Detección de enfermedad hepática avanzada incorporando el uso de la elastografía de transición en atención primaria

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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 cirrosis es una de las principales causas de muerte&#44; de a&#241;os de vida perdidos y de a&#241;os de vida ajustados por discapacidad en todo el mundo&#46; La cirrosis y el carcinoma hepatocelular &#40;CHC&#41; causan el 3&#44;5&#37; de todas las muertes en el mundo&#46; Las principales causas de cirrosis en los pa&#237;ses desarrollados son el alcohol y la esteatosis hep&#225;tica metab&#243;lica &#40;EHmet&#41;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En el caso de la enfermedad hep&#225;tica grasa no alcoh&#243;lica &#40;EHGNA&#41;&#44; actualmente renombrada como enfermedad esteat&#243;sica hep&#225;tica asociada a disfunci&#243;n metab&#243;lica &#40;MASLD&#41; por el reciente consenso internacional<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a>&#44; y como EHmet en nuestro pa&#237;s<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a>&#44; varios estudios europeos&#44; anglosajones y espa&#241;oles han analizado su alta carga de comorbilidad y utilizaci&#243;n de recursos sanitarios&#44; que aumenta a medida que avanza la enfermedad<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5&#8211;8</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La enfermedad hep&#225;tica cr&#243;nica suele cursar de forma asintom&#225;tica y raramente se diagnostica en estadios precoces&#46; Adem&#225;s&#44; la bioqu&#237;mica hep&#225;tica no permite detectar la fibrosis hep&#225;tica&#44; que es la que determina la morbimortalidad de estos pacientes&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En la EHmet es la fibrosis&#44; no otros hallazgos histol&#243;gicos&#44; la que mejor predice como factor independiente la mortalidad general a largo plazo&#44; el trasplante hep&#225;tico y los eventos relacionados con hepatopat&#237;a<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Los m&#233;todos no invasivos para evaluar la fibrosis hep&#225;tica son la elastograf&#237;a de transici&#243;n &#40;ET&#41; que mide la rigidez hep&#225;tica&#44; y los m&#233;todos s&#233;ricos&#44; que incluyen determinaciones anal&#237;ticas patentadas e indicadores bioqu&#237;micos de fibrosis estimados por calculadoras en base a par&#225;metros habituales&#59; siendo los m&#225;s utilizados estos &#250;ltimos y concretamente el NAFLD fibrosis <span class="elsevierStyleItalic">score</span> &#40;NFS&#41; y el FIB-4 &#40;fibrosis-4&#41;&#44; que permiten excluir la fibrosis avanzada en una alta proporci&#243;n de pacientes &#40;valores predictivos negativos &#62;<span class="elsevierStyleHsp" style=""></span>90&#37;&#41;&#44; permitiendo un uso m&#225;s selectivo de la ET&#46; Las gu&#237;as actuales recomiendan el uso de los &#237;ndices s&#233;ricos de fibrosis en la pr&#225;ctica cl&#237;nica en atenci&#243;n primaria &#40;AP&#41;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;11</span></a>&#46; Se ha demostrado que el uso secuencial de diferentes pruebas no invasivas&#44; en concreto &#237;ndices s&#233;ricos m&#225;s ET&#44; mejoran la precisi&#243;n diagn&#243;stica<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Una revisi&#243;n sistem&#225;tica sobre los estudios poblacionales en AP estima la prevalencia de fibrosis significativa con distintos puntos de corte de la ET&#44; siendo para una medici&#243;n de la rigidez hep&#225;tica de 8 kilopascales &#40;kPa&#41; del 5&#44;8-7&#44;5&#37; y para una de 9-9&#44;6<span class="elsevierStyleHsp" style=""></span>kPa&#44; del 2-3&#44;6&#37;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">En un estudio realizado en los centros de salud de varias &#225;reas de Barcelona a m&#225;s de 3&#46;000 pacientes&#44; estableciendo puntos de corte en 6&#44;8&#44; 8 y 9<span class="elsevierStyleHsp" style=""></span>kPa&#44; se estimaron prevalencias de fibrosis significativa del 9&#44;5&#44; 8 y 3&#44;6&#37;&#44; respectivamente<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En los &#250;ltimos a&#241;os&#44; todas las gu&#237;as y publicaciones sobre la detecci&#243;n de fibrosis y cirrosis&#44; y espec&#237;ficamente en la EHmet&#44; han recomendado el uso secuencial de los m&#233;todos no invasivos bioqu&#237;micos de fibrosis y la ET<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;11&#44;15&#8211;18</span></a>&#46; Si los valores del indicador s&#233;rico hacen sospechar fibrosis&#44; se recomienda realizar ET o un indicador s&#233;rico de fibrosis patentado&#46; El cribado de la fibrosis hep&#225;tica con ET en AP es una intervenci&#243;n rentable para las poblaciones europeas y asi&#225;ticas e incluso puede suponer un ahorro de costes<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Por todo esto iniciamos un proyecto en poblaci&#243;n seleccionada en AP&#44; en colaboraci&#243;n con el servicio de