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Multivariate analysis of predictive factors in the evolution of renal lithiasis
Análisis multivariante de factores predictivos de evolución en litiasis renal
E. Pierasa,
Corresponding author
32477apa@comb.es

Corresponding author.
, J. Ruizb, A. Vicensa, G. Fronteraa, F. Grasesc, P. Pizáa
a Servicio de Urología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
b Servicio de Urología, Hospital Universitario Joan XXIII, Tarragona, Spain
c Laboratorio de Investigación en Litiasis Renal, Universidad Islas Baleares, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Despite the ongoing technological advances incorporated into the treatment of kidney stones &#40;endourology and extracorporeal shock wave lithotripsy&#41;&#44; the incidence and prevalence of kidney stones have been increasing gradually in recent years&#59; in the U&#46;S&#46; there has been an increase of 37&#37; over the last 20 years&#44; and in Germany in the last decade an increased incidence of 0&#46;54&#8211;1&#46;47&#37; has been observed&#44; reaching a prevalence of 4&#46;7&#37;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#59; particularly&#44; in Spain we found an incidence of 0&#46;73&#37; and a prevalence of 5&#46;06&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In addition to this high incidence and prevalence&#44; we must note its high recurrence rate of up to 13&#37; during the first year&#44; 35&#37; at 5 years&#44; and 50&#37; at 10 years<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#59; therefore&#44; we must consider kidney stones a chronic disease&#44; with a high expenditure on healthcare&#44; treatment&#44; and follow-up&#44; this being the most common reason for admission in urology&#44; and the most common reason for emergency assistance in urology&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Therefore&#44; it is interesting to study predictors of clinical outcome&#59; the present study aims to evaluate a number of different factors together &#40;epidemiological&#44; clinical&#44; and biochemical factors&#41;&#44; which can predict the evolution of the lithiasis&#44; in an attempt to define risk groups that allow us to design more individualized treatment and follow-up strategies&#44; based on scientific evidence&#44; a difficult aspect to achieve if we consider the multifactorial etiology of kidney stones&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">Analytical&#44; descriptive&#44; and retrospective study on a database of patients with kidney stones treated at our center during the period 2003&#8211;2007 and in which we know the epidemiological&#44; clinical&#44; and biochemical information noted above&#46; From an initial basis of 330 patients&#44; 248 entered the analysis for having in them all the data analyzed in the study&#59; of them&#44; 65&#46;7&#37; &#40;163 patients&#41; were treated with extracorporeal shock wave lithotripsy&#44; 21&#46;3&#37; &#40;53 patients&#41; expelled the lithiasis spontaneously&#44; 8&#46;4&#37; &#40;21 patients&#41; were treated with ureteroscopy&#44; and 4&#46;4&#37; &#40;11 patients&#41; with percutaneous nephrolithotomy&#46; All the data analyzed as potential predictors were collected in the first episode of the patient&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The dependent variable&#44; main and fundamental objective of the study is the final evolution&#59; in this we considered two possibilities&#58; persistence &#40;which includes those cases that were treatment failure and the cases of new onset of lithiasis&#41; and being clean of lithiasis&#46; All the patients were evaluated two months after treatment with imaging &#40;plain and&#47;or ultrasound radiological study&#41;&#44; requesting then the urinary and stone biochemical study&#46; The final evolution is that presented in the last check-up performed during their follow-up&#46; Once the treatment is performed and the episode resolved&#44; yearly check-ups are carried out with plain radiography&#44; ultrasound&#44; and urinary sediment&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We divided the independent variables introduced in the study into epidemiological factors &#40;sex and age&#41;&#44; clinical factors &#40;personal history of lithiasis&#44; number&#44; location&#44; and size of the stones&#44; bilaterality&#41;&#44; and biochemical factors &#40;urinary biochemistry and composition of the stone&#41; in relation to the different evolution of kidney stones &#40;persistency versus clean of lithiasis&#41;&#46; In the epidemiological variables&#44; we recoded age at intervals older or younger than 47&#44; as it is in this range where we found significant differences in relation to evolution&#46; In the clinical variables&#44; we considered lithiasic history those patients with a history of prior expelled kidney stones&#46; We defined the location of the lithiasis in calyceal&#44; pyelic&#44; and ureteral&#46; Bilaterality exists when the existence of bilateral lithiasis at the time of study entry is proven by radiological study&#46; Multiplicity was considered when there were kidney stones in two or more different locations radiologically verified&#46; We analyzed the size of the stones comparing stones larger or smaller than 1<span class="elsevierStyleHsp" style=""></span>cm&#44; because it is the average