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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La enfermedad renal cr&#243;nica &#40;ERC&#41; se asocia a un elevado riesgo morbimortalidad cardiovascular &#40;CV&#41;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El tejido graso epic&#225;rdico &#40;EAT&#41; es un factor de riesgo CV emergente<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3-5</span></a>&#46; Es un tejido de grasa perivisceral que envuelve las arterias coronarias y el coraz&#243;n&#44; y contacta directamente con el miocardio subyacente&#46; Procede embriol&#243;gicamente del mesodermo esplacnopleural y es un tejido metab&#243;licamente activo<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a>&#46; En situaciones patol&#243;gicas&#44; produce citocinas proinflamatorias&#46; Estas citocinas se liberan al miocardio adyacente y al flujo sangu&#237;neo coronario&#44; de forma que act&#250;an de forma sist&#233;mica y paracrina&#44; influyendo en el desarrollo de la ateroesclerosis coronaria<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a>&#46; En poblaci&#243;n general&#44; el EAT se ha relacionado con el s&#237;ndrome metab&#243;lico&#44; la diabetes mellitus &#40;DM&#41;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6-9</span></a> y la enfermedad arterial coronaria &#40;CAD&#41;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">10-12</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">El tejido mediast&#237;nico &#40;MAT&#41; es el tejido adiposo depositado fuera de la fascia parietal del pericardio&#46; La distinci&#243;n entre las distintas localizaciones de los dep&#243;sitos de grasa es importante&#44; puesto que la grasa peric&#225;rdica tiene caracter&#237;sticas metab&#243;licas espec&#237;ficas y distinto drenaje sangu&#237;neo<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">13-17</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La cuantificaci&#243;n del EAT no est&#225; estandarizada&#44; los estudios son heterog&#233;neos en cuanto a la t&#233;cnica radiol&#243;gica empleada y a la localizaci&#243;n del dep&#243;sito graso medido y no existe consenso sobre los rangos de referencia<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">13&#44;18</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">En los pacientes con ERC avanzada o en tratamiento renal sustitutivo el volumen de EAT se ha relacionado con la calcificaci&#243;n arterial coronaria &#40;CaC&#41;&#44; la ateroesclerosis&#44; la inflamaci&#243;n y la malnutrici&#243;n<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#44;19-22</span></a>&#46; Sin embargo&#44; existen pocos datos sobre su capacidad predictiva de eventos CV y mortalidad en estos pacientes<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">El objetivo primario de nuestro estudio es determinar si la cuantificaci&#243;n del EAT y el MAT mediante tomograf&#237;a computarizada sincronizada multicorte &#40;MSCT&#41; se asocia con un aumento de mortalidad en pacientes con ERC avanzada &#40;estadios 4 y 5&#41; y en hemodi&#225;lisis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Como objetivos secundarios&#44; exploramos la asociaci&#243;n de estos par&#225;metros con la variable objetivo combinada de mortalidad y eventos CV&#44; la relaci&#243;n con el score de CaC y con factores de riesgo CV bioqu&#237;micos y cl&#237;nicos propios de esta poblaci&#243;n&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><p id="par0040" class="elsevierStylePara elsevierViewall">Se llev&#243; a cabo un an&#225;lisis <span class="elsevierStyleItalic">post hoc</span> de una serie prospectiva y de cohortes&#44; dise&#241;ada inicialmente para estudiar la capacidad predictiva de riesgo CV del score de CaC<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a>&#46; La poblaci&#243;n inicial a estudio inclu&#237;a a 137 pacientes con ERC avanzada o en programa de hemodi&#225;lisis cr&#243;nica&#44; en seguimiento en la Unidad de Nefrolog&#237;a del Hospital Universitario Pr&#237;ncipe de Asturias&#46; El periodo de inclusi&#243;n fue de 2 a&#241;os&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Los criterios de inclusi&#243;n fueron&#58; edad mayor de 18 a&#241;os&#44; ERC avanzada &#40;estadios 4-5&#41; y en programa de hemodi&#225;lisis&#44; al menos durante los 6 meses previos al reclutamiento&#46; Los criterios de exclusi&#243;n fueron&#58; el fracaso renal agudo&#44; el embarazo&#44; una enfermedad intercurrente que condicionase una supervivencia estimada inferior a 12 meses y la imposibilidad para realizar una MSCT&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Se seleccionaron aquellos casos que tuvieran disponible un estudio de imagen adecuado&#44; el cual permitiera calcular el grosor del tejido graso alrededor del coraz&#243;n en sus diferentes localizaciones o surcos&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Todos los pacientes firmaron el consentimiento informado&#46; El protocolo del estudio fue aprobado por el comit&#233; &#233;tico local&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Como parte de la valoraci&#243;n rutinaria de los pacientes en la Unidad de Nefrolog&#237;a&#44; se obtuvo una muestra de sangre en el mes previo a la realizaci&#243;n