digestivo&#44; en los dos municipios de la zona sur de la Comunidad de Madrid de los que es referencia&#44; incorporando el uso de FIB-4 y ET realizada en AP&#44; y derivando a los pacientes con sospecha de fibrosis tras dicho estudio&#44; con base en un protocolo consensuado entre AP y hospitalaria&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">El objetivo general fue conocer la proporci&#243;n de pacientes con fibrosis hep&#225;tica en la poblaci&#243;n con factores de riesgo &#40;FR&#41; de enfermedad hep&#225;tica avanzada&#44; identificada entre los pacientes atendidos en los centros de salud del &#225;rea sanitaria por cualquier motivo de salud&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Los objetivos secundarios fueron evaluar la correlaci&#243;n entre el indicador s&#233;rico de fibrosis FIB-4 y la ET&#44; y la correlaci&#243;n interobservador entre la ET realizada en AP y en atenci&#243;n hospitalaria &#40;AH&#41;&#44; e identificar los FR asociados con la presencia de fibrosis en la poblaci&#243;n estudiada&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes y m&#233;todos</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se trata de un estudio observacional descriptivo transversal&#44; realizado durante nueve meses &#40;desde noviembre de 2021 hasta julio de 2022&#41;&#46; Se incluyeron pacientes mayores de 16 a&#241;os procedentes de los centros de salud de Fuenlabrada y Humanes con FR de enfermedad hep&#225;tica cr&#243;nica&#46; Se excluyeron los pacientes con enfermedad hep&#225;tica diagnosticada previamente&#44; en seguimiento y tratamiento en el servicio de digestivo&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Para poder estimar una prevalencia esperada de fibrosis en sujetos de riesgo de un 6&#37;&#44; con una precisi&#243;n de<span class="elsevierStyleHsp" style=""></span>&#177; 0&#44;03&#44; en una poblaci&#243;n finita de unos 1&#46;000 sujetos con un error tipo I inferior a 0&#44;05&#44; se deb&#237;an incluir 194 pacientes&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se estudiaron variables sociodemogr&#225;ficas &#40;sexo y edad&#41; y la presencia de FR&#58; alteraci&#243;n de las pruebas bioqu&#237;micas hep&#225;ticas&#44; s&#237;ndrome metab&#243;lico o alguno de sus componentes&#44; diabetes tipo 2&#44; obesidad&#44; consumo de alcohol de riesgo&#44; y esteatosis hep&#225;tica diagnosticada por ecograf&#237;a o <span class="elsevierStyleItalic">fatty liver index</span> &#40;FLI&#41;&#46; Se midieron los siguientes par&#225;metros cl&#237;nicos&#58; valor del FIB-4&#44; valor del par&#225;metro de atenuaci&#243;n controlada &#40;CAP&#41; en decibelios por metro&#44; valor de la medici&#243;n de la rigidez hep&#225;tica por ET de vibraci&#243;n controlada &#40;VCTE&#41; en kilopascales&#44; en AP&#44; y en AH en aquellos pacientes derivados seg&#250;n el protocolo consensuado&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">A los pacientes con la bioqu&#237;mica hep&#225;tica alterada se les hicieron los estudios correspondientes seg&#250;n la pr&#225;ctica cl&#237;nica habitual&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">El valor del FIB-4 fue calculado de forma autom&#225;tica por el laboratorio bajo petici&#243;n espec&#237;fica en el formulario de AP&#46; A aquellos pacientes con valores iguales o superiores a 1&#44;3 se les realiz&#243; ET en AP con determinaci&#243;n asociada del CAP para cuantificar la esteatosis hep&#225;tica<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">20&#44;21</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Se utiliz&#243; un dispositivo de VCTE&#44; con sondas M y XL&#44; que incorpora CAP&#44; modelo FibroScan&#174; 430 Mini en AP&#59; y un modelo FibroScan&#174; 402 en el hospital&#44; ambos fabricados por Echosens&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">El elast&#243;grafo de AP se localiz&#243; en un centro de salud donde se centralizaron todas las exploraciones de los pacientes incluidos en el estudio&#44; realizadas por un grupo de profesionales de medicina y enfermer&#237;a previamente instruidos en su uso&#46; En AP efectuaron la elastograf&#237;a todos los miembros del grupo investigador del centro de salud donde se ubic&#243; el FibroScan&#174;&#58; siete m&#233;dicos de familia y cinco enfermeras&#44; de acuerdo con las especificaciones t&#233;cnicas del fabricante&#44; y habiendo realizado previamente m&#225;s de 25 exploraciones&#46; En AH la realizaron los seis gastroenter&#243;logos del servicio que las hacen habitualmente&#44; todos expertos con m&#225;s de 300 procedimientos realizados&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Se sigui&#243; un algoritmo consensuado entre los centros de salud y el hospital para la derivaci&#243;n de los pacientes con riesgo de fibrosis seg&#250;n los resultados del FIB-4 y de la medici&#243;n de la rigidez hep&#225;tica por VCTE &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Se hizo un an&#225;lisis de