Letter to the Editor
Spontaneous severe hemoperitoneum in peritoneal dialysis patients
Hemoperitoneo espontáneo grave en pacientes en diálisis peritoneal
Laura del Río García, Carmen Merino Bueno, Emilio Sánchez-Álvarez
Corresponding author
Área de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
Read
Not available
Timeswas read the article
Total PDF
Total HTML
Share statistics
array:24 [ "pii" => "S2387020617304564" "issn" => "23870206" "doi" => "10.1016/j.medcle.2017.06.044" "estado" => "S300" "fechaPublicacion" => "2017-08-10" "aid" => "3973" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2017" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2017;149:137-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0025775317301458" "issn" => "00257753" "doi" => "10.1016/j.medcli.2017.02.004" "estado" => "S300" "fechaPublicacion" => "2017-08-10" "aid" => "3973" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2017;149:137-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 13 "formatos" => array:2 [ "HTML" => 11 "PDF" => 2 ] ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>" "titulo" => "Hemoperitoneo espontáneo grave en pacientes en diálisis peritoneal" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "137" "paginaFinal" => "138" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Spontaneous severe hemoperitoneum in peritoneal dialysis patients" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Laura del Río García, Carmen Merino Bueno, Emilio Sánchez-Álvarez" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Laura" "apellidos" => "del Río García" ] 1 => array:2 [ "nombre" => "Carmen" "apellidos" => "Merino Bueno" ] 2 => array:2 [ "nombre" => "Emilio" "apellidos" => "Sánchez-Álvarez" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020617304564" "doi" => "10.1016/j.medcle.2017.06.044" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617304564?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775317301458?idApp=UINPBA00004N" "url" => "/00257753/0000014900000003/v1_201707120034/S0025775317301458/v1_201707120034/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2387020617304412" "issn" => "23870206" "doi" => "10.1016/j.medcle.2017.06.029" "estado" => "S300" "fechaPublicacion" => "2017-08-10" "aid" => "3820" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2017;149:140" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image in medicine</span>" "titulo" => "Superficial basal cell carcinoma" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "140" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Carcinoma basocelular superficial" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1179 "Ancho" => 827 "Tamanyo" => 101637 ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Roberto Cullen, Paula Hasbún, Matías Campos-Villenas" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Roberto" "apellidos" => "Cullen" ] 1 => array:2 [ "nombre" => "Paula" "apellidos" => "Hasbún" ] 2 => array:2 [ "nombre" => "Matías" "apellidos" => "Campos-Villenas" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775316305267" "doi" => "10.1016/j.medcli.2016.10.017" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775316305267?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617304412?idApp=UINPBA00004N" "url" => "/23870206/0000014900000003/v1_201708260033/S2387020617304412/v1_201708260033/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020617304473" "issn" => "23870206" "doi" => "10.1016/j.medcle.2017.06.035" "estado" => "S300" "fechaPublicacion" => "2017-08-10" "aid" => "3987" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2017;149:136-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Ayahuasca intoxication" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "136" "paginaFinal" => "137" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Intoxicación por ayahuasca" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Bernat de Pablo Márquez, Beatriz Dietl Gómez-Luengo" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Bernat" "apellidos" => "de Pablo Márquez" ] 1 => array:2 [ "nombre" => "Beatriz" "apellidos" => "Dietl Gómez-Luengo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775317301793" "doi" => "10.1016/j.medcli.2017.02.017" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775317301793?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617304473?idApp=UINPBA00004N" "url" => "/23870206/0000014900000003/v1_201708260033/S2387020617304473/v1_201708260033/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Spontaneous severe hemoperitoneum in peritoneal dialysis patients" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">Dear Editor</span>," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "137" "paginaFinal" => "138" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Laura del Río García, Carmen Merino Bueno, Emilio Sánchez-Álvarez" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Laura" "apellidos" => "del Río García" ] 1 => array:2 [ "nombre" => "Carmen" "apellidos" => "Merino Bueno" ] 2 => array:4 [ "nombre" => "Emilio" "apellidos" => "Sánchez-Álvarez" "email" => array:1 [ 0 => "jesastur@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Área de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemoperitoneo espontáneo grave en pacientes en diálisis peritoneal" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Spontaneous hemoperitoneum is a common complication in patients on peritoneal dialysis (PD). Different causes determine the drainage of a peritoneal effluent with blood content. Generally, this situation has a benign and self-limiting course. Severe forms of presentation are less frequent, usually secondary to intra-abdominal disease and may lead to a significant morbidity and mortality. We intend to make a review of all cases of severe spontaneous hemoperitoneum in our unit to analyze the causes, forms of presentation, differential diagnosis and treatment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Throughout the 24 years of operation of our hospital's PD unit, 786 patients have been treated. Of these, 6 (0.76%) had severe spontaneous hemoperitoneum. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the characteristics of these patients.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In all cases the diagnosis was made by CT angiography, which showed the bleeding site, and the treatment was the selective embolization of the same. Complete recovery occurred in all 6 patients, and they were able to continue in the PD program.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Hemoperitoneum in PD is a complication whose incidence varies between 6 and 8.4%, according to previous reviews.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> In most cases they are mild and follow a benign course, occurring more frequently in women of childbearing age (it is related to ovulation, retrograde menses, rupture of a cyst or endometriosis).