre la evoluci&#243;n de la funci&#243;n renal en el HPTP&#44; que comparen pacientes con PTX frente a un grupo control &#40;observacional&#41;&#44; y medir el filtrado glomerular con m&#233;todos m&#225;s exactos&#44; en los que se excluya a la creatinina como marcador<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">4</span></a>&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusiones</span><p id="par0200" class="elsevierStylePara elsevierViewall">En mujeres de edad avanzada el HPTP es un trastorno endocrino frecuente&#44; que cursa de modo asintom&#225;tico en m&#225;s de la mitad de los pacientes&#46; Se debe descartar el HPTP cuando un paciente presenta hipercalcemia y litiasis renal&#46; Teniendo en cuenta todas las limitaciones mencionadas anteriormente&#44; nuestros datos muestran que la curaci&#243;n quir&#250;rgica de PHPT no se acompa&#241;a de una mejor&#237;a en la funci&#243;n renal&#44; y este efecto es manifiesto desde la primera semana y se mantienen en el tiempo&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicto de intereses</span><p id="par0205" 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">El hiperparatiroidismo primario &#40;HPTP&#41; es un trastorno endocrino frecuente&#44; caracterizado por hipercalcemia y elevaci&#243;n de la parathormona&#46; La disminuci&#243;n del filtrado glomerular &#40;&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; se mantiene en la gu&#237;as como un criterio para la realizaci&#243;n de la paratiroidectom&#237;a &#40;PTX&#41; en el HPTP asintom&#225;tico&#46; La influencia que tiene la PTX sobre la evoluci&#243;n de la funci&#243;n renal es controvertida&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Analizar las caracter&#237;sticas cl&#237;nicas&#44; anal&#237;ticas e histol&#243;gicas de los pacientes intervenidos por HPTP&#44; as&#237; como la evoluci&#243;n de la funci&#243;n renal tras la PTX&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material y m&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de 297 pacientes con HPTP remitidos a cirug&#237;a en un &#250;nico centro entre 1998 y 2016&#46; Los par&#225;metros anal&#237;ticos se determinaron en situaci&#243;n basal&#44; a la semana y al a&#241;o de la PTX&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La incidencia de PTX fue de 38<span class="elsevierStyleHsp" style=""></span>casos&#47;mill&#243;n&#47;a&#241;o&#46; La edad media fue 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 a&#241;os y el 80&#44;5&#37; de los pacientes eran mujeres&#46; El 65&#44;3&#37; estaban asintom&#225;ticos&#46; La nefrolitiasis fue el hallazgo cl&#237;nico m&#225;s frecuente &#40;33&#37;&#41; seguido de la afectaci&#243;n &#243;sea &#40;29&#44;5&#37;&#41;&#46; Las indicaciones de PTX fueron&#58; s&#237;ntomas cl&#237;nicos &#40;34&#44;7&#37;&#41;&#44; hipercalcemia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;27&#37;&#41;&#44; litiasis renal &#40;13&#37;&#41;&#44; baja masa &#243;sea &#40;12&#37;&#41;&#44; edad<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50 a&#241;os &#40;11&#37;&#41; y disminuci&#243;n del filtrado<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;2&#44;3&#37;&#41;&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En el diagn&#243;stico de localizaci&#243;n el spect-MIBI present&#243; una sensibilidad del 92&#37; y la ecograf&#237;a cervical del 70&#37;&#46; El 94&#44;3&#37; de los casos de HPTP eran debidos a un adenoma paratiroideo&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Tras la PTX se objetiv&#243; normalizaci&#243;n de los par&#225;metros relacionados con el HPTP&#46; Objetivamos un incremento significativo de la creatinina s&#233;rica &#40;0&#44;81 vs&#46; 0&#44;85<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; desde la primera semana del postoperatorio y que se mantiene al a&#241;o&#46; Cuando comparamos los pacientes seg&#250;n el filtrado glomerular basal&#44; encontramos que el deterioro de la funci&#243;n renal solamente fue significativo en pacientes con filtrado glomerular<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;creatinina s&#233;rica basal 0&#44;77<span class="elsevierStyleHsp" style=""></span>mg&#47;dl vs&#46; creatinina s&#233;rica al a&#241;o 0&#44;81<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El HPTP curs&#243; asintom&#225;tico en la mayor&#237;a de los pacientes intervenidos&#46; La hipercalcemia y la nefrolitiasis fueron las indicaciones m&#225;s frecuentes de paratiroidectom&#237;a en los pacientes asintom&#225;ticos&#46; El scan-MIBI fue el m&#233;todo de localizaci&#243;n m&#225;s &#250;til&#46; La curaci&#243;n quir&#250;rgica del HPTP se sigue de un deterioro de la funci&#243;n renal&#44; que se mantiene desde la primera semana de la cirug&#237;a&#46;</p></span>"
        "secciones" => array:5 [
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            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objetivos"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Material y m&#233;todos"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Resultados"
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            "titulo" => "Conclusiones"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Primary hyperparathyroidism &#40;PHPT&#41; is a common endocrine disorder characterised by hypercalcaemia and parathormone increase&#46; Decreased glomerular filtration rate &#40;&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; continues to be a parathyroidectomy &#40;PTX&#41; criterion in asymptomatic PHPT&#46; The influence of PTX on renal function evolution is the subject of debate&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objective</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">To analyse the clinical&#44; laboratory and histological characteristics of patients undergoing PHPT&#44; as well as renal function evolution after PTX&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Material and methods</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of 297 patients diagnosed with PHPT and referred to surgery in a single centre between 1998 and 2016&#46; Laboratory parameters were determined at baseline&#44; one week and one year after PTX&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The Incidence of PTX was 38 cases&#47;million&#47;year&#46; Mean age was 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 years and 80&#46;5&#37; of the patients were female&#46; Approximately 65&#46;3&#37; were asymptomatic&#46; Nephrolithiasis was the most common clinical finding &#40;33&#37;&#41;&#44; followed by bone involvement &#40;29&#46;5&#37;&#41;&#46; PTX indications were&#58; clinical symptoms &#40;34&#46;7&#37;&#41;&#44; hypercalcaemia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;27&#37;&#41;&#44; nephrolithiasis &#40;13&#37;&#41;&#44; low bone mass &#40;12&#37;&#41;&#44; age<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50 years &#40;11&#37;&#41; and decreased glomerular filtration rate<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;2&#46;3&#37;&#41;&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">For diagnostic localisation&#44; spect-MIBI had a sensitivity of 92&#37; and cervical ultrasound of 70&#37;&#46; A total of 94&#46;3&#37; of PHPT cases were due to a parathyroid adenoma&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">After PTX&#44; normalisation of PHPT-related parameters was observed&#46; We found a significant increase in serum creatinine levels &#40;0&#46;81 vs 0&#46;85<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; from the first week post-PTX until the end of the first year&#46; The renal function was only found to be significant in patients with glomerular filtration rate<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;baseline serum creatinine levels 0&#46;77<span class="elsevierStyleHsp" style=""></span>mg&#47;dl vs serum creatinine levels after one year 0&#46;81<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">PHPT was asymptomatic in most patients who underwent surgery&#46; Hypercalcaemia and nephrolithiasis were the most common indications of parathyroidectomy in asymptomatic patients&#46; MIBI scan was the most useful localisation method&#46; Surgical treatment of PHPT is followed by renal function impairment&#44; which persists after the first week post-PTX&#46;</p></span>"