las variables estudiadas describiendo las continuas por sus medidas de tendencia central y de dispersi&#243;n&#44; y las cualitativas por sus frecuencias&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Se estim&#243; el porcentaje de pacientes con fibrosis significativa&#44; considerando como valor de referencia el resultado de la ET en AH&#46; Se estudi&#243; la correlaci&#243;n entre los valores del FIB-4 y de la ET en AP y en AH&#44; y entre los resultados de la ET en AP y AH mediante el coeficiente de correlaci&#243;n intraclase&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">La presencia de fibrosis hep&#225;tica y su grado se ha estratificado seg&#250;n FIB-4 y seg&#250;n resultados de la ET&#44; clasificando como fibrosis descartada valores de FIB-4<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#44;3&#44; sospecha de fibrosis significativa con valores &#8805; 1&#44;3&#44; y de fibrosis avanzada valores &#8805; 2&#44;67&#46; Para los resultados de la medici&#243;n de la rigidez hep&#225;tica por ET se ha estratificado con los puntos de corte de &#8805; 8 y &#8805; 12<span class="elsevierStyleHsp" style=""></span>kPa &#40;seg&#250;n las recomendaciones de las gu&#237;as m&#225;s recientes&#41;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;16&#44;22&#8211;25</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Se estudi&#243; la asociaci&#243;n entre los FR y la presencia de fibrosis&#44; y se construy&#243; un modelo explicativo mediante una regresi&#243;n log&#237;stica predictiva&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0115" class="elsevierStylePara elsevierViewall">El diagrama de flujo de los pacientes estudiados se describe en la <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Se cribaron 676 pacientes con FR de enfermedad hep&#225;tica&#44; de ellos 334 presentaron FIB 4<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#44;3&#46; Ocho pacientes fueron excluidos del estudio por no haberse podido hacer la ET en AP&#44; por dificultades en la t&#233;cnica en siete de ellos y uno por no acudir a hacerla&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">De los 326 pacientes restantes&#44; 95 pacientes ten&#237;an valores de rigidez hep&#225;tica &#8805; 8<span class="elsevierStyleHsp" style=""></span>kPa en AP&#44; siendo derivados a AH&#46; Doce pacientes no acudieron a la cita de AH&#44; perdi&#233;ndose en el seguimiento&#46; La exploraci&#243;n fue factible en todos los casos&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">El 70&#44;9&#37; de los pacientes con sospecha de fibrosis significativa por los valores del FIB-4&#44; no se derivaron al hospital por tener una medida de la rigidez hep&#225;tica en AP &#60;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">De los 83 pacientes derivados que se hicieron ET en el servicio de digestivo&#44; 45 &#40;54&#44;2&#37;&#41; ten&#237;an valores &#8805; 8<span class="elsevierStyleHsp" style=""></span>kPa&#59; y en 25 de estos &#40;30&#37; del total&#41; la medida de la rigidez hep&#225;tica era &#8805; 12<span class="elsevierStyleHsp" style=""></span>kPa&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se describen las caracter&#237;sticas de la poblaci&#243;n total estudiada &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>326&#41; y por sexo &#40;el 57&#37; fueron hombres&#41; respecto a la presencia de los FR&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">La frecuencia de esteatosis hep&#225;tica medida por el CAP y definida por valores &#62;<span class="elsevierStyleHsp" style=""></span>275 decibelios por metro &#40;dB&#47;m&#41;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a>&#44; en nuestra poblaci&#243;n fue del 54&#37; &#40;IC 95&#37;&#58;48&#44;4-59&#44;5&#41;&#58; 176 de los pacientes estudiados&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se describen los pacientes en relaci&#243;n con el valor del FIB-4 y de la ET&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">La proporci&#243;n de los pacientes con una medida de la rigidez hep&#225;tica por ET &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa en AH&#44; el valor de referencia para determinar la presencia de fibrosis significativa fue del 13&#44;8&#37; &#40;45&#47;326&#41;&#44; y con una rigidez &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa o sospecha de fibrosis avanzada&#44; del 7&#44;6&#37; &#40;25&#47;326&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Se estudi&#243; la utilidad diagn&#243;stica del FIB-4 calculando sus valores predictivos&#44; cocientes de probabilidad&#44; sensibilidad y especificidad con relaci&#243;n a los valores de la ET en AP y en AH&#44; considerando esta como el valor de referencia &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Elevar el punto de corte del FIB-4 a &#8805;<span class="elsevierStyleHsp" style=""></span>2 en &#8805;<span class="elsevierStyleHsp" style=""></span>65 a&#241;os hubiera reducido de 213 a 63 el n&#250;mero