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> In addition, there are other relatively common causes, such as small traumas in the peritoneal wall caused by catheters, rupture of renal, liver or splenic cysts, or some abdominal trauma. The course of all these conditions is usually benign and is resolved by peritoneal lavage with dialysis solutions at room temperature and sodium heparin. Temporary suspension of antiplatelet agents and/or oral anticoagulants may sometimes be necessary. However, up to 20% of cases can be severe (resulting in a severe hemoperitoneum incidence of 1.2–1.7%), causing hemodynamic instability, transfusions or surgical interventions, and are usually secondary to intra-abdominal disease.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,3–5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We found 6 episodes of severe hemoperitoneum in our site, with an incidence of 0.8% (somewhat lower than that described in the medical literature). All patients started with abdominal pain and hemoperitoneum (5 with frank hemoperitoneum and one with clear fluid but abundant red cells in the peritoneal fluid count), associated with hemodynamic instability in one of the cases. All cases were spontaneous, unrelated to previous trauma or recent surgeries, and no patient was receiving oral anticoagulants (only one with oral antiplatelet and one with LMWH). The time from the implementation of the technique and the development of this complication was very variable, from the training stage to the 28 months of the technique's progression. The diagnosis was established by CAT and angiography, showing abdominal and retroperitoneal hematomas. In addition, embolization of the active bleeding focus was achieved through the angiography. Bleeding sites were located at the left gastric artery, left hypogastric, L3 and L4 lumbar, left inferior epigastric, splenic pseudoaneurysm and branches of the right renal artery. Progression was good in most cases, except for one patient, who died; another patient required ICU admission for temporary hemodynamic support, reflecting the potential morbidity and mortality of these patients.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We conclude, therefore, that hemoperitoneum in patients on PD can be easily detectable during the exchange. However, it implies a wide range of possible causes, ranging from the most trivial to the most serious. The finding of hemoperitoneum together with signs of anemia and hemodynamic instability makes possible the early diagnosis of severe abdominal bleeding, which may improve the prognosis of this complication. In all cases the exact diagnosis was reached through an angiography and embolization of the affected branches was performed, with good angiographic result.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: del Río García L, Merino Bueno C, Sánchez-Álvarez E. Hemoperitoneo espontáneo grave en pacientes en diálisis peritoneal. Med Clin (Barc). 2017;149:137–138.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time on PD (months) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anti-platelets/anticoagulation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cause \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">61-year-old female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ruptured gastric artery pseudoaneurysm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">77-year-old female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">L3 and L4 lumbar arteries hemorrhage \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">82-year-old female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">On anticoagulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left inferior epigastric artery hemorrhage \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">60-year-old male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ruptured splenic artery pseudoaneurysm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">62-year-old male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left hypogastric artery hemorrhage \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">47-year-old male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">On anti-platelets \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right renal artery hemorrhage \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1497831.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics of cases of severe spontaneous hemoperitoneum.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hemoperitoneum complicating chronic peritoneal dialysis: single-center experience and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Greenberg" 1 => "J. Bernardini" 2 => "B.M. Piraino" 3 => "J.R. Johnston" 4 => "J.A. Perlmutter" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Kidney Dis" "fecha" => "1992" "volumen" => "19" "paginaInicial" => "252" "paginaFinal" => "256" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1553970" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recurrent hemoperitoneum complicating continuous ambulatory peritoneal dialysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.C. Tse" 1 => "P.S. Yip" 2 => "M.F. Lam" 3 => "F.K. Li" 4 => "B.Y. Choy" 5 => "T.M. Chan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Perit Dial Int" "fecha" => "2002" "volumen" => "22" "paginaInicial" => "488" "paginaFinal" => "491" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12322820" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Noninfectious complications of peritoneal dialysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.M. Bargman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:5 [ "titulo" => "Nolph and Gokal's Textbook of Peritoneal Dialysis" "paginaInicial" => "571" "paginaFinal" => "609" "edicion" => "3rd ed." "serieFecha" => "2009" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Sociedad Española de Nefrología. Guías de práctica clínica en diálisis peritoneal. Available from: <a href="http://www.senefro.org/modules/webstructure/files/guas_de_dilisis_peritoneal.pdf?check_idfile=1173">http://www.senefro.org/modules/webstructure/files/guas_de_dilisis_peritoneal.pdf?check_idfile=1173</a> [accessed 26.10.16]." ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Significado pronóstico del hemoperitoneo en diálisis peritoneal" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.P. Valenzuela Mújica" 1 => "E. Ponz" 2 => "J.C. Martínez Ocaña" 3 => "C. Blasco" 4 => "D. Marquina" 5 => "N. Mañé" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Nefrologia" "fecha" => "2008" "volumen" => "28" "paginaInicial" => "73" "paginaFinal" => "76" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18336135" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014900000003/v1_201708260033/S2387020617304564/v1_201708260033/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014900000003/v1_201708260033/S2387020617304564/v1_201708260033/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617304564?idApp=UINPBA00004N" ]