        "secciones" => array:5 [
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          1 => array:2 [
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            "titulo" => "Objective"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Material and methods"
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          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Results"
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            "identificador" => "abst0050"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">CL&#58; columna lumbar&#59; CT&#58; cadera total&#59; DE&#58; desviaci&#243;n est&#225;ndar&#59; DMO&#58; densitometr&#237;a &#243;sea&#59; DXA&#58; absorciometr&#237;a con rayos X de doble energ&#237;a&#59; RD&#58; radio distal&#59; RM&#58; resonancia magn&#233;tica&#59; TC&#58; tomograf&#237;a computarizada&#59; VFA&#58; vertebral fracture assesment&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Fuente&#58; Bilezikian et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">9</span></a>&#46;</p>"
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                  \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>mg&#47;dl mayor del l&#237;mite de normalidad&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Tiempo de evoluci&#243;n &#40;meses&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Hipertensi&#243;n arterial &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126 &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sintom&#225;ticos &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103 &#40;34&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Litiasis renal &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Afectaci&#243;n &#243;sea &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88 &#40;29&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcio s&#233;rico &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#44;4 &#40;10&#44;8-12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#44;1-17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&#243;sforo s&#233;rico &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PTHi &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Creatinina s&#233;rica &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;43-1&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Filtrado glomerular &#40;ml&#47;min&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84&#44;7 &#40;71-97&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calciuria &#40;mg en 24<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">393<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>168&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98-521&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cociente Ca&#47;creatinina orina &#40;mg&#47;mg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;07-0&#44;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">189&#47;269 &#40;70&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tomograf&#237;a axial computarizada&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#47;76 &#40;68&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Gammagraf&#237;a &#40;MIBI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">266&#47;289 &#40;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;ntomas cl&#237;nicos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103 &#40;34&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hipercalcemia &#40;Ca<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;2 mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80 &#40;27&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Litiasis renal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 &#40;13&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Osteoporosis&#47;osteopenia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Edad<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50 a&#241;os&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;11&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Filtrado glomerular<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;2&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Histolog&#237;a</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Adenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">280 &#40;94&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hiperplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;5&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              ]
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            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Se expresan como la raz&#243;n entre los resultados positivos&#47;pruebas realizadas&#46;</p>"
            ]
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          "es" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Paratiroidectom&#237;a&#58; localizaci&#243;n&#44; indicaciones e histolog&#237;a</p>"
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          "leyenda" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Cr&#58; creatinina&#58; DE&#58; desviaci&#243;n est&#225;ndar&#59; ND&#58; no determinado&#59; PTHi&#58; parathormona intacta&#59; PTX&#58; paratiroidectom&#237;a&#46;</p><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Los valores de laboratorio se expresan como mediana &#40;p25-p75&#41; y media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DE&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preoperatorio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1 semana post-PTX&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">12 meses post-PTX&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcio &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#44;4 &#40;10&#44;8-12&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#44;0 &#40;8&#44;5-9&#44;5&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#44;5 &#40;9&#44;2-9&#44;8&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&#243;sforo &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;5 &#40;2&#44;2-2&#44;8&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;2 &#40;2&#44;8-3&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;3 &#40;2&#44;9-2&#44;6&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PTHi &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">164 &#40;116-221&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42 &#40;25-61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;33-59&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cr s&#233;rica &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;81 &#40;0&#44;7-0&#44;9&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;85 &#40;0&#44;7-1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;85 &#40;0&#44;7-1&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Filtrado glomerular &#40;ml&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#44;1 &#40;70-97&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#44;4 &#40;65-90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#44;1 &#40;67-91&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calciuria &#40;mg&#47;d&#237;a&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">393<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>168<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">158<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ca&#47;Cr orina &#40;mg&#47;mg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;16&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">FG<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>39&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preoperatorio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">12 meses post-PTX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcio &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#44;4 &#40;10&#44;8-12&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#44;5 &#40;9&#44;2-9&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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Original
¿Mejora la función renal tras la paratiroidectomía en el hiperparatirodismo primario?
Does renal function improve after parathyroidectomy in primary hyperparathyroidism?
Florencio García-Martína,b,
Autor para correspondencia
florenciogarcia@yahoo.es

Autor para correspondencia.