de pacientes de esta edad que precisaron la realizaci&#243;n de ET en AP y se hubieran derivado menos pacientes&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Al comparar un valor del FIB-4 &#8805;<span class="elsevierStyleHsp" style=""></span>2&#44;67&#44; con sospecha de fibrosis avanzada&#44; con un valor de ET concordante en AP y AH de &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa&#44; que corresponder&#237;a tambi&#233;n a fibrosis avanzada&#44; los valores predictivos positivos ser&#237;an del 58&#37; y 57&#37;&#44; respectivamente&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">En cuanto a la correlaci&#243;n interobservador entre los resultados de la ET en AP y en AH&#44; el coeficiente de correlaci&#243;n intraclase para n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>83&#44; fue de 0&#44;433&#44; con un IC 95&#37; entre 0&#44;137 y 0&#44;630&#44; con p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#44; que corresponde con un grado de acuerdo moderado en la escala de Landis y Koch&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Al estudiar la rentabilidad de la ET en AP comparando con el valor final en AH&#44; para valores de rigidez hep&#225;tica &#8805;<span class="elsevierStyleHsp" style=""></span>8 kPa &#40;fibrosis significativa&#41;&#44; el 54&#37; de los que la presentan en la ET de AP&#44; la tendr&#225;n tambi&#233;n en AH&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">De los pacientes que en AP tengan valores de rigidez hep&#225;tica &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa &#40;fibrosis avanzada&#41;&#44; el 57&#37; de ellos los tendr&#225;n tambi&#233;n en la ET en AH&#44; siendo adem&#225;s tres veces m&#225;s probable que estos pacientes tengan fibrosis avanzada&#44; a que no la tengan&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">En cuanto a la asociaci&#243;n entre la presencia de fibrosis y los FR &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#44; en el an&#225;lisis bivariante se encuentra asociaci&#243;n para valores de ET &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa con la alteraci&#243;n de las pruebas hep&#225;ticas &#40;PH&#41; &#40;OR 2&#44;77 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; con la diabetes tipo 2 &#40;DT2&#41; &#40;OR 3&#44;3 y p&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; y con la presencia de esteatosis hep&#225;tica ecogr&#225;fica o valorada mediante FLI &#40;OR 2&#44;39 y p&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">Para valores de ET &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa&#44; se encuentra asociaci&#243;n con la alteraci&#243;n de PH &#40;OR 5&#44;38 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;006&#41;&#44; DT2 &#40;OR 2&#44;9 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#44; y obesidad &#40;OR 2&#44;79 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007&#41;&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">No existe asociaci&#243;n con el s&#237;ndrome metab&#243;lico ni con el consumo de alcohol&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">En el an&#225;lisis multivariante con una regresi&#243;n log&#237;stica&#44; para un valor de rigidez hep&#225;tica &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa en AP&#44; se encontraron como variables asociadas la alteraci&#243;n de las PH&#44; la DT2 y la presencia de esteatosis&#44; y para valores de ET &#8805; 12<span class="elsevierStyleHsp" style=""></span>kPa la elevaci&#243;n de las PH&#44; la DT2 y la obesidad&#46; Sin embargo&#44; al aplicar este modelo para los valores de la ET en AH&#44; para &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa no se asocia la DT2&#44; y para &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa solo la obesidad&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Un 30&#37; de los pacientes derivados fueron incluidos en programa de cribado de CHC&#44; detectando en uno de los pacientes un hepatocarcinoma en la ecograf&#237;a de cribado&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><p id="par0215" class="elsevierStylePara elsevierViewall">El creciente inter&#233;s por la MASLD&#47;EHmet en la comunidad cient&#237;fica se explica por el aumento continuado de su prevalencia&#44; y de sus complicaciones&#44; fundamentalmente el hepatocarcinoma<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">22&#8211;24</span></a>&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">El aumento de la prevalencia de la enfermedad hep&#225;tica avanzada y sus consecuencias en morbilidad y mortalidad&#44; as&#237; como en el uso y coste de los servicios sanitarios&#44; merece una especial atenci&#243;n por parte del sistema sanitario&#44; y potenciar el papel de la AP y el m&#233;dico de familia&#44; que debe tener acceso a las principales herramientas diagn&#243;sticas&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">La b&#250;squeda de enfermedad hep&#225;tica avanzada en AP se puede