size&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the biochemical variables&#44; we considered the chemical composition of the stones in 4 groups according to their main component&#44; thus including 90&#37; of the entire sample &#40;calcium oxalate monohydrate&#44; calcium oxalate dihydrate&#44; hydroxyapatite&#44; and uric acid&#41; in order to simplify the study&#46; The study of the stones was performed with Optomic stereoscopic microscope&#44; Brucker IFS 66 infrared spectrometry&#44; and scanning electron microscopy coupled with X-ray microanalysis&#46; The urinary biochemistries consisted of a 2-h urine sample to find the pH &#40;Crison&#41;&#44; and a 24-h urine sample to find the levels of uric acid&#44; calcium&#44; and citrates&#46; We considered risk of crystallization of calcium salts present when we evidenced a high calciuria and&#47;or hypocitraturia&#44; and risk of crystallization of uric acid when there is hyperuricosuria and&#47;or hyperuricemia and&#47;or urinary pH<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>5&#46;5&#44; depending on the previous experience and the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The reference values are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">We divide the final evolution of kidney stones into two possibilities&#58; clean and persistence&#44; with the aim of analyzing the dependent variable with a dichotomous character and being able to perform a binomial logistic regression&#46; The univariate statistical analysis was performed with Chi-square to analyze each variable separately and relate it to the final outcome &#40;clean or persistence&#41;&#46; The multivariate analysis was performed with a binomial logistic regression with the conditional method&#44; including the variables that in the univariate analysis were statistically significant&#46; We considered statistical significance when <span class="elsevierStyleItalic">p</span> is &#8804;0&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">With a mean follow-up of 60 months &#40;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>52&#46;5&#8211;67&#46;4&#41;&#44; we observed persistence of kidney stones in 121 patients &#40;48&#46;8&#37;&#41;&#44; 127 patients &#40;51&#46;2&#37;&#41; being clean of stones&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The mean age was 44 years&#46; 69&#46;7&#37; &#40;173&#41; were men and 30&#46;3&#37; &#40;75&#41; women&#46; 54&#46;8&#37; &#40;136&#41; had a personal history of prior expulsive kidney stones&#44; compared to 45&#46;2&#37; with no history &#40;112&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the distribution of the variables called clinical&#44; in most cases it was a single lithiasis &#40;75&#37;&#41; versus multiple &#40;25&#37;&#41;&#44; unilateral &#40;78&#37;&#41; versus bilateral &#40;22&#37;&#41;&#44; and the main renal location was calyceal &#40;40&#37;&#41; versus pyelic &#40;20&#37;&#41;&#44; the ureteral being the rest &#40;40&#37;&#41;&#46; The average size of the stones was 10<span class="elsevierStyleHsp" style=""></span>mm &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">We can observe how the majority of the patients &#40;78&#37;&#41; had a positive risk of crystallization of calcium salts&#44; whereas the risk of crystallization of uric acid is much lower &#40;15&#37;&#41;&#46; The most frequently observed chemical composition of the stones is calcium oxalate dihydrate &#40;47&#37;&#41;&#44; followed by calcium oxalate monohydrate &#40;26&#37;&#41;&#44; calcium phosphate &#40;19&#37;&#41;&#44; and uric acid &#40;8&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The univariate statistical analysis performed with Chi-square relating each variable with the final outcome &#40;clean or persistence&#41; shows significant differences in favor of greater persistence when the age is lower than 47 years&#44; the lithiasis is multiple&#44; the location is calyceal&#44; the lithiasis is bilateral&#44; the risk of crystallization of calcium salts is positive&#44; and the stones are calcium oxalate dihydrate &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The binary logistic regression multivariate analysis with the variables that were significant in the univariate analysis confirms age &#40;&#60;47 years&#41;&#44; bilaterality&#44; calyceal location&#44; and calcium oxalate dihydrate stones as variables independently associated with higher persistence rates &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The high persistence of kidney stones of 48&#46;8&#37; should be emphasized&#46; Previous studies with a similar follow-up to ours encrypt this persistence in 28&#8211;60&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#8211;9</span></a> Most authors speak in general of recurrence&#44; encompassing the true recurrence &#40;new stones&#41; and persistence &#40;same stone&#41;&#59; we also included ourselves in the same variable&#44; but it seems more appropriate to call it persistence&#44; as this term includes treatment failures and recurrence cases &#40;new stones&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Regarding the effect of the epidemiological aspects&#44; we observe how sex does not seem to be a differentiating factor with respect to the patients&#8217; outcome&#46; However&#44; age is associated with a poorer outcome independently&#59; at ages under 47&#44; we found higher rates of