, Sonsoles Guadalixb,c, Fernando García-Boyanob, Natalia Melón Peñab, José Ignacio Martínez Pueyod, Ramiro Callejas Martíneze, Manuel Praga Terentea,b
a Servicio de Nefrología, Hospital Universitario Doce de Octubre, Madrid, España
b Departamento de Medicina, Universidad Complutense, Madrid, España
c Servicio de Endocrinología, Hospital Universitario Doce de Octubre, Madrid, España
d Servicio de Cirugía General, Hospital Universitario Doce de Octubre, Madrid, España
e Sección de Nefrología, Hospital General de Segovia, Segovia, España
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enfermedad &#243;sea y s&#237;ntomas de hipercalcemia franca&#46; La segunda&#44; desde hace unos 40 a&#241;os&#44; tras la aparici&#243;n de los autoanalizadores&#44; en la que se detecta ante hipercalcemias leves y ausencia de las caracter&#237;sticas cl&#237;nicas cl&#225;sicas&#46; En la actualidad podemos estar entrando en una tercera etapa&#44; en la que los pacientes presentan concentraciones s&#233;ricas de calcio total e ionizado dentro de los intervalos de normalidad y niveles de PTH persistentemente elevados&#44; constituyendo la entidad conocida como HPTP normocalc&#233;mico<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En la era del HPTP sintom&#225;tico con frecuencia los pacientes presentaban litiasis renal y complicaciones relacionadas con c&#225;lculos&#44; tales como infecciones del tracto urinario&#44; hidronefrosis y deterioro de funci&#243;n renal&#46; Actualmente son raras&#44; ya que la mayor&#237;a de los HPTP cursan asintom&#225;ticos&#59; a nivel renal pueden presentar hipercalciuria&#44; microlitiasis renal y leves disminuciones en la funci&#243;n renal<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">2&#44;3</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El ri&#241;&#243;n es un &#243;rgano diana cl&#225;sico de PTH&#44; y la relaci&#243;n que existe entre el HPTP severo y el da&#241;o renal ha sido descrita desde hace a&#241;os<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3&#8211;7</span></a>&#46; Por otra parte&#44; en el HPTP el deterioro progresivo de la funci&#243;n renal eleva de forma secundaria los niveles de PTH<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">8</span></a>&#46; Tradicionalmente se asume que la resoluci&#243;n del HPTP mediante cirug&#237;a podr&#237;a preservar la funci&#243;n renal en estos pacientes<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">4</span></a>&#46; La disminuci&#243;n del filtrado glomerular &#40;&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; se mantiene en la gu&#237;as como un criterio para la realizaci&#243;n de paratiroidectom&#237;a &#40;PTX&#41;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La influencia que la PTX tiene sobre la evoluci&#243;n de la funci&#243;n renal es controvertida&#46; La mayor&#237;a de los estudios retrospectivos que han abordado este problema no han evidenciado una mejor&#237;a en la funci&#243;n renal despu&#233;s de la PTX <a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">11&#8211;16</span></a>&#46; Por otra parte&#44; los ensayos controlados&#44; aleatorizados&#44; realizados principalmente en pacientes con HPTP asintom&#225;ticos leves no han mostrado ning&#250;n efecto de la PTX en la funci&#243;n renal<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">17&#8211;20</span></a>&#46; Por el contrario&#44; en otros estudios objetivan que la PTX influye negativamente en la funci&#243;n renal<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">21</span></a>&#44; y de manera particular en pacientes con aclaramiento de creatinina<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">22</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Aunque no se puede negar que la curaci&#243;n quir&#250;rgica de HPTP evita un mayor deterioro de la funci&#243;n renal&#44; una cuesti&#243;n importante es si la PTX en pacientes con insuficiencia renal es capaz de enlentecer el descenso del filtrado glomerular<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">4&#44;22</span></a>&#46; El objetivo de nuestro trabajo es el estudio de una amplia serie de pacientes con HPTP intervenido&#44; y analizar los cambios en la funci&#243;n renal despu&#233;s de la PTX&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material y m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Dise&#241;o y pacientes</span><p id="par0035" class="elsevierStylePara elsevierViewall">Revisamos las historias de todos los pacientes diagnosticados de HPTP que fueron intervenidos mediante PTX en nuestro centro entre los a&#241;os 1998 y 2016&#44; con un seguimiento posquir&#250;rgico superior a un a&#241;o&#46; Se trata de un estudio observacional y retrospectivo&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se recogieron datos epidemiol&#243;gicos &#40;edad&#44; sexo&#41; y de la historia cl&#237;nica de cada paciente &#40;tiempo de evoluci&#243;n del HPTP&#44; presencia de litiasis renal&#44; hipertensi&#243;n arterial&#44; s&#237;ntomas asociados y par&#225;metros bioqu&#237;micos&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Definiciones</span><p id="par0045" class="elsevierStylePara elsevierViewall">Hipercalcemia&#58; calcio s&#233;rico superior a 11&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;calcio s&#233;rico<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mg&#47;dl al rango superior de la normalidad&#41;&#46; La medida de la calcemia se corrigi&#243; por la alb&#250;mina&#58; calcio corregido &#40;mg&#47;dl&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#40;4&#44;0<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>alb&#250;mina s&#233;rica &#91;g&#47;dl&#93;&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#44;8<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Ca total &#40;mg&#47;dl&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">HPTP sintom&#225;ticos&#58; pacientes que presentaban s&#237;ntomas en relaci&#243;n con litiasis renal recidivante&#44; manifestaciones &#243;seas &#40;dolor &#243;seo&#44; articular o fracturas&#41; o s&#237;ntomas generales atribuibles al HPTP &#40;digestivos o neuromusculares&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Hipertensi&#243;n arterial&#58; se consideraron como hipertensos aquellos pacientes que recib&#237;an tratamiento hipotensor&#44; con independencia de los valores de presi&#243;n arterial registrados&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Afectaci&#243;n &#243;sea relacionada con el HPTP&#58; La densidad &#243;sea mineral se midi&#243; mediante densitometr&#237;a dual de rayos X &#40;DEXA&#41; a nivel lumbar &#40;L2-L4&#41; y femoral&#46; Se consider&#243; que ten&#237;a afectaci&#243;n &#243;sea cuando present&#243; una disminuci&#243;n de la densidad mineral &#243;sea en la DEXA &#40;T score<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#44;5<span class="elsevierStyleHsp" style=""></span>DE en columna vertebral o a nivel femoral&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se identific&#243; la indicaci&#243;n quir&#250;rgica de la PTX en pacientes asintom&#225;ticos seg&#250;n las gu&#237;as internacionales<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">9</span></a>&#46; Un paciente pod&#237;a tener m&#225;s de una indicaci&#243;n&#44; por