hacer al disponer de pruebas no invasivas que&#44; aplicadas en las poblaciones de riesgo&#44; pueden mejorar la detecci&#243;n precoz de fibrosis y la estratificaci&#243;n del riesgo&#44; as&#237; como la vinculaci&#243;n del paciente con la atenci&#243;n sanitaria m&#225;s apropiada&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">En nuestro estudio se aplica un algoritmo ya propuesto y validado en estudios previos&#44; sum&#225;ndose recientemente nuevas gu&#237;as cl&#237;nicas que lo avalan<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">25&#8211;28</span></a>&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">El uso de la ET en AP es algo que ya se realiza en otros pa&#237;ses como el Reino Unido&#44; donde desde 2020 hay un informe al respecto del <span class="elsevierStyleItalic">National Institute for Health and Care Excelence</span> &#40;NICE&#41;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a>&#46; Existe un amplio consenso entre sociedades cient&#237;ficas proponiendo el cribado de enfermedad hep&#225;tica en AP y otras especialidades m&#233;dicas que atienden a pacientes de grupos de riesgo&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">En nuestro pa&#237;s no hemos encontrado publicaciones sobre experiencias similares a la que se ha llevado a cabo en este estudio&#44; aplicando a la pr&#225;ctica cl&#237;nica diaria un protocolo que incorpore la determinaci&#243;n autom&#225;tica en el informe de laboratorio del FIB-4 a petici&#243;n del m&#233;dico de AP&#44; y disponiendo de ET en AP para una mejor selecci&#243;n de los pacientes que precisan ser derivados a AH&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">La proporci&#243;n final entre la poblaci&#243;n de riesgo testada con FIB-4 en nuestro estudio&#44; con sospecha de fibrosis significativa &#40;&#8805; 8<span class="elsevierStyleHsp" style=""></span>kPa&#41; y de fibrosis avanzada &#40;&#8805; 12<span class="elsevierStyleHsp" style=""></span>kPa&#41; fue del 13&#44;8&#37; y 7&#44;6&#37;&#44; respectivamente&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Una de las limitaciones de nuestro estudio es que no se puede calcular una prevalencia poblacional&#44; al no haberse realizado correctamente el registro de todos los pacientes a los que se hizo FIB-4 y se obtuvo un valor &#8804; 1&#44;3&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Las pruebas no invasivas en AP y AH fueron bien aceptadas por los pacientes incluidos en el estudio&#46; Un paciente en AP y 12 en AH &#40;12&#44;6&#37; de los derivados&#41; se perdieron en el seguimiento al no acudir a la realizaci&#243;n de ET&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Tanto el valor predictivo positivo como el negativo del FIB-4 en nuestro estudio result&#243; inferior a lo publicado en estudios previos&#44; esto puede ser debido a que se ha hecho el cribado en AP en vez de en AH&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">El bajo rendimiento general de la determinaci&#243;n del FIB-4 hace que se est&#233;n buscando alternativas con otros indicadores s&#233;ricos de fibrosis<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a>&#44; y que se haga necesario ajustar en &#8805; 65 a&#241;os a &#8805; 2 el punto de corte del FIB-4 para hacer ET&#44; como se recoge en varios consensos o gu&#237;as<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11&#44;18&#44;23</span></a>&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Consideramos relevantes como resultados del estudio que&#44; con el cribado de pacientes con FR para enfermedad hep&#225;tica&#44; incorporando en los centros de salud el FIB-4 y la ET&#44; solo se haya derivado un 29&#44;1&#37; de los pacientes testados&#59; y haber identificado en un periodo de nueve meses 25 pacientes con medida de la rigidez hep&#225;tica &#8805; 12 kPa&#44; que fueron incluidos en programa de cribado de CHC&#46; La concordancia interobservador moderada entre la ET en AP y AH se puede mejorar con la realizaci&#243;n de m&#225;s exploraciones&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">En cuanto a la falta de asociaci&#243;n de la presencia de fibrosis con el s&#237;ndrome metab&#243;lico tomado de manera laxa&#44; parece conveniente limitar las indicaciones para hacer FIB-4 a pacientes que cumplan los criterios diagn&#243;sticos de s&#237;ndrome metab&#243;lico estrictamente&#46; Se encontr&#243; una clara asociaci&#243;n&#44; tambi&#233;n en el an&#225;lisis multivariante con la alteraci&#243;n de las PH&#44; la DT2 y la presencia de esteatosis hep&#225;tica&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Como conclusiones se puede resaltar que nuestro estudio reafirma la viabilidad de las recomendaciones de las gu&#237;as para el cribado y detecci&#243;n precoz de fibrosis hep&#225;tica en las poblaciones de riesgo&#46; La aplicaci&#243;n en la pr&#225;ctica cl&#237;nica de un algoritmo diagn&#243;stico y de derivaci&#243;n ha sido bien aceptado por los