persistence&#46; Several authors also observed that at younger ages there are higher recurrence rates and worse clinical outcome&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;11</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Of all the clinical factors analyzed&#44; we observe how the number of lithiases &#40;multiplicity&#41;&#44; bilateralism&#44; and calyceal location are associated with higher rates of persistence&#44; although only bilateralism and calyceal location independently&#46; The number of lithiases &#40;multiplicity&#41; implies higher persistence rates&#44; because the same as bilateralism involves greater number and lithiasic burden and&#44; logically&#44; more probabilities that some lithiasic remainder persists over time&#46; The calyceal location has worse evolution&#44; which may be because they have a harder eject than the renal pelvis&#44; as they were more closed cavities and farther from the kidney outlet&#46; In a study larger than ours&#44; and analyzing predictors of response to external lithotripsy&#44; it is shown how the location &#40;renal versus ureteral&#41;&#44; the number &#40;multiplicity&#41;&#44; and the previous history of kidney stones are factors associated with a worse outcome&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;12</span></a> The size of the stones and the personal history of previous lithiasis were described as predictors of outcome&#44; although we did not obtain these results&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">When we analyze the influence of the urinary biochemistry and of the composition of the stone in the global outcome&#44; we can clearly see that the risk of crystallization of calcium salts &#40;hypercalciuria and&#47;or hypocitraturia&#41; is a factor associated with a higher rate of persistence&#44; but not independently&#46; Several studies agree that hypercalciuria and hypocitraturia are urinary disorders associated with higher rates of recurrence&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;17</span></a> so our results would agree with them&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">These factors on their own are not predictors&#44; as evidenced by the fact that healthy subjects with no lithiasis also have urinary disorders<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a>&#59; however&#44; possibly in conjunction with other factors&#44; they do have predictive value&#44; as suggested by the studies showing that the hypercalciuria and hypocitraturia&#44; when associated with the presence of heterogeneous nucleants &#40;for example remains after lithotripsy&#41;&#44; induce their growth<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;20&#44;21</span></a>&#59; in fact&#44; several studies confirm better results in the treatment of lithiasis when medical treatment oriented to the associated urinary disorder<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;26</span></a> is associated with the treatment of the stone &#40;intra or extracorporeal lithotripsy&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Most studies designed to define predictors in kidney stones have been conducted on oxalocalcic lithiasis in general&#59; to us it seemed interesting to analyze uric and hydroxyapatite lithiasis as well&#44; because it corresponds to 32&#37; of the sample studied &#40;11 and 18&#41;&#59; this aspect becomes more important when we observe that the chemical composition of the stones is an independent predictor&#46; We must emphasize that the calcium oxalate dihydrate lithiasis is the one with the most persistence&#44; followed by calcium oxalate monohydrate lithiasis&#44; hydroxyapatite lithiasis&#44; and uric acid lithiasis&#46; These results seem logical&#44; calcium oxalate dihydrate lithiasis being the most associated with hypercalciuria and hypocitraturia&#44; known as lithogenic risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Other authors have observed different lithiasic recurrence figures relating to the composition of the stones&#44; and with similar results&#44; although they have not been able to be defined as independent predictors in relation to the outcome&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;27</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">We are aware that this study may have the biases inherent to a retrospective design and the multifactorial nature of the subject matter&#59; in fact&#44; we did not discuss the possible influence of diet&#44; lifestyle&#44; and socioeconomic factors&#46; Neither did we analyze the role of medical treatment&#44; because we believe that the indications and duration thereof were not uniform&#44; so the results would not be representative&#46; Despite all this&#44; and taking into account these limitations&#44; it is interesting to note that this study makes it possible to define a risk group with worse outcome&#59; the stratification of the risk for progression of kidney stones must be carried out depending on their multifactorial etiology and their knowledge will allow us to define more individualized treatment&#44; follow-up&#44; and prevention strategies&#44; with the aim of improving the outcome and quality of life of the lithiasic patient&#59; other studies of greater volume and follow-up prove it&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#8211;31</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0105" class="elsevierStylePara