ello se estableci&#243; un orden jer&#225;rquico para poder establecer criterio predominante sobre los dem&#225;s&#58; litiasis renal&#44; afectaci&#243;n &#243;sea&#44; hipercalcemia&#44; edad<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50 a&#241;os y disminuci&#243;n del filtrado glomerular &#40;&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Localizaci&#243;n</span><p id="par0070" class="elsevierStylePara elsevierViewall">Se recogieron tambi&#233;n los resultados de las t&#233;cnicas de imagen procedentes de nuestros pacientes entre las que se hallaban la ecograf&#237;a paratiroidea&#44; la tomograf&#237;a computarizada c&#233;rvico-tor&#225;cica con contraste intravenoso&#44; con secciones tomogr&#225;ficas cada 5<span class="elsevierStyleHsp" style=""></span>mm y la gammagraf&#237;a paratiroidea preoperatoria con Tc99m-Sestamibi&#44; a dosis de 25<span class="elsevierStyleHsp" style=""></span>mCi&#44; mediante gammac&#225;mara planar&#46; Los registros de la gammagraf&#237;a se realizaron a los 10<span class="elsevierStyleHsp" style=""></span>min y a las 2<span class="elsevierStyleHsp" style=""></span>h postinyecci&#243;n&#44; utilizando colimador pin-hole y de agujeros paralelos&#46; Se consider&#243; patol&#243;gica la persistencia a las 2<span class="elsevierStyleHsp" style=""></span>h del trazador en las im&#225;genes registradas&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Procedimiento quir&#250;rgico</span><p id="par0075" class="elsevierStylePara elsevierViewall">Se realiz&#243; adenomectom&#237;a simple en los adenomas &#250;nicos&#46; Por otro lado&#44; se procedi&#243; a una exploraci&#243;n cervical de inicio en la afectaci&#243;n multiglandular&#44; en casos de reintervenci&#243;n por HPTP persistente&#44; cuando exist&#237;a patolog&#237;a tiroidea concomitante y en los casos con estudio de localizaci&#243;n negativo&#46; Durante la cirug&#237;a se monitoriz&#243; la PTH intacta &#40;PTHi&#41; y se consider&#243; como satisfactorio un descenso superior al 50&#37; del valor preoperatorio&#46; En los casos de hiperplasia se llev&#243; a cabo una PTX subtotal o reimplantaci&#243;n en antebrazo&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Metodolog&#237;a de las determinaciones anal&#237;ticas</span><p id="par0080" class="elsevierStylePara elsevierViewall">Las determinaciones anal&#237;ticas se realizaron mediante autoanalizador HPLC &#40;analizador ADAMS A1c&#44; HA-8160&#44; de Menarini&#41; y la PTHi mediante quimioluminiscencia &#40;Roche diagnostics GmbH&#44; Mannheim&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">El filtrado glomerular se estim&#243; seg&#250;n la ecuaci&#243;n CKD-EPI<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">23</span></a>&#44; que incluye como variables la creatinina s&#233;rica&#44; la edad&#44; el sexo y la raza&#46; La determinaci&#243;n de creatinina en suero se realiz&#243; mediante un m&#233;todo de Jaff&#233; cin&#233;tico compensado &#40;Roche Diagnostics&#41; que presenta trazabilidad frente al m&#233;todo de referencia IDMS&#46; La calciuria se determin&#243; en una muestra de la orina de 24<span class="elsevierStyleHsp" style=""></span>h&#44; y se calcul&#243; el cociente Ca&#47;creatinina urinario&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Los rangos normales de laboratorio considerados fueron&#58; calcio 8&#44;2-10&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; f&#243;sforo 2&#44;3-4&#44;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; creatinina plasm&#225;tica en varones entre 0&#44;7-1&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y en mujeres entre 0&#44;5-0&#44;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y PTHi 15&#44;0-51&#44;0<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#46; En orina la calciuria<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#237;a y el cociente Ca&#47;creatinina<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;20&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Los estudios anal&#237;ticos se realizaron en situaci&#243;n basal previa a la cirug&#237;a&#44; a la semana de la PTX &#40;1 semana-PTX&#41; y a los 12 meses de la misma &#40;12 meses-PTX&#41;&#46; En lo referente a la creatinina s&#233;rica&#44; no se objetivaron modificaciones significativas desde el momento del diagn&#243;stico del HPTP hasta la determinaci&#243;n basal&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">An&#225;lisis estad&#237;stico</span><p id="par0100" class="elsevierStylePara elsevierViewall">El an&#225;lisis estad&#237;stico se realiz&#243; usando el programa SPSS &#40;IBM SPSS Statistics<span class="elsevierStyleSup">&#174;</span> 20&#41;&#46; La normalidad de las variables se analiz&#243; mediante el test de Kolmogorov-Smirnov&#46; Las variables categ&#243;ricas fueron expresadas como frecuencias &#40;&#37;&#41; y las variables continuas como medias y desviaci&#243;n est&#225;ndar en caso de presentar distribuci&#243;n normal&#44; o medianas &#40;p25-p75&#41; si no cumplen esa caracter&#237;stica&#46; Para valorar la asociaci&#243;n entre los distintos tipos de HPTP y las variables categ&#243;ricas se emple&#243; el test de la Chi-cuadrado&#46; En el caso de variables continuas param&#233;tricas se utiliz&#243; la t de Student&#46; En el caso de variables continuas no param&#233;tricas se emple&#243; el test de Mann-Whitney para las muestras independientes o el test de Wilcoxon para muestras pareadas&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Resultados</span><p id="par0105" class="elsevierStylePara elsevierViewall">A un total de 297 pacientes con HPTP se les realiz&#243; PTX&#46; La incidencia de PTX fue de 39&#47;mill&#243;n de habitantes&#47;a&#241;o&#46; La edad media de los pacientes fue de 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 a&#241;os&#46; La relaci&#243;n mujer&#47;var&#243;n fue de 4&#44;1&#47;1&#44; los varones ten&#237;an una menor edad en el momento de la PTX&#46; El tiempo medio desde el diagn&#243;stico hasta la realizaci&#243;n de la cirug&#237;a fue de 14&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 meses&#46; La hipertensi&#243;n arterial se detect&#243; en un total de 126 pacientes &#40;42&#37;&#41;&#46; El HPTP fue asintom&#225;tico en 194 pacientes &#40;65&#44;3&#37;&#41;&#46; El resto de las caracter&#237;sticas cl&#237;nicas y anal&#237;ticas se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">En cuanto al diagn&#243;stico de localizaci&#243;n&#44; la gammagraf&#237;a sestamibi fue el mejor m&#233;todo para la localizaci&#243;n de la afectaci&#243;n glandular&#59; se realiz&#243; en 289 pacientes y fue diagn&#243;stica en 266 &#40;92&#37;&#41;&#46; La ecograf&#237;a cervical se llev&#243; a cabo en 269 pacientes y en 189 &#40;70&#37;&#41; fue positiva&#46; La tomograf&#237;a computarizada tuvo unos resultados parecidos&#44; resultando positiva en 52 &#40;68&#37;&#41; de 76 pacientes en los que se efectu&#243; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; Con el estudio gammagr&#225;fico se encontraron 22 falsos negativos&#46; De ellos en 11 el diagn&#243;stico se realiz&#243; con ecograf&#237;a&#44; y en 9 con la tomograf&#237;a computarizada&#59; en 2 pacientes no se dispon&#237;a de im&#225;genes de localizaci&#243;n previa a la cirug&#237;a&#46; Respecto de las indicaciones de PTX&#44; en el 34&#44;7&#37; de los pacientes fue por HPTP sintom&#225;tico&#46; De los asintom&#225;ticos&#44; la hipercalcemia &#40;Ca<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; fue la causa m&#225;s frecuente &#40;27&#37;&#41;&#44; seguido de la litiasis renal &#40;13&#37;&#41;&#44; de la afectaci&#243;n &#243;sea &#40;12&#37;&#41; y de una edad menor de 50 a&#241;os &#40;11&#37;&#41;&#46; En 280 casos &#40;94&#44;3&#37;&#41; la histolog&#237;a de la pieza quir&#250;rgica era compatible con adenoma paratiroideo &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">La evoluci&#243;n anal&#237;tica tras la PTX mostr&#243; una disminuci&#243;n significativa del calcio&#44; de la PTHi y de la calciuria&#44; con aumento del f&#243;sforo a la en la primera semana&#44; que se mantienen a lo largo del tiempo&#46; La creatinina s&#233;rica aument&#243; y el filtrado glomerular descendi&#243; en la primera semana tras la cirug&#237;a&#44; con valores similares a los 12 meses de la PTX &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Dividimos a los pacientes en 2 grupos en relaci&#243;n con el filtrado glomerular basal &#40;mayor o menor de 60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#46; Los pacientes con filtrado<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min ten&#237;an m&#225;s edad &#40;70<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12 vs&#46; 59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 a&#241;os&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y con mayor frecuencia eran hipertensos &#40;72 vs&#46; 39&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Encontramos que la elevaci&#243;n en la creatinina y el descenso del filtrado glomerular a los 12 meses de la PTX tuvieron significaci&#243;n estad&#237;stica en los casos con aclaramiento de creatinina<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#59; tambi&#233;n los pacientes con filtrado glomerular<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min deterioraron la funci&#243;n renal al a&#241;o de la PTX&#44; aunque no alcanz&#243; significaci&#243;n estad&#237;stica &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discusi&#243;n</span><p id="par0125" class="elsevierStylePara elsevierViewall">El HPTP es un trastorno frecuente&#44; su prevalencia var&#237;a en diferentes an&#225;lisis seg&#250;n la forma de detecci&#243;n y la poblaci&#243;n estudiada&#46; Los estudios poblacionales de cribado&#44; que inclu&#237;an la medici&#243;n de calcio s&#233;rico&#44; ayudaron a definir la epidemiolog&#237;a del HPTP&#46; La incidencia se ha modificado en las &#250;ltimas d&#233;cadas&#59; en EE&#46; UU&#46; la incidencia anual de HPTP en 1974 fue de 78 casos&#47;mill&#243;n&#47;a&#241;o y un a&#241;o despu&#233;s&#44; tras la medici&#243;n de calcio s&#233;rico de forma rutinaria&#44; se elev&#243; a 277 casos&#47;mill&#243;n&#47;a&#241;o&#46; De 1983 a 1992&#44; a pesar del uso m&#225;s amplio y continuo de la medici&#243;n de calcio&#44; la incidencia disminuye a 208 casos&#47;mill&#243;n&#47;a&#241;o<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">24</span></a>&#46; En Europa la situaci&#243;n es similar&#44; en la actualidad se estima entre 100-150 casos&#47;mill&#243;n&#47;a&#241;o<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">25</span></a>&#46; En Espa&#241;a en un estudio reciente estima una incidencia de HPTP de 99&#44;5 casos&#47;mill&#243;n&#47;a&#241;o<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Existen pocos estudios que analicen la incidencia de PTX en la poblaci&#243;n general&#44; y estos se remontan a estudios anteriores al a&#241;o 2000&#59; en EE&#46; UU&#46; se estima en 44&#47;mill&#243;n&#47;a&#241;o y en Suecia 50-100&#47;mill&#243;n&#47;a&#241;o<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">24</span></a>&#44; en nuestra serie fue de 38 casos por mill&#243;n de poblaci&#243;n y a&#241;o&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">El HPTP es m&#225;s frecuente en mujeres&#44; en nuestro estudio fue del 80&#44;5&#37; &#40;tasa M&#47;V 4&#44;1&#47;1&#41; con una incidencia ligeramente superior a lo referido en la literatura&#44; que se estima alrededor del 75&#37;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">27&#8211;29</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Las t&#233;cnicas de localizaci&#243;n de referencia son la gammagraf&#237;a paratiroidea con Tc99m-sestamibi &#40;asociado o no a SPECT&#41; y la ecograf&#237;a cervical&#46; La gammagraf&#237;a conTc99m-sestamibi presenta una sensibilidad entre el 74-90&#37; seg&#250;n las diferentes series<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">10&#44;30</span></a>&#59; en nuestra serie fue del 92&#37;&#46; La rentabilidad de la ecograf&#237;a cervical depende de la pericia del explorador&#44; su rentabilidad es variable entre el 70-87&#37;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">31</span></a>&#44; en nuestro estudio fue diagn&#243;stica en el 70&#37; de los pacientes&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Las manifestaciones cl&#237;nicas del HPTP han cambiado a lo largo de los a&#241;os&#44; actualmente en pa&#237;ses desarrollados cursan asintom&#225;ticos el 80&#37; de los pacientes<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">10&#44;32</span></a>&#46; El 65&#37; de nuestros pacientes sometidos a PTX estaban asintom&#225;ticos&#44; pero hemos de tener en cuenta que se trata de una poblaci&#243;n seleccionada&#44; que cumpl&#237;a criterios para la cirug&#237;a de paratiroides&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">La PTX es el tratamiento definitivo y conduce a la curaci&#243;n total del HPTP&#46; Se sigue de normalizaci&#243;n de la calcemia&#44; la disminuci&#243;n del riesgo de litiasis y el aumento de la masa &#243;sea&#44; con una disminuci&#243;n del riesgo de fracturas&#46; El efecto sobre los s&#237;ntomas cardiovasculares y neurocognitivos es controvertido&#46; La tasa de curaci&#243;n es superior al 95&#37;&#44; con escasa complicaciones y baja morbimortalidad<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">33</span></a>&#46; Otro aspecto importante es que la cirug&#237;a reduce costes en el HPTP&#59; de tal manera que cuando se realiza al inicio del diagn&#243;stico es 2&#44;5 veces m&#225;s rentable que en aquellos casos en que se realiza tras un per&#237;odo de seguimiento con tratamiento m&#233;dico&#44; y 1&#44;5 veces m&#225;s rentable sobre los pacientes que solamente siguen tratamiento m&#233;dico<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">34</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">En las 3 &#250;ltimas ediciones sobre el consenso del manejo del HPTP asintom&#225;tico se incluye a la insuficiencia renal &#40;filtrado glomerular<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41; entre los criterios quir&#250;rgicos<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">En las formas leves de HPTP&#44; los estudios observacionales no son muy consistentes&#44; es decir&#44; no hay evidencia definitiva de que el HPTP asintom&#225;tico&#47;leve tenga un impacto negativo en la funci&#243;n renal<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">18&#44;32&#44;35&#44;36</span></a>&#46; El PEARS es un estudio prospectivo reciente que compara a 1&#46;424 pacientes con HPTP con 7&#46;120 controles&#44; y encuentran que los individuos con HPTP tienen un riesgo de presentar insuficiencia renal a los 10 a&#241;os 13&#44;83 veces superior a los controles<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">36</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">A pesar de que la disminuci&#243;n del filtrado glomerular es indicaci&#243;n de PTX<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">9</span></a>&#44; apenas hay estudios que demuestren el efecto beneficioso de la PTX sobre la funci&#243;n renal&#46; Cuando buscamos en la literatura evidencia de que la PTX puede cambiar el curso hacia la insuficiencia renal&#44; encontramos que la mayor&#237;a de los trabajos retrospectivos no mostraron ning&#250;n cambio en la funci&#243;n renal &#40;tanto si se estima con creatinina s&#233;rica&#44; aclaramiento de creatinina o tasa de filtraci&#243;n glomerular&#41;&#44; durante per&#237;odos de seguimiento que van desde 6 meses a 11 a&#241;os<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">11&#44;37&#44;38</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">En 2 trabajos recientes dise&#241;ados para valorar el efecto de la PTX encuentran un empeoramiento de la funci&#243;n renal tras la PTX<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">21&#44;22</span></a>&#46; En el estudio de Egan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">21</span></a> estudian la evoluci&#243;n de la funci&#243;n renal en 62 pacientes&#44; y objetivan que la creatinina se eleva desde el postoperatorio &#40;1&#44;09 vs&#46; 1&#44;15<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; y el filtrado glomerular disminuye de 78 a 73<span class="elsevierStyleHsp" style=""></span>ml&#47;min a las 8-12 semanas&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Tassone et al&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">22</span></a> analizan la evoluci&#243;n de la funci&#243;n renal a los 6 meses de la PTX en 109 pacientes &#40;14 con aclaramiento<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#46; La creatinina s&#233;rica se increment&#243; significativamente en los pacientes con aclaramiento de creatinina<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;0&#44;82 vs&#46; 0&#44;87<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#59; tambi&#233;n empeor&#243; la creatinina s&#233;rica en los 14 pacientes que presentaban disminuci&#243;n del filtrado glomerular &#40;1&#44;32 vs&#46; 1&#44;41<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;5&#41; aunque sin alcanzar la significaci&#243;n estad&#237;stica&#46; De los estudios publicados&#44; nuestra serie es la que incluye a un mayor n&#250;mero de pacientes&#44; y los resultados son superponibles&#46; La funci&#243;n renal empeora en todos los pacientes&#44; desde la primera semana y se mantiene al a&#241;o de la cirug&#237;a&#46; Este empeoramiento es particularmente llamativo en pacientes con funci&#243;n renal previa normal&#46; Tambi&#233;n los pacientes con aclaramiento de creatinina<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min presentaron un empeoramiento de la funci&#243;n renal&#44; aunque este no alcanz&#243; significaci&#243;n estad&#237;stica&#44; probablemente por el tama&#241;o muestral&#46; Nuestros pacientes con insuficiencia renal ten&#237;an una edad mayor y mayor prevalencia de hipertensi&#243;n arterial&#44; por lo que probablemente estos factores no justifican dicho empeoramiento&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">En un estudio realizado en pacientes con trasplante renal&#44; a los 6 meses de la PTX presentaron un deterioro significativo de la creatinina s&#233;rica&#44; compar&#225;ndolos con un grupo control de similares caracter&#237;sticas<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">39</span></a>&#46; Los pacientes intervenidos ten&#237;an insuficiencia renal &#40;aclaramiento medio de 47<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; y el grupo control no ten&#237;a elevaci&#243;n de la PTHi&#46; Los autores lo atribuyen a un efecto hemodin&#225;mico mediado por la disminuci&#243;n de los niveles de PTH&#44; pero no se explican que el deterioro se mantenga m&#225;s all&#225; de los primeros meses&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">En nuestro trabajo se incluy&#243; un gran n&#250;mero de pacientes&#44; pero debido a la naturaleza observacional retrospectiva del estudio no podemos establecer una relaci&#243;n directa de causa y efecto entre la funci&#243;n renal y la PTX&#46; Otra limitaci&#243;n del estudio es el m&#233;todo utilizado en la estimaci&#243;n del filtrado glomerular mediante CKD-EPI que&#44; aunque infraestima menos que el MDRD en pacientes con filtrados superiores a 60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; no es una medida exacta del mismo<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">40</span></a>&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Solo podemos plantear la hip&#243;tesis de que los pacientes sin insuficiencia renal mostraron una disminuci&#243;n de la funci&#243;n renal despu&#233;s de PTX&#44; posiblemente no debido a factores relacionados con el HPTP&#46; En este sentido&#44; el mecanismo que podr&#237;a explicarlo ser&#237;a que la PTH tiene un efecto vasodilatador preglomerular&#59; otra explicaci&#243;n ser&#237;a el efecto hipertensivo de la hipercalcemia&#44; aunque solamente explicar&#237;a un deterioro agudo y no mantenido en el tiempo<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">41</span></a>&#46; Otro mecanismo propuesto es que la PTH aumenta la secreci&#243;n tubular de creatinina por incremento de la permeabilidad a nivel del t&#250;bulo proximal<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">42</span></a>&#44; y as&#237; la normalizaci&#243;n de la PTH elevar&#237;a los niveles de creatinina s&#233;rica&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Aunque un filtrado glomerular<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min es criterio de cirug&#237;a&#44; se necesitan estudios prospectivos sobre la evoluci&#243;n de la funci&#243;n renal en el HPTP&#44; que comparen pacientes con PTX frente a un grupo control &#40;observacional&#41;&#44; y medir el filtrado glomerular con m&#233;todos m&#225;s exactos&#44; en los que se excluya a la creatinina como marcador<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">4</span></a>&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusiones</span><p id="par0200" class="elsevierStylePara elsevierViewall">En mujeres de edad avanzada el HPTP es un trastorno endocrino frecuente&#44; que cursa de modo asintom&#225;tico en m&#225;s de la mitad de los pacientes&#46; Se debe descartar el HPTP cuando un paciente presenta hipercalcemia y litiasis renal&#46; Teniendo en cuenta todas las limitaciones mencionadas anteriormente&#44; nuestros datos muestran que la curaci&#243;n quir&#250;rgica de PHPT no se acompa&#241;a de una mejor&#237;a en la funci&#243;n renal&#44; y este efecto es manifiesto desde la primera semana y se mantienen en el tiempo&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicto de intereses</span><p id="par0205" 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">El hiperparatiroidismo primario &#40;HPTP&#41; es un trastorno endocrino frecuente&#44; caracterizado por hipercalcemia y elevaci&#243;n de la parathormona&#46; La disminuci&#243;n del filtrado glomerular &#40;&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; se mantiene en la gu&#237;as como un criterio para la realizaci&#243;n de la paratiroidectom&#237;a &#40;PTX&#41; en el HPTP asintom&#225;tico&#46; La influencia que tiene la PTX sobre la evoluci&#243;n de la funci&#243;n renal es controvertida&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Analizar las caracter&#237;sticas cl&#237;nicas&#44; anal&#237;ticas e histol&#243;gicas de los pacientes intervenidos por HPTP&#44; as&#237; como la evoluci&#243;n de la funci&#243;n renal tras la PTX&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material y m&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de 297 pacientes con HPTP remitidos a cirug&#237;a en un &#250;nico centro entre 1998 y 2016&#46; Los par&#225;metros anal&#237;ticos se determinaron en situaci&#243;n basal&#44; a la semana y al a&#241;o de la PTX&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La incidencia de PTX fue de 38<span class="elsevierStyleHsp" style=""></span>casos&#47;mill&#243;n&#47;a&#241;o&#46; La edad media fue 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 a&#241;os y el 80&#44;5&#37; de los pacientes eran mujeres&#46; El 65&#44;3&#37; estaban asintom&#225;ticos&#46; La nefrolitiasis fue el hallazgo cl&#237;nico m&#225;s frecuente &#40;33&#37;&#41; seguido de la afectaci&#243;n &#243;sea &#40;29&#44;5&#37;&#41;&#46; Las indicaciones de PTX fueron&#58; s&#237;ntomas cl&#237;nicos &#40;34&#44;7&#37;&#41;&#44; hipercalcemia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;27&#37;&#41;&#44; litiasis renal &#40;13&#37;&#41;&#44; baja masa &#243;sea &#40;12&#37;&#41;&#44; edad<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50 a&#241;os &#40;11&#37;&#41; y disminuci&#243;n del filtrado<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;2&#44;3&#37;&#41;&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En el diagn&#243;stico de localizaci&#243;n el spect-MIBI present&#243; una sensibilidad del 92&#37; y la ecograf&#237;a cervical del 70&#37;&#46; El 94&#44;3&#37; de los casos de HPTP eran debidos a un adenoma paratiroideo&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Tras la PTX se objetiv&#243; normalizaci&#243;n de los par&#225;metros relacionados con el HPTP&#46; Objetivamos un incremento significativo de la creatinina s&#233;rica &#40;0&#44;81 vs&#46; 0&#44;85<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; desde la primera semana del postoperatorio y que se mantiene al a&#241;o&#46; Cuando comparamos los pacientes seg&#250;n el filtrado glomerular basal&#44; encontramos que el deterioro de la funci&#243;n renal solamente fue significativo en pacientes con filtrado glomerular<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;creatinina s&#233;rica basal 0&#44;77<span class="elsevierStyleHsp" style=""></span>mg&#47;dl vs&#46; creatinina s&#233;rica al a&#241;o 0&#44;81<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El HPTP curs&#243; asintom&#225;tico en la mayor&#237;a de los pacientes intervenidos&#46; La hipercalcemia y la nefrolitiasis fueron las indicaciones m&#225;s frecuentes de paratiroidectom&#237;a en los pacientes asintom&#225;ticos&#46; El scan-MIBI fue el m&#233;todo de localizaci&#243;n m&#225;s &#250;til&#46; La curaci&#243;n quir&#250;rgica del HPTP se sigue de un deterioro de la funci&#243;n renal&#44; que se mantiene desde la primera semana de la cirug&#237;a&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objetivos"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Material y m&#233;todos"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Resultados"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Primary hyperparathyroidism &#40;PHPT&#41; is a common endocrine disorder characterised by hypercalcaemia and parathormone increase&#46; Decreased glomerular filtration rate &#40;&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; continues to be a parathyroidectomy &#40;PTX&#41; criterion in asymptomatic PHPT&#46; The influence of PTX on renal function evolution is the subject of debate&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objective</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">To analyse the clinical&#44; laboratory and histological characteristics of patients undergoing PHPT&#44; as well as renal function evolution after PTX&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Material and methods</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of 297 patients diagnosed with PHPT and referred to surgery in a single centre between 1998 and 2016&#46; Laboratory parameters were determined at baseline&#44; one week and one year after PTX&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The Incidence of PTX was 38 cases&#47;million&#47;year&#46; Mean age was 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 years and 80&#46;5&#37; of the patients were female&#46; Approximately 65&#46;3&#37; were asymptomatic&#46; Nephrolithiasis was the most common clinical finding &#40;33&#37;&#41;&#44; followed by bone involvement &#40;29&#46;5&#37;&#41;&#46; PTX indications were&#58; clinical symptoms &#40;34&#46;7&#37;&#41;&#44; hypercalcaemia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;27&#37;&#41;&#44; nephrolithiasis &#40;13&#37;&#41;&#44; low bone mass &#40;12&#37;&#41;&#44; age<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50 years &#40;11&#37;&#41; and decreased glomerular filtration rate<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;2&#46;3&#37;&#41;&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">For diagnostic localisation&#44; spect-MIBI had a sensitivity of 92&#37; and cervical ultrasound of 70&#37;&#46; A total of 94&#46;3&#37; of PHPT cases were due to a parathyroid adenoma&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">After PTX&#44; normalisation of PHPT-related parameters was observed&#46; We found a significant increase in serum creatinine levels &#40;0&#46;81 vs 0&#46;85<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; from the first week post-PTX until the end of the first year&#46; The renal function was only found to be significant in patients with glomerular filtration rate<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;baseline serum creatinine levels 0&#46;77<span class="elsevierStyleHsp" style=""></span>mg&#47;dl vs serum creatinine levels after one year 0&#46;81<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">PHPT was asymptomatic in most patients who underwent surgery&#46; Hypercalcaemia and nephrolithiasis were the most common indications of parathyroidectomy in asymptomatic patients&#46; MIBI scan was the most useful localisation method&#46; Surgical treatment of PHPT is followed by renal function impairment&#44; which persists after the first week post-PTX&#46;</p></span>"
        "secciones" => array:5 [
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            "identificador" => "abst0030"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Objective"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Material and methods"
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            "identificador" => "abst0045"
            "titulo" => "Results"
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            "identificador" => "abst0050"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">CL&#58; columna lumbar&#59; CT&#58; cadera total&#59; DE&#58; desviaci&#243;n est&#225;ndar&#59; DMO&#58; densitometr&#237;a &#243;sea&#59; DXA&#58; absorciometr&#237;a con rayos X de doble energ&#237;a&#59; RD&#58; radio distal&#59; RM&#58; resonancia magn&#233;tica&#59; TC&#58; tomograf&#237;a computarizada&#59; VFA&#58; vertebral fracture assesment&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Fuente&#58; Bilezikian et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">9</span></a>&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Criterio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Edad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>50 a&#241;os&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Calcio s&#233;rico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>mg&#47;dl mayor del l&#237;mite de normalidad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Afectaci&#243;n &#243;sea&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">DMO &#40;DXA&#41;&#58; T<span class="elsevierStyleItalic">-score</span> CL&#44; CT o RD<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#44;5<span class="elsevierStyleHsp" style=""></span>DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fractura vertebral&#58; radiograf&#237;a simple&#44; TC&#44; RM&#44; VFA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Afectaci&#243;n renal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Nefrolitiasis o nefrocalcinosis &#40;radiograf&#237;a simple&#44; ecograf&#237;a&#44; TC&#41;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">DE&#58; desviaci&#243;n est&#225;ndar&#59; PTHi&#58; parathormona intacta&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Los valores de laboratorio se expresan como mediana &#40;p25-p75&#41; o media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DE&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Edad &#40;a&#241;os&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sexo femenino &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">239 &#40;80&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Tiempo de evoluci&#243;n &#40;meses&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126 &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Sintom&#225;ticos &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103 &#40;34&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Litiasis renal &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Afectaci&#243;n &#243;sea &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88 &#40;29&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcio s&#233;rico &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#44;4 &#40;10&#44;8-12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#44;1-17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&#243;sforo s&#233;rico &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;5 &#40;2&#44;2-2&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;1-4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PTHi &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">164 &#40;116-221&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58-1104&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Creatinina s&#233;rica &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;8 &#40;0&#44;7-0&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;43-1&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Filtrado glomerular &#40;ml&#47;min&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84&#44;7 &#40;71-97&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36-142&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calciuria &#40;mg en 24<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">393<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>168&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98-521&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cociente Ca&#47;creatinina orina &#40;mg&#47;mg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;07-0&#44;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas cl&#237;nicas y anal&#237;tica basal</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Diagn&#243;stico de localizaci&#243;n</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ecograf&#237;a cervical&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">189&#47;269 &#40;70&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tomograf&#237;a axial computarizada&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#47;76 &#40;68&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Gammagraf&#237;a &#40;MIBI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">266&#47;289 &#40;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Indicaci&#243;n paratiroidectom&#237;a</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;ntomas cl&#237;nicos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103 &#40;34&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hipercalcemia &#40;Ca<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;2 mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80 &#40;27&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Litiasis renal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 &#40;13&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Osteoporosis&#47;osteopenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;12&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Edad<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;11&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Filtrado glomerular<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;2&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Histolog&#237;a</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Adenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">280 &#40;94&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hiperplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;5&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Cr&#58; creatinina&#58; DE&#58; desviaci&#243;n est&#225;ndar&#59; ND&#58; no determinado&#59; PTHi&#58; parathormona intacta&#59; PTX&#58; paratiroidectom&#237;a&#46;</p><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Los valores de laboratorio se expresan como mediana &#40;p25-p75&#41; y media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DE&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#44;85 &#40;0&#44;7-1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calciuria &#40;mg&#47;d&#237;a&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">158<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>96&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">FG&#58; filtrado glomerular estimado &#40;CKD-EPI&#41;&#59; PTHi&#58; parathormona intacta&#59; PTX&#58; paratiroidectom&#237;a&#46;</p><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Los valores se expresan como mediana &#40;p25-p75&#41;&#46;</p>"
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Información del artículo
ISSN: 02116995
Idioma original: Español
DOI:10.1016/j.nefro.2018.08.007
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