pacientes y por los profesionales de AP y AH&#44; obteniendo buenos resultados en el diagn&#243;stico precoz de fibrosis&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">La realizaci&#243;n de FIB-4 y ET en AP permite disminuir el porcentaje de pacientes que se derivan a AH&#44; as&#237; como una mejor estratificaci&#243;n de los pacientes de riesgo&#44; siendo un aspecto importante para mejorar la rentabilidad del FIB-4&#44; su correcci&#243;n por edad del paciente&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">Dadas las limitaciones del estudio&#44; parece adecuado realizar estudios futuros de mayor calidad&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Limitaciones</span><p id="par0295" class="elsevierStylePara elsevierViewall">Una recogida deficiente de los datos de cribado con FIB-4 en los pacientes con FIB-4<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#44;3&#44; no permiten extraer conclusiones poblacionales sino solo de los pacientes con resultado de FIB-4 &#8805; 1&#44;3 en AP&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">El tiempo transcurrido entre las dos exploraciones con VCTE ha podido influir en la correlaci&#243;n de los valores de la rigidez hep&#225;tica entre AP y AH&#44; en parte por la modificaci&#243;n de los h&#225;bitos en los pacientes incluidos en el estudio&#46; El estudio de la correlaci&#243;n interobservador en la ET entre AP y AH tambi&#233;n puede estar sesgado al comparar solo los 83 valores derivados desde AP a AH&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicto de intereses</span><p id="par0305" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => "Abstract"
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    "fechaRecibido" => "2024-03-14"
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            0 => "Fibrosis hep&#225;tica"
            1 => "Indicadores s&#233;ricos de fibrosis"
            2 => "Elastograf&#237;a de transici&#243;n"
            3 => "Atencion primaria"
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            0 => "Liver fibrosis"
            1 => "Non-invasive fibrosis biomarkers"
            2 => "Transient elastography"
            3 => "Primary care"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Describir la proporci&#243;n de pacientes con fibrosis hep&#225;tica en poblaciones de riesgo en atenci&#243;n primaria &#40;AP&#41;&#46; Conocer la correlaci&#243;n entre el FIB-4 y la elastograf&#237;a de transici&#243;n &#40;ET&#41;&#44; correlaci&#243;n interobservador entre AP y atenci&#243;n hospitalaria &#40;AH&#41; en la ET&#44; y factores de riesgo &#40;FR&#41; asociados&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; descriptivo&#44; transversal en &#8805;<span class="elsevierStyleHsp" style=""></span>16 a&#241;os con FR para hepatopat&#237;a cr&#243;nica&#46; Se recogieron sexo y edad&#44; FR &#40;alteraci&#243;n pruebas hep&#225;ticas &#40;PH&#41;&#44; s&#237;ndrome metab&#243;lico&#44; diabetes&#44; obesidad&#44; consumo alcohol&#44; esteatosis hep&#225;tica&#41;&#44; y los valores del FIB-4&#44; par&#225;metro de atenuaci&#243;n controlada &#40;CAP&#41;&#44; ET en AP y en AH&#46; Seg&#250;n algoritmo consensuado&#44; se realiz&#243; ET de vibraci&#243;n controlada &#40;VCTE&#41; en AP a los pacientes con FIB-4<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#44;3&#44; deriv&#225;ndose a AH aquellos con medici&#243;n&#8805;<span class="elsevierStyleHsp" style=""></span>8 kilopascales &#40;kPa&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se estudiaron 326 pacientes&#46; El 71&#37; no se derivaron a AH&#44; por rigidez hep&#225;tica&#60;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa&#59; 83 de los 95 derivados hicieron ET en AH&#59; 45 &#40;54&#44;2&#37;&#41; ten&#237;an ET &#8805;<span class="elsevierStyleHsp" style=""></span>8&#44; siendo en 25 &#40;30&#37;&#41; &#8805;<span class="elsevierStyleHsp" style=""></span>12&#46; La proporci&#243;n de pacientes con rigidez &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa fue del 13&#44;8&#37; &#40;45&#47;326&#41; y &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa&#44; del 7&#44;6&#37; &#40;25&#47;326&#41;&#46; Los valores predictivos del FIB-4 fueron bajos&#46; El coeficiente de correlaci&#243;n interobservador entre la ET en AP y AH fue del 0&#44;433&#46; Variables asociadas con ET &#8805;<span class="elsevierStyleHsp" style=""></span>8 en AP&#58; alteraci&#243;n PH&#44; diabetes y esteatosis&#46; Con ET &#8805;<span class="elsevierStyleHsp" style=""></span>12&#58; alteraci&#243;n PH&#44; diabetes y obesidad&#46; Variables predictoras en an&#225;lisis multivariante&#58; alteraci&#243;n PH y obesidad&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El estudio apoya la realizaci&#243;n secuencial de &#237;ndices s&#233;ricos y ET como cribado de fibrosis en poblaci&#243;n de riesgo en AP&#44; que permite disminuir el porcentaje de pacientes que se derivan a AH&#44; y una mejor estratificaci&#243;n