de una MSCT&#44; para la determinaci&#243;n de par&#225;metros bioqu&#237;micos relacionados con la funci&#243;n renal&#44; el metabolismo lip&#237;dico y mineral-&#243;seo&#46; El tiempo de permanencia en hemodi&#225;lisis se defini&#243; como el tiempo transcurrido desde la entrada del paciente en hemodi&#225;lisis hasta el d&#237;a de la realizaci&#243;n de la MSCT&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Todos los pacientes incluidos ten&#237;an MSCT de 16 detectores&#44; Light Speed Plus GE medical System&#46; No se utiliz&#243; contraste por v&#237;a intravenosa y las im&#225;genes adquiridas fueron reconstruidas en cortes de 2-3<span class="elsevierStyleHsp" style=""></span>mm&#46; El procesado de im&#225;genes se llev&#243; a cabo en una consola Advantage Workstation 4&#46;0 &#40;General Electric&#44; Nueva York&#44; EE&#46; UU&#46;&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Se utiliz&#243; un umbral de atenuaci&#243;n entre &#8211;200 y &#8211;20 unidades Hounsfield &#40;UH&#41; para aislar la grasa peric&#225;rdica&#46; La medici&#243;n del grosor del dep&#243;sito graso de inter&#233;s se defini&#243; mediante la delineaci&#243;n manual en<span class="elsevierStyleHsp" style=""></span>mil&#237;metros&#44; y siguiendo la distribuci&#243;n propuesta por otros autores<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a>&#46; La cantidad de grasa total de cada compartimento result&#243; de la suma del grosor del dep&#243;sito adiposo de cada surco o regi&#243;n&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0075" class="elsevierStylePara elsevierViewall">MAT&#58; dep&#243;sito graso situado en el mediastino&#44; fuera del pericardio parietal &#40;grasa preesternal&#44; pleural anterior&#44; pleuro-&#225;cigo-esof&#225;gica&#44; paravertebrales y senos cardiofr&#233;nicos&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0080" class="elsevierStylePara elsevierViewall">EAT&#58; dep&#243;sito graso visceral situado intraperic&#225;rdico y contiguo a la superficie mioc&#225;rdica &#40;surcos aur&#237;culo-ventriculares izquierdo y derecho&#44; surco interventricular&#44; &#225;pex y grosor peric&#225;rdico derecho o pared libre del ventr&#237;culo derecho&#46;</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">La cuantificaci&#243;n del score de CaC se determin&#243; mediante el m&#233;todo desarrollado por Agatston&#44; que establece un umbral de 130 UH para determinar si una lesi&#243;n est&#225; calcificada<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a>&#46; Las puntuaciones de CaC con un <span class="elsevierStyleItalic">score</span> entre 100 y 400 UH indican ateroesclerosis moderada y una probabilidad relativamente alta de enfermedad coronaria&#59; los valores de CaC &#62; 400 UH indican una enfermedad ateroescler&#243;tica grave&#44; con elevada probabilidad de CAD obstructiva y elevado riesgo de isquemia<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Para el objetivo primario se registraron los eventos CV incidentes que causaron hospitalizaci&#243;n &#40;insuficiencia card&#237;aca aguda&#44; cardiopat&#237;a isqu&#233;mica aguda&#44; fibrilaci&#243;n auricular&#44; accidente cerebrovascular y enfermedad arterial perif&#233;rica&#41;&#46; Tambi&#233;n se recogieron la mortalidad total y la mortalidad asociada a evento CV&#46; La supervivencia global se defini&#243; como el tiempo desde el momento del reclutamiento hasta el fallecimiento del paciente&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">An&#225;lisis estad&#237;stico</span><p id="par0095" class="elsevierStylePara elsevierViewall">Las variables cuantitativas se expresaron en sus medias y desviaci&#243;n est&#225;ndar&#44; o mediana y rango intercuartil&#44; seg&#250;n su ajuste a la normalidad&#44; aplicando la prueba de Kolmogorov-Smirnov&#46; Las variables categ&#243;ricas se expresaron en porcentajes relativos al tama&#241;o de la muestra&#44; salvo que se especifique lo contrario&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Para llevar a cabo el an&#225;lisis del objetivo primario se dividi&#243; la serie en 2<span class="elsevierStyleHsp" style=""></span>cohortes de casos seleccionados de acuerdo con el punto de corte que determine una mayor sensibilidad &#40;S&#41; y especificidad &#40;E&#41; en la curva ROC para mortalidad total seg&#250;n el &#237;ndice de Youden&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Los 2<span class="elsevierStyleHsp" style=""></span>grupos as&#237; dise&#241;ados fueron comparados mediante una prueba de la t de Student o de Kruskal-Wallis&#44; seg&#250;n estuviese indicado&#46; Tambi&#233;n se llev&#243; a cabo un modelo lineal de regresi&#243;n m&#250;ltiple para estimar aquellas variables que se asociaron a un mayor grosor del tejido adiposo definido en el EAT&#46; Las pruebas de correlaci&#243;n de Pearson o Spearman se utilizaron para explorar la relaci&#243;n del tejido adiposo con las diferentes variables de riesgo CV&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">La influencia de las variables definidas&#44; EAT y MAT&#44; sobre la mortalidad global y los eventos CV se determin&#243; aplicando modelos proporcionales univariados de Cox&#46; El m&#233;todo de Kaplan-Meier &#40;KM&#41; y el de Mantel-Cox <span class="elsevierStyleItalic">&#40;log-rank test&#41;</span> fueron aplicados para comparar las curvas de supervivencia de cohortes definidas por el mejor punto de corte de EAT&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Los datos fueron analizados utilizando el paquete estad&#237;stico versi&#243;n SPSS 20&#46;0 &#40;SPSS Software&#44; Chicago&#44; IL&#44; EE&#46; UU&#46;&#41; y R versi&#243;n 3&#46;5&#46;2 &#40;2018&#41;&#59; se estableci&#243; un nivel de significaci&#243;n de la p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Resultados</span><p id="par0120" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas basales de la serie analizada est&#225;n recogidas en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; Se incluyeron finalmente 104 casos&#44; de los cuales 63 pacientes estaban en programa de hemodi&#225;lisis y 41 pacientes ten&#237;an ERC avanzada sin tratamiento sustitutivo&#59; el 50&#37; de los casos eran mujeres&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">El EAT fue mayor en los pacientes en hemodi&#225;lisis respecto a aquellos con ERC avanzada sin tratamiento renal sustitutivo &#40;17&#44;98<span class="elsevierStyleHsp" style=""></span>mm &#91;5&#44;27&#93; vs&#46; 13&#44;1<span class="elsevierStyleHsp" style=""></span>mm &#91;3&#44;98&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Los casos con DM tipo 2 ten&#237;an una mayor cantidad de tejido adiposo peric&#225;rdico&#44; respecto a aquellos sin DM tipo 2&#59; EAT &#40;18&#44;74<span class="elsevierStyleHsp" style=""></span>mm &#91;6&#44;16&#93; vs&#46; 15&#44;16<span class="elsevierStyleHsp" style=""></span>mm &#91;4&#44;77&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;011&#41; y MAT &#40;59&#44;67<span class="elsevierStyleHsp" style=""></span>mm &#91;20&#44;88&#93; vs&#46; 52&#44;94<span class="elsevierStyleHsp" style=""></span>mm &#91;32&#44;65&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">De acuerdo con el &#237;ndice de Youden&#44; el &#225;rea bajo la curva &#40;AUC&#41; para EAT y mortalidad total fue de 0&#44;76 &#40;IC del 95&#37;&#44; 0&#44;66-0&#44;84&#41;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; El punto de corte de EAT para predecir mortalidad total fue 11&#44;45<span class="elsevierStyleHsp" style=""></span>mm &#40;S 92&#44;86&#37;&#59; E 43&#44;75&#37;&#59; valor predictivo positivo &#91;VPP&#93; 65&#44;82&#37;&#59; valor predictivo negativo &#91;VPN&#93; 84&#37; y precisi&#243;n 70&#44;2&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">El AUC para MAT y mortalidad total fue de 0&#44;6 &#40;IC del 95&#37;&#44; 0&#44;49-0&#44;71&#41;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;08&#46; El punto de corte de MAT para predecir mortalidad total fue de 55&#44;6<span class="elsevierStyleHsp" style=""></span>mm &#40;S 44&#44;64&#37;&#59; E 83&#44;33&#37;&#46; VPP 75&#44;76&#37;&#59; VPN 56&#44;34&#37; y precisi&#243;n 62&#44;5&#37;&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Se observaron diferencias estad&#237;sticamente significativas al comparar ambas curvas AUC &#40;EAT vs&#46; MAT&#41; a favor de EAT &#40;Z<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;44&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;015&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Los pacientes con un EAT basal &#62; 11&#44;45<span class="elsevierStyleHsp" style=""></span>mm presentaban niveles de alb&#250;mina s&#233;rica m&#225;s bajos &#40;4&#44;04 g&#47;dl &#91;0&#44;46&#93; vs&#46; 4&#44;29 &#91;0&#44;31&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#41; y un mayor score de CaC &#40;1&#46;541&#44;95 &#91;1&#46;837&#44;65&#93; vs&#46; 371&#44;24 &#91;631&#44;33&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Tambi&#233;n exist&#237;a en este grupo una mayor prevalencia de casos con hipertensi&#243;n arterial&#44; DM tipo 2 y antecedentes de eventos cardiol&#243;gicos previos&#46; No hubo diferencias significativas en relaci&#243;n con la edad y el sexo entre ambos grupos&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Las variables que se correlacionaron de forma positiva con el EAT fueron&#58; el nivel s&#233;rico de triglic&#233;ridos&#44; el f&#243;sforo y el producto fosfo-c&#225;lcico&#46; La alb&#250;mina s&#233;rica se correlacion&#243; de forma negativa con el EAT &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; No encontramos correlaci&#243;n con otros par&#225;metros bioqu&#237;micos&#46; Los antecedentes cardiol&#243;gicos&#44; de hipertensi&#243;n arterial y de DM tipo 2 se correlacionaron de forma positiva con el tejido adiposo en los distintos territorios&#46; No encontramos correlaci&#243;n significativa con la edad ni con el tiempo de permanencia previo en hemodi&#225;lisis&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Al realizar el modelo lineal de regresi&#243;n m&#250;ltiple&#44; las variables que pod&#237;an predecir un mayor grosor de EAT fueron&#58; la alb&#250;mina&#44; el <span class="elsevierStyleItalic">score</span> de CaC&#44; la creatinina&#44; la DM tipo 2 y el evento cardiol&#243;gico previo&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;37&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Adem&#225;s&#44; el tejido graso medido en distintos territorios se correlacion&#243; de forma positiva con el <span class="elsevierStyleItalic">score</span> de CaC&#44; alcanz&#225;ndose una relaci&#243;n m&#225;s significativa en el caso del EAT &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41; en comparaci&#243;n con MAT &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;39&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 vs&#46; &#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;3&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Mortalidad&#44; evento CV y EAT</span><p id="par0165" class="elsevierStylePara elsevierViewall">Durante un periodo de seguimiento de 112&#44;68 &#40;IC&#160;95&#37; 109&#44;94 -115&#44;42&#41; meses&#44; hubo 56 fallecidos&#46; De estos&#44; 48 pacientes pertenec&#237;an al grupo de mayor EAT &#40;&#62; 11&#44;45<span class="elsevierStyleHsp" style=""></span>mm&#41; y 8 pacientes al de menor grasa &#40;&#60; 11&#44;45<span class="elsevierStyleHsp" style=""></span>mm&#41; &#40;&#967;<span class="elsevierStyleSup">2</span> 12&#44;25&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Seg&#250;n el an&#225;lisis de KM&#44; los casos con un grosor de EAT &#62; 11&#44;45<span class="elsevierStyleHsp" style=""></span>mm ten&#237;an mayor mortalidad&#44; en comparaci&#243;n con aquellos con un grosor inferior&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">La supervivencia media de los pacientes con EAT<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>11&#44;45<span class="elsevierStyleHsp" style=""></span>mm fue de 97&#44;48 meses &#40;IC del 95&#37;&#44; 81&#44;46-113&#44;51&#41; vs&#46; 76&#44;65 meses &#40;IC del 95&#37;&#44; 66&#44;28-91&#44;47&#41; en aquellos con EAT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;45<span class="elsevierStyleHsp" style=""></span>mm&#59; &#967;<span class="elsevierStyleSup">2</span> 7&#44;35&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>A&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">En relaci&#243;n con la mortalidad por causa CV&#44; de los 20 fallecidos&#44; 16 pacientes ten&#237;an un grosor EAT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;45<span class="elsevierStyleHsp" style=""></span>mm&#46; La supervivencia media para mortalidad CV fue de 109&#44;11 meses &#40;IC del 95&#37;&#44; 95&#44;59-122&#44;64&#41; para aquellos con grosor EAT &#60; 11&#44;45<span class="elsevierStyleHsp" style=""></span>mm y de 104&#44;57 meses &#40;IC del 95&#37;&#44; 94-113&#44;8&#41; para los de EAT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;45<span class="elsevierStyleHsp" style=""></span>mm &#40;&#967;<span class="elsevierStyleSup">2</span> 1&#44;7&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>NS&#41;&#46; Hubo un total de 53 eventos CV incidentes que causaron ingreso hospitalario &#40;eventos no fatales&#41;&#59; el 52&#44;1&#37; ocurri&#243; en pacientes con un grosor total de EAT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;45<span class="elsevierStyleHsp" style=""></span>mm vs&#46; 47&#44;9&#37; con EAT &#60; 11&#44;45<span class="elsevierStyleHsp" style=""></span>mm &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>NS&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">El an&#225;lisis de KM para la variable combinada de mortalidad y evento CV fue estad&#237;sticamente significativo &#40;&#967;<span class="elsevierStyleSup">2</span> 4&#44;25&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;039&#41;&#46; Mientras que la supervivencia media libre de cualquier evento fue de 105&#44;04 meses &#40;IC del 95&#37;&#44; 91&#44;1-118&#44;97&#41; para un grosor total de EAT<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>11&#44;45<span class="elsevierStyleHsp" style=""></span>mm en comparaci&#243;n con 88&#44;36 meses &#40;IC del 95&#37;&#44; 84&#44;54-101&#44;57&#41; para un grosor de EAT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;45<span class="elsevierStyleHsp" style=""></span>mm &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>B&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">En el an&#225;lisis de supervivencia univariado de Cox&#44; la presencia de un grosor EAT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;45<span class="elsevierStyleHsp" style=""></span>mm se asoci&#243; con un aumento del riesgo de mortalidad global&#44; HR 2&#44;28 &#40;IC del 95&#37;&#44; 1&#44;03-5&#44;04&#41;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;042&#44; y de mortalidad CV HR 3&#44;01 &#40;IC del 95&#37;&#44; 0&#44;87-10&#44;44&#41;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;08&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Mortalidad combinada seg&#250;n score de CaC y EAT</span><p id="par0190" class="elsevierStylePara elsevierViewall">La relaci&#243;n positiva encontrada entre el score de CaC y el EAT nos llev&#243; a explorar si ambas variables ten&#237;an potencia estad&#237;stica para el grupo de pacientes que cumplieran los valores de mayor riesgo para ambas&#58; <span class="elsevierStyleItalic">score</span> de CaC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>400 UH y EAT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;45<span class="elsevierStyleHsp" style=""></span>mm&#46; De este modo&#44; y aplicando un an&#225;lisis univariante de Cox&#44; se observ&#243; un incremento de mortalidad total y CV&#44; con valores de HR 2&#44;11 &#40;IC del 95&#37;&#44; 1&#44;18-3&#44;79&#41;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#44; y HR 4&#44;4 &#40;IC del 95&#37;&#44; 1&#44;09-17&#44;8&#41;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;038&#44; respectivamente&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">As&#237; mismo&#44; en el an&#225;lisis de supervivencia&#44; se obtuvieron valores de supervivencia media libre de eventos CV no fatales y de mortalidad CV &#40;combinado&#41; significativos&#44; &#967;<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>29&#44;16&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#44; para el grupo no afectado <span class="elsevierStyleItalic">&#40;score</span> de CaC<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>400 UH y EAT<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>11&#44;45<span class="elsevierStyleHsp" style=""></span>mm&#58; 112&#44;41 meses &#91;IC del 95&#37;&#44; 103&#44;68-121&#44;14&#41; en comparaci&#243;n con el grupo de los casos afectados <span class="elsevierStyleItalic">&#40;score</span> de CaC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>400 UH y EAT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#44;45<span class="elsevierStyleHsp" style=""></span>mm&#41;&#58; 76&#44;09 meses &#40;IC del 95&#37;&#44; 64&#44;22-87&#44;95&#41; &#40;<a class="elsevierStyleCrossRef" href="#sec0075">material suplementario&#44; anexo&#44; figura 1 suplementaria A</a>&#41;&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">En el caso de la mortalidad total&#44; esta significaci&#243;n estad&#237;stica se mantuvo &#40;&#967;<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#44;97 p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; con supervivencias para el grupo no afectado de 96&#44;3 meses &#40;IC del 95&#37;&#44; 84&#44;63-107&#44;97&#41;&#44; en comparaci&#243;n con la menor supervivencia del grupo afectado&#58; 69&#44;19 meses &#40;IC del 95&#37;&#44; 57&#44;9-80&#44;49&#41; &#40;<a class="elsevierStyleCrossRef" href="#sec0075">material suplementario&#44; anexo&#44; figura 1 sumplemtaria B</a>&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Mortalidad&#44; evento CV y MAT</span><p id="par0205" class="elsevierStylePara elsevierViewall">El total de pacientes fallecidos que presentaban un grosor mediast&#237;nico superior a 55&#44;6<span class="elsevierStyleHsp" style=""></span>mm alcanz&#243; el 23&#44;08&#37;&#46; Seg&#250;n el an&#225;lisis de Kaplan-Meier&#44; los pacientes con un grosor total de MAT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>55&#44;6<span class="elsevierStyleHsp" style=""></span>mm tuvieron una mayor mortalidad que aquellos con un grosor total inferior &#40;&#967;<span class="elsevierStyleSup">2</span> 5&#44;85&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;016&#41; &#40;<a class="elsevierStyleCrossRef" href="#sec0075">material suplementario&#44; anexo</a>&#44; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a> S-A&#41;&#46; No fue as&#237; en el caso de mortalidad y eventos CV combinados &#40;<a class="elsevierStyleCrossRef" href="#sec0075">material suplementario&#44; anexo&#44; figura 2 suplementaria</a>&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discusi&#243;n</span><p id="par0210" class="elsevierStylePara elsevierViewall">Diversos estudios realizados en poblaci&#243;n general sugieren una asociaci&#243;n entre el EAT y el s&#237;ndrome metab&#243;lico<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">8&#44;27</span></a>&#44; la resistencia a la insulina&#44; la adiponectina<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> y con par&#225;metros bioqu&#237;micos de inflamaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;8&#44;10</span></a>&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Al igual que en otros estudios&#44; en nuestra serie encontramos que los pacientes con DM y ERC ten&#237;an un mayor deposito graso peric&#225;rdico en todos los territorios medidos respecto a los pacientes sin DM<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">19&#44;29</span></a>&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">En el an&#225;lisis univariado&#44; objetivamos una correlaci&#243;n negativa entre el nivel s&#233;rico de alb&#250;mina y el grosor total de EAT&#46; La hipoalbuminemia es un componente del complejo inflamaci&#243;n-malnutrici&#243;n&#44; que&#44; a su vez&#44; est&#225; implicado en la etiopatogenia de la enfermedad CV y en la calcificaci&#243;n vascular de los pacientes con ERC avanzada y en hemodi&#225;lisis&#44; lo que podr&#237;a indicar una posible asociaci&#243;n entre el EAT y el complejo inflamaci&#243;n-malnutrici&#243;n en esos pacientes<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;30</span></a>&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Respecto al perfil lip&#237;dico&#44; los niveles de triglic&#233;ridos podr&#237;an estar relacionados con el grosor total de EAT y MAT&#44; no siendo as&#237; en el caso del colesterol total&#46; Es importante destacar que en la ERC avanzada y en hemodi&#225;lisis existe un perfil lip&#237;dico diferente del de la poblaci&#243;n general&#46; La concentraci&#243;n total de colesterol no es tan importante&#44; ya que influye m&#225;s su capacidad aterog&#233;nica y su densidad<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a>&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">El EAT se correlacion&#243; de forma positiva con los niveles de f&#243;sforo&#44; el producto fosfo-c&#225;lcico y el <span class="elsevierStyleItalic">score</span> de CaC&#46; La calcificaci&#243;n vascular en la ERC avanzada es muy prevalente&#46; Los principales factores patog&#233;nicos implicados son el disbalance en el metabolismo fosfo-c&#225;lcico y la inflamaci&#243;n cr&#243;nica&#46; La hiperfosfatemia y el producto fosfo-c&#225;lcico elevado se relacionan con un aumento de mortalidad y de la calcificaci&#243;n vascular en pacientes con tratamiento renal sustitutivo<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;32</span></a>&#46; Por otro lado&#44; la CaC es mayor y progresa m&#225;s r&#225;pidamente en pacientes con ERC avanzada y se ha asociado en los &#250;ltimos a&#241;os con el desarrollo de eventos y mortalidad CV<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">33&#44;34</span></a>&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Sin embargo&#44; el MAT no se correlacion&#243; con ning&#250;n par&#225;metro bioqu&#237;mico del metabolismo &#243;seo-mineral y su asociaci&#243;n con el score de CaC fue menos intensa en comparaci&#243;n con el EAT&#46; Este resultado apoyar&#237;a la hip&#243;tesis de que el MAT se relaciona con componentes del s&#237;ndrome metab&#243;lico<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#44;10</span></a> y que el EAT estar&#237;a implicado principalmente con el desarrollo de la aterosclerosis y la CaC<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">16&#44;17&#44;28&#44;35</span></a>&#46; Una posible explicaci&#243;n podr&#237;a ser la proximidad del EAT con las arterias coronarias&#44; produci&#233;ndose un efecto local paracrino inflamatorio sobre el endotelio coronario<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">16&#44;28</span></a>&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">En poblaci&#243;n general&#44; el EAT se ha asociado con eventos coronarios fatales y no fatales<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;36</span></a>&#46; La cuantificaci&#243;n de EAT podr&#237;a ser una herramienta predictora de riesgo CV en pacientes con ERC o en hemodi&#225;lisis&#44; pero los estudios al respecto son escasos<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#44;20&#44;23</span></a>&#46; En nuestra serie&#44; aquellos pacientes con mayor grosor total de EAT y MAT tuvieron una mayor mortalidad y una menor supervivencia libre de eventos CV no fatales y mortalidad CV<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#44;23&#44;37</span></a>&#46; Si bien se necesitar&#237;an m&#225;s estudios prospectivos para valorar si la medici&#243;n del EAT a&#241;ade alguna ventaja a la medici&#243;n del <span class="elsevierStyleItalic">score</span> de CaC como factor predictor de mortalidad&#44; riesgo CV y marcador de CAD&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Nuestro estudio tiene algunas limitaciones&#46; Es un estudio <span class="elsevierStyleItalic">post hoc&#44;</span> por lo que los resultados deben ser considerados como preliminares y no se pueden establecer relaciones causa-efecto&#46; No disponemos de grupo control&#46; El tama&#241;o muestral es relativamente peque&#241;o&#44; por lo que la potencia estad&#237;stica es limitada y no podemos descartar una asociaci&#243;n del EAT con otros factores de riesgo CV&#46; Por &#250;ltimo&#44; nuestro estudio est&#225; realizado con pacientes prevalentes en hemodi&#225;lisis&#44; y es bien sabido que el tiempo de permanencia en tratamiento renal sustitutivo se asocia a un aumento de mortalidad<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a>&#46; En este sentido&#44; el haber podido incluir una muestra de pacientes incidentes en hemodi&#225;lisis habr&#237;a podido evitar un posible sesgo de selecci&#243;n&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusiones</span><p id="par0250" class="elsevierStylePara elsevierViewall">La inflamaci&#243;n cr&#243;nica y la calcificaci&#243;n vascular son los principales mecanismos implicados en la elevada morbimortalidad de la ERC&#44; siendo importante la obtenci&#243;n de marcadores que permitan diagnosticar de forma precoz un elevado riesgo CV&#46; La cuantificaci&#243;n de EAT y MAT mediante MSCT podr&#237;a ser una herramienta pronostica CV adicional al score de CaC en los pacientes con ERC avanzada o hemodi&#225;lisis&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Financiaci&#243;n</span><p id="par0305" class="elsevierStylePara elsevierViewall">El presente estudio no ha recibido ninguna subvenci&#243;n&#44; financiaci&#243;n o apoyo financiero&#46; Disponibilidad de datos y materiales&#46; Los conjuntos de datos utilizados y&#47;o analizados durante el presente estudio est&#225;n disponibles por el autor de correspondencia&#46; Su disponibilidad para terceros se considerar&#225; seg&#250;n la legislaci&#243;n vigente&#44; de forma an&#243;nima&#44; y bajo solicitudes individuales de investigadores o grupos de trabajo&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethics approval and consent to participate</span><p id="par0260" class="elsevierStylePara elsevierViewall">The research has been approved by the local ethics committee&#44; from the &#8216;Pr&#237;ncipe de Asturias&#8217; University Hospital &#40;date 12&#47;1&#47;2004&#41;&#46; All participants have signed a consent form specifically design for current study&#46; La investigaci&#243;n ha sido aprobada por el comit&#233; de &#233;tica local del Hospital Universitario Pr&#237;ncipe de Asturias &#40;fecha 1 de diciembre de 2004&#41;&#46; Todos los participantes han firmado un formulario de consentimiento por escrito&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicto de intereses</span><p id="par0265" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conceptos clave</span><p id="par0270" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0275" class="elsevierStylePara elsevierViewall">El tejido graso epic&#225;rdico es un factor de riesgo cardiovascular emergente&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0280" class="elsevierStylePara elsevierViewall">En poblaci&#243;n general&#44; el tejido graso epic&#225;rdico se ha relacionado con el s&#237;ndrome metab&#243;lico&#44; la diabetes mellitus y la enfermedad arterial coronaria&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0285" class="elsevierStylePara elsevierViewall">El tejido graso epic&#225;rdico tambi&#233;n podr&#237;a ser un factor predictor de riesgo cardiovascular y de mortalidad en pacientes con enfermedad renal cr&#243;nica avanzada&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0290" class="elsevierStylePara elsevierViewall">La cuantificaci&#243;n del tejido graso epic&#225;rdico mediante tomograf&#237;a computarizada sincronizada multicorte podr&#237;a ser una herramienta pron&#243;stica adicional para estimar el riesgo cardiovascular en esta poblaci&#243;n&#46;</p></li></ul></p></span></span>"
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            1 => "Enfermedad renal cr&#243;nica"
            2 => "Calcificaci&#243;n arterial coronaria"
            3 => "Diabetes mellitus"
            4 => "Enfermedad cardiovascular"
            5 => "Mortalidad"
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        0 => array:4 [
          "clase" => "keyword"
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          "identificador" => "xpalclavsec1375842"
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            0 => "Epicardial fat tissue"
            1 => "Chronic kidney disease"
            2 => "Coronary artery calcification"
            3 => "Diabetes mellitus"
            4 => "Cardiovascular disease"
            5 => "Mortality"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n y objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">El tejido graso epicardico &#40;EAT&#41; y mediast&#237;nico &#40;MAT&#41; se relaciona con el s&#237;ndrome metab&#243;lico y la enfermedad arterial coronaria&#46; Los pacientes con enfermedad renal cr&#243;nica &#40;ERC&#41; tienen mayor volumen de EAT&#46; El objetivo de nuestro estudio fue determinar si estos dep&#243;sitos adiposos podr&#237;an estar relacionados con un aumento de mortalidad y eventos cardiovasculares en pacientes con ERC avanzada y en hemodi&#225;lisis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un an&#225;lisis <span class="elsevierStyleItalic">post hoc</span> de una serie prospectiva&#44; de 104 casos&#44; con una tomograf&#237;a computarizada sincronizada multicorte &#40;MSCT&#41; que permitiera cuantificar el grosor EAT&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El periodo de seguimiento fue de 112&#44;68 &#40;109&#44;94-115&#44;42&#41; meses&#46; El punto de corte de EAT con mayor sensibilidad y especificidad para predecir mortalidad total fue 11&#44;45<span class="elsevierStyleHsp" style=""></span>mm &#40;el 92&#44;86 y el 43&#44;75&#37;&#44; respectivamente&#41;&#46; Las variables que se correlacionaron con el EAT fueron la alb&#250;mina&#44; el nivel s&#233;rico de triglic&#233;ridos&#44; de f&#243;sforo y el producto fosfo-c&#225;lcico&#46; El EAT fue mayor en pacientes en hemodi&#225;lisis respecto aquellos con ERC avanzada &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Los pacientes con diabetes mellitus ten&#237;an mayor grosor de EAT y MAT &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#41;&#46; La supervivencia media de los pacientes con EAT &#60; 11&#44;45<span class="elsevierStyleHsp" style=""></span>mm fue de 97&#44;48 meses vs&#46; 76&#44;65 meses para un grosor &#62; 11&#44;45<span class="elsevierStyleHsp" style=""></span>mm &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Un mayor grosor de EAT y MAT se relacion&#243; con un incremento de mortalidad total&#46; Adem&#225;s&#44; el EAT se asoci&#243; con una menor supervivencia libre de eventos cardiovasculares fatales y no fatales&#46; La cuantificaci&#243;n de EAT y MAT mediante MSCT podr&#237;a tener valor pron&#243;stico para pacientes con ERC avanzada y hemodi&#225;lisis&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introducci&#243;n y objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusiones"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction and objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Epicardial and mediastinal adipose tissue &#40;EAT&#44; MAT&#41; are linked to metabolic syndrome and coronary artery disease&#46; Patients with chronic kidney disease &#40;CKD&#41; have thicker EAT&#46; We assessed if EAT and MAT could be associated with increased mortality and cardiovascular events in patients with advanced CKD and haemodialysis therapy&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A post-hoc study was performed&#46; We analyzed a prospective series of 104 cases&#46; EAT thickness was quantified by a multislice synchronized computed tomography &#40;MSCT&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The follow-up period was 112&#46;68 &#40;109&#46;94 -115&#46;42&#41; months&#46; The optimal cut-off point of EAT for prediction of total mortality was 11&#46;45<span class="elsevierStyleHsp" style=""></span>mm &#40;92&#46;86&#37; and 43&#46;75&#37;&#41;&#46; EAT thickness was associated with serum albumin levels&#44; serum triglyceride levels&#44; phosphorus and calcium phosphate product&#46; The EAT was greater in haemodialysis patients compared to those with advanced CKD <span class="elsevierStyleItalic">&#40;P</span>&#60;&#46;001&#41;&#46; Patients with diabetes mellitus had greater EAT and MAT thickness <span class="elsevierStyleItalic">&#40;P</span>&#61;&#46;018&#41;&#46; At the end of follow up&#44; the survival average time of patients with EAT thickness &#60;11&#46;45<span class="elsevierStyleHsp" style=""></span>mm was 97&#46;48 months vs&#46; 76&#46;65 months for thickness &#62; 11&#46;45<span class="elsevierStyleHsp" style=""></span>mm <span class="elsevierStyleItalic">&#40;P</span>&#61;&#46;007&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A higher EAT and MAT thickness was associated with increased mortality&#46; Furthermore&#44; EAT was associated with lower free survival time to fatal and non-fatal cardiovascular events&#46; The measurement of EAT and MAT by MSCT could be a prognostic tool to predict cardiovascular events and mortality risk in advanced CKD patients&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introduction and objectives"
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            "identificador" => "abst0030"
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            "identificador" => "abst0035"
            "titulo" => "Results"
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            "identificador" => "abst0040"
            "titulo" => "Conclusions"
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            "apendice" => "<p id="par0300" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Anexo A"
            "titulo" => "Material adicional"
            "identificador" => "sec0075"
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        ]
      ]
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      0 => array:7 [
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        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Grosor EAT&#58; punto de corte con mayor sensibilidad y especificidad en curva ROC-mortalidad global&#58; &#237;ndice de Youden&#46;</p>"
        ]
      ]
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        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Correlaci&#243;n lineal entre el EAT y el score de CaC &#40;unidades Hounsfield &#91;UH&#93;&#41;&#44; seg&#250;n Spearman&#44; rho<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;39&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">CaC&#58; calcificaci&#243;n arterial coronaria&#59; EAT&#58; tejido graso epic&#225;rdico&#46;</p>"
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      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figura 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
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        "descripcion" => array:1 [
          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">A&#41; Curvas de supervivencia de Kaplan-Meier&#46; Supervivencia libre de eventos fatales seg&#250;n el punto de corte de 11&#44;45<span class="elsevierStyleHsp" style=""></span>mm para EAT&#46; B&#41; Supervivencia media libre de eventos CV no fatales y de mortalidad CV para EAT&#44; seg&#250;n el punto de corte de 11&#44;45<span class="elsevierStyleHsp" style=""></span>mm&#46;</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">CV&#58; cardiovascular&#59; EAT&#58; tejido de grasa epic&#225;rdico&#46;</p>"
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        "identificador" => "tbl0005"
        "etiqueta" => "Tabla 1"
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Diabetes mellitus tipo 2&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Colesterol HDL &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;004&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8211;0&#44;17&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NS&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">PCR &#40;mg&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Urea &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Hemodi&#225;lisis &#40;meses&#41;&nbsp;\t\t\t\t\t\t\n
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