elsevierViewall">There is a high persistence of kidney stones&#46; The patients younger than 47&#44; with bilateral disease&#44; caliceal location&#44; and with calcium oxalate dihydrate stones have increased risk of persistent disease&#46; These patients constitute a risk group with worse clinical outcome&#44; and in them&#44; we should rethink about more intense or aggressive treatment options and promote preventive measures&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Funding</span><p id="par0110" class="elsevierStylePara elsevierViewall">This work received grants from the <span class="elsevierStyleGrantSponsor">Foundation for Research in Urology</span> with the grant Rafael Moll&#225; and Rodrigo 2008&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Materials and methods"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2011-08-22"
    "fechaAceptado" => "2011-09-29"
    "PalabrasClave" => array:2 [
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec88843"
          "palabras" => array:5 [
            0 => "Kidney stone"
            1 => "Multivariate analysis"
            2 => "Risk factor"
            3 => "Predictive factor"
            4 => "Natural history"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:5 [
            0 => "Litiasis renal"
            1 => "An&#225;lisis multivariante"
            2 => "Factor riesgo"
            3 => "Factores predictivos"
            4 => "Evoluci&#243;n"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To perform a multivariate statistical analysis of epidemiological&#44; clinical and biochemical factors that make it possible to identify the variables that can independently predict the course of renal lithiasis&#44; thus defining a group at risk of worse evolution&#46;</p> <span class="elsevierStyleSectionTitle">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective&#44; descriptive and analytic study was in a cohort of 248 patients with kidney stones treated in our center from 2003 to 2007&#46; A univariate analysis &#40;Chi-square&#41; and a multivariate analysis &#40;regression model&#41; of possible epidemiological predictive factors &#40;age and gender&#41;&#44; clinical data of stones &#40;number&#44; localization&#44; size and bilaterality&#41; and biochemical factors &#40;urinary composition and stone composition&#41; were analyzed&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Based on a mean follow-up of 60 months &#40;95&#37; CI&#58; 52&#46;5&#8211;67&#46;4&#41; we observed a global persistence of kidney stones in 121 patients &#40;48&#46;8&#37;&#41; and 127 patients being stone-free &#40;51&#46;2&#37;&#41;&#46; The univariate analysis describes the following variables as being associated to greater persistence of lithiasis&#58; age&#44; number of stones&#44; calyceal localization and bilaterality&#44; urinary biochemical composition&#44; and stone biochemical composition&#46; In regards to all of the above variables&#44; only age less than 47 years&#44; bilaterality&#44; stone localization and chemical composition of the lithiasis &#40;oxalate calcium dehydrated&#41; were significantly associated to a major risk of persistence of kidney stones&#46;</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There is a high persistence rate of kidney stones&#46; Patient age inferior to 47 year&#44; calyceal localization&#44; bilaterality&#44; and biochemical composition of stones &#40;oxalate calcium dihydrate&#41; are independent factors associated to higher persistence rate of kidney stones&#46; These factors indicate a risk group with a worse clinical prognosis in which we should reconsider more individualized diagnostic and therapeutic strategies&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Realizar un an&#225;lisis estad&#237;stico multivariante de factores epidemiol&#243;gicos&#44; cl&#237;nicos y bioqu&#237;micos que permitan identificar las variables que independientemente puedan predecir la evoluci&#243;n de la litiasis renal&#44; definiendo as&#237; un grupo de riesgo con peor evoluci&#243;n&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio anal&#237;tico&#44; descriptivo&#44; retrospectivo sobre 248 pacientes visitados en nuestro centro en el periodo 2003-2007&#46; Se ha realizado an&#225;lisis univariante &#40;Chi-cuadrado&#41; y multivariante &#40;regresi&#243;n log&#237;stica&#41; de posibles factores predictivos epidemiol&#243;gicos &#40;sexo&#44; edad&#41;&#44; cl&#237;nicos &#40;antecedentes personales de litiasis&#44; n&#250;mero&#44; localizaci&#243;n caliciar y tama&#241;o de c&#225;lculos&#44; bilateralidad&#41; y bioqu&#237;micos &#40;bioqu&#237;mica urinaria y composici&#243;n del c&#225;lculo&#41; en relaci&#243;n con la evoluci&#243;n de la litiasis renal &#40;limpio o persistencia renal&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Con un seguimiento medio de 60 meses &#40;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>52&#44;5-67&#44;4&#41; observamos una persistencia global de litiasis renal en 121 pacientes &#40;48&#44;8&#37;&#41;&#44; estando limpios de litiasis 127 pacientes &#40;51&#44;2&#37;&#41;&#46; El an&#225;lisis univariante describe como variables asociadas a mayor persistencia de litiasis la edad&#44; el n&#250;mero de litiasis&#44; la localizaci&#243;n calicilar&#44; la bilateralidad&#44; la composici&#243;n bioqu&#237;mica urinaria y