de los pacientes de riesgo&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To describe the proportion of patients with liver fibrosis in at-risk populations in primary care &#40;PC&#41;&#46; To know the agreement between FIB-4 and transitional elastography &#40;TE&#41;&#44; interobserver agreement between PC and hospital care &#40;HC&#41; in TE&#44; and associated risk Factors &#40;RF&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Observational&#44; descriptive&#44; cross-sectional study in &#8805;<span class="elsevierStyleHsp" style=""></span>16 years of age with RF for chronic liver disease&#46; Sex and age&#44; RF &#40;alteration of liver tests &#91;LT&#93;&#44; metabolic syndrome&#44; diabetes&#44; obesity&#44; alcohol consumption&#44; hepatic steatosis&#41;&#44; and FIB-4&#44; controlled attenuation parameter and TE in PC and in HC&#44; were collected&#46; According to a consensus algorithm&#44; vibration-controlled TE was performed in PC in patients with FIB-4<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#44;3&#44; and those with measurement &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa were referred to HC&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">326 patients were studied&#46; 71&#37; were not referred to HC&#44; due to liver stiffness &#60;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa&#46; 83 of the 95 derivations did TE in HC&#46; 45 &#40;54&#37;&#41; had TE &#8805;<span class="elsevierStyleHsp" style=""></span>8&#44; and 25 &#40;30&#37;&#41; &#8805;<span class="elsevierStyleHsp" style=""></span>12&#46; The proportion of patients with stiffness &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa was 13&#44;8&#37; &#40;45&#47;326&#41; and &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa&#44; 7&#44;6&#37; &#40;25&#47;326&#41;&#46; The predictive values of the FIB-4 were low&#46; The interobserver correlation coefficient between TE in PC and HC was 0&#44;433&#46; Variables associated with TE &#8805;<span class="elsevierStyleHsp" style=""></span>8 in PC&#58; LT alteration&#44; diabetes and steatosis&#46; With TE &#8805;<span class="elsevierStyleHsp" style=""></span>12&#58; LT alteration&#44; diabetes and obesity&#46; Predictor variables&#58; LT alteration and obesity&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The study supports the sequential performance of serum indices and TE as a screening for fibrosis in the at-risk population in PC&#44; which allows a reduction in the percentage of patients referred to AH&#44; and a better stratification of risk patients&#46;</p></span>"
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                  \t\t\t\t">141&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"><span class="elsevierStyleItalic">SEXO</span>&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 ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hombre&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">185 &#40;56&#44;75&#37;&#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="" 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 ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mujer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">141 &#40;43&#44;25&#37;&#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="" 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  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Edad&#44; media &#40;DE&#41;</span>&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">67&#44;19 &#40;8&#44;26&#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">66&#44;67 &#40;8&#44;00&#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">67&#44;86 &#40;8&#44;57&#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">0&#44;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Edad mayores 65</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">213 &#40;63&#44;34&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">123&#40;66&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">90&#40;63&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">ALTERACI&#211;N PH</span>&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="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;042&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>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="left" valign="\n
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                  \t\t\t\t">88 &#40;26&#44;99&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">58 &#40;31&#44;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30 &#40;21&#44;28&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">127 &#40;68&#44;65&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">S&#205;NDROME METAB&#211;LICO</span>&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">0&#44;71&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
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">75 &#40;40&#44;54&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">60 &#40;42&#44;55&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">DM TIPO 2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;39&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>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="left" valign="\n
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                  \t\t\t\t">230 &#40;70&#44;55&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">127 &#40;68&#44;65&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">103 &#40;73&#44;05&#37;&#41;&nbsp;\t\t\t\t\t\t\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="elsevierStyleItalic">ELASTOGRAF&#205;A en AP &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">326&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  """
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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">&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</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FIB-4 &#8805; 1&#44;3 conET &#8805; 8 en AH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43-65&#37;&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><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FIB-4 &#8805; 1&#44;3 conET &#8805; 12 en AH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20-40&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">0&#44;98-2&#44;66&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;057&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes tipo 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;310&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;99-5&#44;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obesidad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;540&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;97-2&#44;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;061&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alcohol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;360&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;82-2&#44;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;231&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Esteatosis hep&#225;tica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;390&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;45-3&#44;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3660808.png"
              ]
            ]
            1 => 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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">An&#225;lisis bivariante para fibrosis avanzada &#40;12 kPa&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Elevaci&#243;n pruebas hep&#225;ticas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;6-17&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#237;ndrome metab&#243;lico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;830&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;89-3&#44;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;095&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes tipo 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;940&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;51-5&#44;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obesidad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;790&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;31-5&#44;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alcohol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;800&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;38-1&#44;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;568&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Esteatosis hep&#225;tica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;760&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;88-3&#44;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;106&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3660810.png"
              ]
            ]
            2 => 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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="6" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AN&#193;LISIS MULTIVARIANTE&#58; Variables predictoras</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#40;-2LL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">R<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Para ET en AP 8</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alteraci&#243;n PH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;56-5&#44;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-176&#44;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes tipo 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;08-6&#44;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Esteatosis&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">1&#44;15-3&#44;34&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes tipo 2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alteraci&#243;n PH&nbsp;\t\t\t\t\t\t\n
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