la composici&#243;n bioqu&#237;mica del c&#225;lculo&#59; de todas estas variables&#44; en el an&#225;lisis multivariante solo mantienen significaci&#243;n estad&#237;stica la edad inferior a 47 a&#241;os&#44; la bilateralidad&#44; la localizaci&#243;n calicilar y la composici&#243;n qu&#237;mica de la litiasis &#40;oxalato c&#225;lcico dihidrado&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Existe una elevada persistencia de litiasis renal&#46; La edad inferior a 47 a&#241;os&#44; la bilateralidad&#44; la localizaci&#243;n calicilar y la composici&#243;n qu&#237;mica de la litiasis &#40;oxalato c&#225;lcico dihidrato&#41; son factores asociados a mayor persistencia de litiasis renal de forma independiente&#46; Estos factores se&#241;alan un grupo con peor evoluci&#243;n cl&#237;nica&#44; en los que deber&#237;amos replantear estrategias diagn&#243;sticas y terap&#233;uticas m&#225;s individualizadas&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Pieras E&#44; et al&#46; An&#225;lisis multivariante de factores predictivos de evoluci&#243;n en litiasis renal&#46; Actas Urol Esp&#46; 2012&#59;36&#58;346&#8211;51&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="\n
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                  """
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t">49 &#40;52&#46;4&#41;&nbsp;\t\t\t\t\t\t\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"><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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">N&#46;S&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Size of the stone</span></td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>&#60;1<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">N&#46; S&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Number</span></td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Single&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Multiple&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Laterality</span></td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Unilateral&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\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"><span class="elsevierStyleHsp" style=""></span>Bilateral&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\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"><span class="elsevierStyleHsp" style=""></span>Calyceal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\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"><span class="elsevierStyleHsp" style=""></span>Pyelic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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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\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;44&#46;6&#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" 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"><span class="elsevierStyleHsp" style=""></span>Ureteral&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95 &#40;38&#46;3&#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="char" valign="\n
                  \t\t\t\t\ttop\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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53 &#40;55&#46;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="" 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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" 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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Ca crystallization risk</span></td></tr><tr title="table-row"><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"><span class="elsevierStyleHsp" style=""></span>Yes&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="char" valign="\n
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                  \t\t\t\t">194 &#40;78&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">113 &#40;58&#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">81 &#40;42&#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">0&#46;048&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&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="char" valign="\n
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                  \t\t\t\t">54 &#40;21&#46;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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ca Ox dihydrate&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ca Ox monohydrate&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">68 &#40;27&#46;4&#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">36 &#40;53&#46;2&#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"><span class="elsevierStyleHsp" style=""></span> Calcium phosphate&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">47 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Uric acid&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9 &#40;46&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">11 &#40;54&#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">3&#46;15 &#40;1&#46;06&#8211;9&#46;31&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Calcium oxalate monohydrate&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;55 &#40;0&#46;51&#8211;4&#46;69&#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"><span class="elsevierStyleHsp" style=""></span>Calcium phosphate&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos