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Impacto de la corrección temprana de la hiponatremia en el pronóstico de la infección del síndrome respiratorio agudo grave del coronavirus 2 (SARS-CoV-2)
The impact of the correction of hyponatremia during hospital admission on the prognosis of SARS-CoV-2 infection
José C. de La Flora,
Autor para correspondencia
josedelaflor81@yahoo.com
jflomer@mde.es

Autor para correspondencia.
, Ana Gomez-Berrocalb, Alexander Marschallc, Francisco Valgad, Tania Linaresa, Cristina Albarracina, Elisa Ruiza, Gioconda Gallegosa, Alberto Gómeze, Andrea de los Santose, Miguel Rodelesa
a Servicio de Nefrología, Hospital Central de la Defensa Gómez Ulla, Madrid, España
b Servicio de Medicina Interna, Hospital Central de la Defensa Gómez Ulla, Madrid, España
c Servicio de Cardiología, Hospital Central de la Defensa Gómez Ulla, Madrid, España
d Servicio de Nefrología, Hospital Negrín, Gran Canaria, España
e Facultad de Medicina, Universidad Alcalá de Henares, Madrid, España
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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 infecci&#243;n del s&#237;ndrome respiratorio agudo grave por el coronavirus 2 &#40;SARS-CoV-2&#41; tiene un espectro cl&#237;nico variable&#44; desde un estado de portador asintom&#225;tico&#44; anosmia&#44; ageusia o una enfermedad leve del tracto respiratorio superior hasta una neumon&#237;a grave que puede conducir al s&#237;ndrome de dificultad respiratoria aguda&#44; insuficiencia respiratoria grave acompa&#241;ada de varias manifestaciones extrapulmonares incluyendo el fallo multiorg&#225;nico con afectaci&#243;n cardiovascular&#44; neurol&#243;gica&#44; renal e incluso la muerte<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Adem&#225;s&#44; la lesi&#243;n renal puede estar asociada a alteraciones de los mecanismos contrarreguladores del agua y del sodio&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">La hiponatremia definida como sodio plasm&#225;tico &#40;Na<span class="elsevierStyleSup">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>135<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#41; es la alteraci&#243;n hidroelectrol&#237;tica m&#225;s frecuente en pacientes hospitalizados<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a>&#46; El riesgo de muerte durante el ingreso hospitalario aumenta m&#225;s de un 50&#37; en comparaci&#243;n con pacientes eunatr&#233;micos<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a>&#46; Se ha descrito una prevalencia de hiponatremia de hasta un 28-30&#37; en pacientes ingresados con neumon&#237;a adquirida en la comunidad &#40;NAC&#41;&#44; incrementando el riesgo de mortalidad y de ingreso en las unidades de cuidados intensivos &#40;UCI&#41; y prolongando la estancia hospitalaria&#44; adem&#225;s de generar una carga econ&#243;mica importante para el sistema sanitario<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; El riesgo de aparici&#243;n de la hiponatremia en pacientes con NAC var&#237;a seg&#250;n el pat&#243;geno causante hasta en un 46&#37; de pacientes con infecci&#243;n por <span class="elsevierStyleItalic">Legionella pneumophila</span> en comparaci&#243;n con un 14&#37; de pacientes con NAC causada por otros pat&#243;genos<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a>&#44; mientras que la incidencia de hiponatremia en pacientes con enfermedad por coronavirus de 2019 &#40;COVID-19&#41; descrita en recientes cohortes alcanza valores en torno a un 20&#37; al 37&#37;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#8211;10</span></a>&#46; Adem&#225;s&#44; se ha descrito en cohortes americanas y chinas una asociaci&#243;n de la hiponatremia con mayor mortalidad de la COVID-19&#46; Es por ello por lo que recientes trabajos intentan asociar la hiponatremia como un marcador de mal pron&#243;stico en estos pacientes<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11&#44;12</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cabe se&#241;alar que hasta un 60&#37; de los pacientes con SARS-CoV-1 presentaron cuadros de diarrea acuosa asociada a leves hiponatremias&#44; secundarias a la replicaci&#243;n del virus dentro de las c&#233;lulas epiteliales intestinales<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a>&#46; Inicialmente&#44; varios reportes de casos describieron la asociaci&#243;n entre un s&#237;ndrome de secreci&#243;n inadecuada de hormona antidiur&#233;tica &#40;SIADH&#41; y la p&#233;rdida de sodio en las heces como los agentes etiol&#243;gicos m&#225;s frecuentes de la COVID-19<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">14&#8211;16</span></a>&#46; A fecha de hoy se desconocen los posibles mecanismos fisiopatol&#243;gicos subyacentes&#44; y no queda claro si la hiponatremia es ocasionada por una afectaci&#243;n espec&#237;fica de la COVID-19 o secundaria a la complicaci&#243;n respiratoria del cuadro infeccioso&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">No obstante&#44; en el momento actual no existe informaci&#243;n disponible que haga menci&#243;n a la capacidad de disminuir el riesgo de mortalidad y el mal pron&#243;stico en pacientes con COVID-19 tras la correcci&#243;n de la hiponatremia&#46; Adem&#225;s&#44; es relevante realizar un correcto manejo terap&#233;utico de la hiponatremia causado por mecanismos f&#225;cilmente reversibles&#44; debido a que una intervenci&#243;n eficaz puede resultar en sobrecorrecci&#243;n &#40;hipernatremia&#41; y secuelas asociadas&#44; incluyendo&#58; hemorragia&#44; arritmia y s&#237;ndrome de desmielinizaci&#243;n osm&#243;tica<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a>&#46; Por ello&#44; nuestros objetivos fueron&#58; analizar la incidencia y gravedad de la hiponatremia al ingreso hospitalario por la COVID-19 en nuestro hospital y determinar la asociaci&#243;n de dicha hiponatremia con el pron&#243;stico&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio</span><p id="par0025" class="elsevierStylePara elsevierViewall">Estudio de cohorte observacional&#44; retrospectivo y unic&#233;ntrico&#46; Se incluyeron todos los pacientes consecutivos mayores de 18 a&#241;os que fueron ingresados en nuestro hospital con diagn&#243;stico de infecci&#243;n por el SARS-CoV-2durante el periodo comprendido entre el 15 de marzo al 15 de mayo del 2020&#44; que presentaban adem&#225;s el diagn&#243;stico de hiponatremia&#46; El diagn&#243;stico de COVID-19 se defini&#243; por la positividad de la reacci&#243;n en cadena de la polimerasa en tiempo real cuantitativa &#40;RT-PCR&#41; en un hisopado nasofar&#237;ngeo para el virus del SARS-CoV-2&#44; acorde con los criterios propuestos por el documento t&#233;cnico del Ministerio de Sanidad Espa&#241;ol<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> y utilizando el kit de COVID-19 de Seegene&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Principios &#233;ticos</span><p id="par0030" class="elsevierStylePara elsevierViewall">El estudio cumpli&#243; con los principios enunciados en la declaraci&#243;n de Helsinki y fue aprobado por el Comit&#233; de &#201;tica de Investigaci&#243;n con medicamentos de nuestro hospital&#46; Se aprob&#243; la solicitud de exenci&#243;n de consentimiento informado en el que se justifica de forma detallada&#44; respet&#225;ndose en todo momento el derecho a la privacidad de los pacientes&#46; Los datos sobre hospitalizaci&#243;n&#44; caracter&#237;sticas cl&#237;nicas y demogr&#225;ficas se obtuvieron de los registros hospitalarios e historias cl&#237;nicas electr&#243;nicas de los pacientes incluidos&#46; Todos los datos se obtuvieron de forma an&#243;nima y ninguno de los autores fueron los m&#233;dicos tratantes de los pacientes&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Definici&#243;n de variables</span><p id="par0040" class="elsevierStylePara elsevierViewall">Se registraron como variables para el estudio&#58; las comorbilidades que presentaban las pacientes previas al ingreso&#44; los datos cl&#237;nicos&#44; anal&#237;ticos y radiol&#243;gicos de la infecci&#243;n por SARS-CoV-2 en el momento del diagn&#243;stico y durante la hospitalizaci&#243;n y&#44; por &#250;ltimo&#44; los datos relacionados con la hiponatremia&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Las comorbilidades registradas fueron hipertensi&#243;n arterial &#40;HTA&#41;&#44; diabetes mellitus tipo 2 &#40;DM2&#41;&#44; obesidad &#40;definida como &#237;ndice de masa corporal<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; dislipidemia&#44; tabaquismo&#44; s&#237;ndrome de la apnea-obstructiva del sue&#241;o &#40;SAOS&#41;&#44; enfermedad pulmonar obstructiva cr&#243;nica&#44; asma&#44; uropat&#237;a obstructiva y enfermedad oncol&#243;gica&#46; La enfermedad renal cr&#243;nica &#40;ERC&#41; se clasific&#243; en funci&#243;n de la tasa de filtrado glomerular estimado &#40;FGe&#41; mediante la ecuaci&#243;n <span class="elsevierStyleItalic">Chronic Kidney Disease Epidemiology Collaboration</span> &#40;CKD-EPI&#44; seg&#250;n sus siglas en ingl&#233;s&#41;&#44; como recomienda el grupo internacional de <span class="elsevierStyleItalic">Kidney Improving Global Outcomes</span>&#46; Consideramos ERC aquellos casos con FGe<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;m<span class="elsevierStyleSup">2</span> &#40;estadios G3-G5&#41;&#46; Se recogi&#243; el antecedente de tratamiento antihipertensivo con inhibidor de la enzima conversora de angiotensina &#40;IECA&#41; o antagonista del receptor de angiotensina <span class="elsevierStyleSmallCaps">ii</span> &#40;ARA-II&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">En cuanto a variables relacionadas con la infecci&#243;n por SARS-CoV-2 en los casos que la RT-PCR inicial result&#243; negativa y la sospecha cl&#237;nica segu&#237;a siendo alta&#44; se realiz&#243; una segunda RT-PCR y&#47;o una tomograf&#237;a axial computarizada &#40;TAC&#41; tor&#225;cica&#46; Se incluy&#243; el diagn&#243;stico radiol&#243;gico de neumon&#237;a&#44; el tratamiento utilizado y la presencia de cuadro diarreico&#46; Adem&#225;s&#44; la gravedad de la infecci&#243;n se defini&#243; seg&#250;n el documento t&#233;cnico del Ministerio de Sanidad Espa&#241;ola<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a>&#44; siendo el estado cr&#237;tico de la COVID-19 la necesidad de ventilaci&#243;n mec&#225;nica u otro criterio de ser atendidos en UCI &#40;insuficiencia respiratoria&#44; shock s&#233;ptico y&#47;o fallo multiorg&#225;nico&#41;&#46; Se registr&#243; tambi&#233;n el desenlace de la COVID-19 como exitus desde el ingreso hospitalario al alta o control posthospitalizaci&#243;n a los 3 meses del alta hospitalaria&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Con respecto a las variables relacionadas con la hiponatremia&#44; se obtuvo al menos una determinaci&#243;n de la concentraci&#243;n plasm&#225;tica de sodio al ingreso hospitalario&#46; Los valores de hiponatremias fueron corregidos con la glucemia&#44; por cada 100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl de aumento de glucosa utilizamos un factor de correcci&#243;n de 1&#44;7<span class="elsevierStyleHsp" style=""></span>mmol&#47;l de sodio plasm&#225;tico<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a>&#46; Los pacientes fueron clasificados en 3 grupos seg&#250;n los niveles de gravedad de la hiponatremia en el momento del ingreso hospitalario&#58; se defini&#243; la hiponatremia leve como natremia entre 130 y 135<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#44; moderada entre 125 y 129<span class="elsevierStyleHsp" style=""></span>mmol&#47;l y grave si los valores de Na<span class="elsevierStyleSup">&#43;</span> eran menores de 125<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#46; La correcci&#243;n de la hiponatremia se realiz&#243; seg&#250;n las recomendaciones de las gu&#237;as cl&#237;nicas vigentes<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a>&#46; No hubo una periodicidad en los controles de las natremias&#44; se realizaron seg&#250;n criterios de los m&#233;dicos tratantes&#46; Se recogi&#243; longitudinalmente el resultado de la variable del sodio s&#233;rico en el d&#237;a del ingreso&#44; a las 24-48<span class="elsevierStyleHsp" style=""></span>horas y a las 72-96<span class="elsevierStyleHsp" style=""></span>horas del ingreso hospitalario&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lisis estad&#237;stico</span><p id="par0060" class="elsevierStylePara elsevierViewall">Se utiliz&#243; estad&#237;stica descriptiva para la presentaci&#243;n de las variables&#46; Mediante medianas y rangos intercuart&#237;licos se expusieron las variables cuantitativas no param&#233;tricas&#44; mientras que las variables cuantitativas param&#233;tricas se expresaron con medias y desviaciones est&#225;ndar&#46; Se utiliz&#243; el test de Kolmogorov-Smirnov para evaluar la distribuci&#243;n de las variables&#46; Para variables continuas&#44; el an&#225;lisis de la varianza de un solo factor &#40;test de ANOVA&#41; se utiliz&#243; cuando la normalidad y la homogeneidad de la varianza se cumplieron&#46; De lo contrario&#44; se utiliz&#243; el test no param&#233;trico de Mann-Whitney U o de Kruskal-Wallis&#46; Adem&#225;s&#44; se generaron tablas cruzadas&#44; utilizando la prueba de Chi-cuadrado y la prueba exacta de Fisher en el an&#225;lisis de variables categ&#243;ricas&#46; Con el fin de analizar la asociaci&#243;n entre la correcci&#243;n de la hiponatremia y la mortalidad hospitalaria de la COVID-19 se emplearon los test de Chi-cuadrado y &#171;t&#187; de Student&#44; y posteriormente se gener&#243; un modelo multivariable mediante regresi&#243;n de Cox&#46; Todas las pruebas estad&#237;sticas se consideraron bilaterales y como valores significativos aquellos con una p bilateral<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; Los datos fueron analizados con el programa estad&#237;stico SPSS-IBM &#40;versi&#243;n 21&#44;0&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><p id="par0065" class="elsevierStylePara elsevierViewall">Entre el 15 de marzo y el 15 de mayo del 2020 un total de 414 pacientes fueron ingresados en nuestro hospital con diagn&#243;stico de COVID-19&#44; con test positivo RT-PCR para el SARS-CoV-2&#46; La incidencia de hiponatremia<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>135<span class="elsevierStyleHsp" style=""></span>mmol&#47;l fue del 21&#44;98&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>91&#41;&#44; con una media de edad de 68&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;1<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; aumentando en funci&#243;n de la gravedad de la hiponatremia&#46; El 70&#44;3&#37; de nuestra muestra fueron varones&#46; La estancia media hospitalaria fue de 13 d&#237;as &#40;RIQ&#58; 7-38&#41;&#46; Las comorbilidades m&#225;s comunes fueron&#58; HTA &#40;55&#37;&#41;&#44; dislipidemia &#40;30&#44;3&#37;&#41; y la DM2 &#40;29&#44;7&#37;&#41;&#44; mientras que la ERC &#40;FGe<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; fue observada en 11 pacientes &#40;12&#44;1&#37;&#41;&#46; El 22&#37; y el 13&#37; de los pacientes estaban en tratamiento previo antihipertensivo con IECA y ARA-II respectivamente&#44; el resto de las caracter&#237;sticas basales est&#225;n descritas en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Los pacientes fueron clasificados en 3 grupos seg&#250;n el grado de hiponatremia al ingreso hospitalario&#58; 74 pacientes &#40;81&#44;32&#37;&#41; presentaron hiponatremia leve&#44; 9 pacientes &#40;9&#44;89&#37;&#41; hiponatremia moderada y 8 pacientes &#40;8&#44;79&#37;&#41; hiponatremia grave &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Se encontr&#243; una relaci&#243;n estad&#237;sticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;029&#41; entre la gravedad de la hiponatremia y el grado de ERC&#44; siendo el grado 3<span class="elsevierStyleHsp" style=""></span>b el m&#225;s frecuente en 7 &#40;7&#44;7&#37;&#41;&#59; distribuido en 4 &#40;5&#44;4&#37;&#41; y 3 &#40;33&#44;3&#37;&#41; en hiponatremia leve y moderada&#44; respectivamente&#44; as&#237; como tambi&#233;n con el tratamiento con IECA&#58; 13 &#40;17&#44;6&#37;&#41;&#44; 2 &#40;22&#44;2&#37;&#41; y 5 &#40;62&#44;5&#37;&#41; en el grupo de hiponatremia leve&#44; moderada y severa&#44; respectivamente &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;014&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">No se encontraron diferencias estad&#237;sticamente significativas entre los grupos de hiponatremias con los valores s&#233;ricos de glucosa&#44; urea&#44; creatinina&#44; &#225;cido &#250;rico&#44; troponina&#44; creatina-fosfocinasa&#44; calcio&#44; f&#243;sforo&#44; potasio&#44; hormonas tiroideas y fibrin&#243;geno&#46; La procalcitonina &#40;1&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41;&#44; prote&#237;na C-reactiva &#40;6&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#44; lactato deshidrogenasa &#40;513<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>708&#44;7<span class="elsevierStyleHsp" style=""></span>UI&#47;l&#41;&#44; hormona estimulante de la tiroides &#40;5&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;5<span class="elsevierStyleHsp" style=""></span>U&#47;mL&#41; y d&#237;mero-D &#40;3&#46;297&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;341&#44;9<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; presentaron valores m&#225;s altos en los pacientes con hiponatremia grave en comparaci&#243;n con en el resto de los grupos&#44; sin llegar a ser estad&#237;sticamente significativos &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; Las medias de los valores s&#233;ricos de cloro fueron significativamente m&#225;s bajos &#40;84&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6 mEq&#47;l&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;032&#41; y la ferritina significativamente m&#225;s alta &#40;5825&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1231&#44;3&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; en el grupo de hiponatremia grave &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">El 95&#44;6&#37; de los pacientes presentaron neumon&#237;a&#44; de estos 80 &#40;87&#44;9&#37;&#41; pacientes desarrollaron neumon&#237;a con infiltrados bilaterales&#46; Veintitr&#233;s &#40;25&#44;3&#37;&#41; padecieron diarrea&#44; siendo esta m&#225;s frecuente en los pacientes con hiponatremia grave &#40;37&#44;5&#37;&#41;&#46; El estado cr&#237;tico por COVID-19 se observ&#243; en 11 pacientes &#40;12&#44;1&#37;&#41;&#59; 7 de ellos presentaron hiponatremia leve &#40;9&#44;5&#37;&#41; y los 4 restantes hiponatremia grave &#40;50&#37;&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Con respecto al tratamiento de la infecci&#243;n por SARS-Cov-2&#44; la hidroxicloroquina fue el f&#225;rmaco m&#225;s usado durante el ingreso hospitalario en el 89&#37; de los casos&#44; manteni&#233;ndose esta predominancia en los 3 grupos de hiponatremia&#44; seguido de la azitromicina &#40;67&#37;&#41;&#44; dexametasona &#40;65&#44;9&#37;&#41;&#44; interfer&#243;n &#40;41&#44;8&#37;&#41; y lopinavir-ritonavir &#40;37&#44;4&#37;&#41;&#46; Se trat&#243; con heparina de bajo peso molecular &#40;HBPM&#41; al 58&#44;2&#37; de los pacientes &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Fallecieron 19 pacientes &#40;20&#44;9&#37;&#41;&#44; 10 de ellos durante el ingreso y los 9 restantes tras el alta hospitalaria&#46; Se observ&#243; un aumento de la mortalidad en pacientes con hiponatremia grave en comparaci&#243;n con el grupo de hiponatremia moderada y leve &#40;50&#37; versus 22&#44;2&#37; versus 17&#44;6&#37;&#44; respectivamente&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;10&#41;&#46; Este resultado fue estad&#237;sticamente significativo con respecto a la mortalidad intrahospitalaria &#40;37&#44;5&#37; versus 11&#44;1&#37; versus 8&#44;1&#37; respectivamente&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041&#41;&#46; De los 19 pacientes fallecidos la media de supervivencia fue de 19&#44;5 d&#237;as &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">La correcci&#243;n de la hiponatremia a las 24-48<span class="elsevierStyleHsp" style=""></span>horas no tuvo relaci&#243;n significativa con la supervivencia en el an&#225;lisis univariante &#40;<span class="elsevierStyleItalic">odds ratio</span> &#91;OR&#93;&#58; 0&#44;425 &#91;0&#44;096-1&#44;777&#93;&#59; 95&#37; de intervalo de confianza &#91;IC&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;206&#41;&#44; mientras que la correcci&#243;n a las 72-96<span class="elsevierStyleHsp" style=""></span>horas se relacion&#243; de forma estad&#237;sticamente significativa con la supervivencia &#40;OR&#58; 0&#44;185 &#91;0&#44;042-0&#44;812&#93;&#59; 95&#37; IC&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;024&#41;&#46; Esta relaci&#243;n se mantuvo en un modelo de regresi&#243;n de Cox que inclu&#237;a variables relacionadas en otros estudios con la mortalidad en la enfermedad por COVID-19 como la edad&#44; el sexo y el D-d&#237;mero&#46; Adem&#225;s&#44; se incluy&#243; la creatinina basal por presentar tambi&#233;n asociaci&#243;n estad&#237;sticamente significativa con la mortalidad y potencialmente con los niveles de sodio &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">tabla 6</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discusi&#243;n</span><p id="par0100" class="elsevierStylePara elsevierViewall">Esta cohorte retrospectiva longitudinal de 414 pacientes hospitalizados con diagn&#243;stico de COVID-19 demuestra una alta incidencia de hiponatremia<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>135<span class="elsevierStyleHsp" style=""></span>mmol&#47;l al ingreso hospitalario del 21&#44;98&#37;&#44; siendo la hiponatremia leve las m&#225;s frecuente en el 81&#37; de los casos&#44; que coinciden con los datos publicados por otras cohortes<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;9&#44;21&#8211;23</span></a>&#44; como el estudio <span class="elsevierStyleItalic">Health Outcome Predictive Evaluation for COVID-19</span>&#40;HOPE-COVID-19&#41;&#44;estudio multic&#233;ntrico de 37 hospitales de 7 pa&#237;ses&#44; con colaboraci&#243;n espa&#241;ola&#44; donde un 25&#37; de los pacientes hospitalizados por COVID-19 presentaron hiponatremia<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a>&#46; Tzoulis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> publicaron recientemente un estudio retrospectivo de 488 pacientes hospitalizados con COVID-19&#44; con una media de edad de 68 a&#241;os&#44; de 2 hospitales de Londres entre febrero y mayo del 2020&#59; la hiponatremia al ingreso fue del 24&#44;6&#37;&#44; coincidiendo con nuestros datos&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Se han postulado diferentes mecanismos que conducen a un incremento de la prevalencia de hiponatremia en pacientes con NAC no COVID-19&#44; tales como el SIADH&#44; algunos f&#225;rmacos como los diur&#233;ticos y ciertos pat&#243;genos como la <span class="elsevierStyleItalic">Legionella pneumoniae</span><a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a><span class="elsevierStyleItalic">&#46;</span> Seg&#250;n los resultados publicados previamente en reportes de casos y estudios descriptivos&#44; el SIADH parece ser la causa principal de la hiponatremia asociada a la COVID-19<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a>&#44; atendiendo a los criterios diagn&#243;sticos propuestos por Bartter y Schwartz<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a>&#46; La explicaci&#243;n fisiopatol&#243;gica de este evento ocurre como en otras enfermedades infecciosas&#44; donde est&#225; implicada alguna alteraci&#243;n del sistema inmunol&#243;gico del hu&#233;sped<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a>&#46; Esto puede conducir al desarrollo de una mala respuesta en los mecanismos de contrarregulaci&#243;n del agua&#44; lo que lleva en los casos graves a una sobreproducci&#243;n de hormona antidiur&#233;tica &#40;ADH&#41; de causa no osm&#243;tica&#46; Este problema se debe principalmente a un exceso de agua y no a un d&#233;ficit de sal&#44; acumul&#225;ndose en el sistema nervioso y empeorando su funcionamiento&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Por otro lado&#44; numerosos estudios han demostrado una elevaci&#243;n significativa de niveles s&#233;ricos de interleucina 1 y 6 &#40;IL-1&#44; IL-6&#41; en los pacientes con COVID-19 grave<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a>&#46; Se presume que la IL-6 desempe&#241;a un papel en la homeostasis del sodio por liberaci&#243;n no osm&#243;tica de vasopresina&#47;arginina<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a>&#46; En apoyo a esta hip&#243;tesis Berni et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> observaron en una peque&#241;a cohorte de 29 pacientes con COVID-19 una mejor&#237;a de la hiponatremia despu&#233;s de la terapia anti-IL-6&#46; Coincidiendo con estos datos&#44; en nuestro estudio observamos como etiolog&#237;as principales al SIADH y la hiponatremia hipovolemia por p&#233;rdidas digestivas en el grupo de pacientes con hiponatremia grave&#44; en aquellos casos donde se pudo obtener una correcta evaluaci&#243;n del estado de volumen&#44; osmolaridad urinaria y s&#233;rica para un diagnostico fiable&#44; pero no se realiz&#243; de rutina la medici&#243;n de IL-6&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Por otro lado&#44; esta alteraci&#243;n del equilibrio h&#237;drico producido por factores desconocidos puede estar acentuada o desencadenada en aquellos pacientes con enfermedades subyacentes graves como la insuficiencia card&#237;aca&#44; c&#225;ncer o problemas respiratorios&#46; Adem&#225;s&#44; la alteraci&#243;n directa del sistema renina angiotensina-aldosterona mediante la uni&#243;n del SARS-CoV-2 a la enzima conversora de angiotensina 2 tambi&#233;n se ha implicado en la patogenia de la COVID-19 y las alteraciones electrol&#237;ticas relacionadas<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Al igual que en otras enfermedades infecciosas&#44; la hiponatremia en la COVID-19 se ha mostrado como un marcador de mal pron&#243;stico&#46; En nuestro estudio&#44; la hiponatremia grave y la ausencia de correcci&#243;n de la hiponatremia a las 72-96<span class="elsevierStyleHsp" style=""></span>horas del ingreso hospitalario se asoci&#243; a mayor riesgo de mortalidad y gravedad de la COVID-19&#46; Fallecieron m&#225;s pacientes que presentaron hiponatremia grave al ingreso hospitalario en comparaci&#243;n con la hiponatremia moderada y leve&#46; Atila et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> estudiaron la prevalencia y el impacto en la mortalidad a los 30 d&#237;as del ingreso hospitalario de las disnatremias en pacientes con COVID-19 con PCR SARS-CoV-2 positivas comparado con pacientes con sospecha de COVID-19&#44; pero con PCR SARS-CoV-2 negativas&#46; De 172 casos y 849 controles la hiponatremia estuvo presente en el 29&#37; versus el 17&#44;6&#37; respectivamente&#44; el riesgo de mortalidad atribuible a la hiponatremia en los casos fue estad&#237;sticamente significativa &#40;<span class="elsevierStyleItalic">hazard ratio</span> &#91;HR&#93;&#58; 1&#44;4&#59; IC 95&#37;&#58; 1&#44;1-16&#44;6&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Por lo tanto&#44; los autores concluyen que la hiponatremia deber&#237;a ser considerada un marcador de mal pron&#243;stico asociado a mortalidad por la COVID-19 y a peores eventos adversos &#40;necesidad de ventilaci&#243;n mec&#225;nica&#44; ingreso en las unidades de cuidados intensivos y mayor estancia hospitalaria&#41;&#46; Otro estudio de una cohorte retrospectiva multic&#233;ntrica de 1&#46;254 pacientes con diagn&#243;stico de COVID-19 observ&#243; una prevalencia del 9&#44;9&#37; de hiponatremia y un 2&#44;4&#37; de hipernatremia en 3 hospitales en Hubei&#44; China&#46; Los pacientes con hiponatremia eran m&#225;s ancianos&#44; con mayor n&#250;mero de comorbilidades y desarrollaron un cuadro grave de hiponatremia&#46; Requirieron mayor aporte de ox&#237;geno&#44; antibioticoterapia y corticoesteroides&#46; La hiponatremia fue el trastorno hidroel&#233;ctrico m&#225;s frecuente en esta poblaci&#243;n y se asoci&#243; a un mayor riesgo de enfermedad grave y a una mayor mortalidad hospitalaria<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a>&#46; Otro estudio muy similar fue publicado por el grupo de De-Carvalho et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a>&#44; quienes describieron el impacto de la hiponatremia sobre el mal pron&#243;stico de la COVID-19&#46; De una cohorte retrospectiva longitudinal en Nantes&#44; de 296 pacientes&#44; se compararon 2 grupos&#58; pacientes con hiponatremia<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>135<span class="elsevierStyleHsp" style=""></span>mmol&#47;l &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>92&#59; 31&#37;&#41; versus pacientes normonatr&#233;micos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>198&#59; 67&#37;&#41;&#46; La hiponatremia fue un predictor independiente de resultados adversos &#40;OR ajustada&#58; 2&#44;77 &#91;1&#44;26-6&#44;15&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;011&#41;&#46; La gravedad de la COVID-19&#44; la duraci&#243;n de la estancia hospitalaria de los pacientes supervivientes y la mortalidad fueron mayores entre los pacientes con hiponatremia comparados con los normonatr&#233;micos&#46; Por &#250;ltimo&#44; Tzoluis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> observaron datos muy similares a los ya comentados previamente&#46; Los autores recomiendan el uso de las natremias al ingreso hospitalario como otros biomarcadores sistem&#225;ticos ya estudiados &#40;cifra de leucocitos&#44; linfocitos y prote&#237;na C reactiva&#41; con el fin de proporcionar una herramienta para la estratificaci&#243;n din&#225;mica del riesgo durante el curso cl&#237;nico de la COVID-19 y ayudar a la toma de decisiones cl&#237;nicas&#46; Sin embargo&#44; unas de las limitaciones de este estudio fue la ausencia de datos del uso de diur&#233;ticos y la administraci&#243;n de l&#237;quidos&#44; siendo dif&#237;cil de afirmar con ello si el sodio s&#233;rico es un predictor de mal pron&#243;stico o si es un efecto secundario de otros problemas no documentados&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Actualmente no existen consensos ni gu&#237;as cl&#237;nicas para el manejo de la hiponatremia en la COVID-19&#46; El abordaje terap&#233;utico depender&#225; de su etiolog&#237;a&#44; tonicidad&#44; estado de volumen y comorbilidades del paciente&#44; en concordancia con las recomendaciones de las gu&#237;as cl&#237;nicas de hiponatremia vigentes<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a>&#46; Como se comenta previamente&#44; es muy probable que la causa de la hiponatremia en la COVID-19 sea multifactorial&#44; incluyendo al SIADH y a las p&#233;rdidas digestivas de sodio por diarreas o v&#243;mitos&#46; Es importante enfatizar la necesidad de un juicio cl&#237;nico temprano del estado del volumen para decidir entre 2 estrategias terap&#233;uticas&#58; la terapia de reemplazo de l&#237;quidos&#44; en los casos de hiponatremia hipovol&#233;mica secundaria a p&#233;rdidas gastrointestinales&#59; ingesta reducida de l&#237;quidos o el uso de diur&#233;ticos en los casos de hiponatremia secundaria a SIADH se puede asociar la administraci&#243;n de urea&#44; antagonista selectivo de la vasopresina V2 &#40;tolvapt&#225;n&#41; y soluci&#243;n salina hipert&#243;nica&#44; dependiendo de la gravedad de los s&#237;ntomas neurol&#243;gicos&#44; estos pacientes deben ser monitorizados en unidades de cr&#237;ticos&#44; ya que es tan importante tratar la hiponatremia como el tiempo de correcci&#243;n&#46; Este abordaje terap&#233;utico es relevante en los pacientes con COVID-19&#44; ellos requieren una reanimaci&#243;n con l&#237;quidos cautelosa y conservadora para evitar complicaciones iatrog&#233;nicas&#44; como el edema agudo de pulm&#243;n y la exacerbaci&#243;n del da&#241;o pulmonar secundario a la infecci&#243;n por SARS-CoV-2&#44; pero a su vez se debe prevenir la hipernatremia&#44; que se induce por el balance negativo de l&#237;quidos&#46; Es por ello que el uso de osmolalidad s&#233;rica&#44; osmolalidad y sodio urinario es crucial para establecer un diagn&#243;stico correcto del estado de tonicidad vascular y de la volemia en los casos de hiponatremia&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Aunque la correcci&#243;n de la hiponatremia disminuye el aumento del riesgo de mortalidad asociado con la hiponatremia en pacientes no COVID-19&#44; hasta ahora no se ha determinado con claridad este evento&#46; Sin embargo&#44; un suban&#225;lisis de la poblaci&#243;n del estudio EVEREST&#44; con pacientes con hiponatremia<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#44; mostr&#243; una reducci&#243;n significativa de la morbimortalidad cardiovascular despu&#233;s del alta en pacientes tratados con tolvapt&#225;n<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a>&#46; Por otro lado&#44; Corona et al&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> realizaron un metaan&#225;lisis basado en 15 estudios publicados de 13&#46;816 pacientes hiponatr&#233;micos con un seguimiento medio de 33&#44;6 meses&#44; que inclu&#237;an datos sobre el efecto de la correcci&#243;n del Na<span class="elsevierStyleSup">&#43;</span> sobre la mortalidad&#46; En aquellos pacientes que corrigieron la hiponatremia la tasa de mortalidad global se redujo hasta un 60&#37; en comparaci&#243;n con los pacientes que no corrigieron&#46; Sin embargo&#44; la asociaci&#243;n fue m&#225;s fuerte y persisti&#243; a los 12 meses&#44; con una reducci&#243;n de hasta un 70&#37; de la tasa de mortalidad cuando se realiz&#243; un an&#225;lisis de sensibilidad basado en aquellos estudios en los que el umbral de la correcci&#243;n de la hiponatremia fue de hasta 130<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#46; Aunque nuestros datos no pueden extrapolar una relaci&#243;n causa-efecto&#44; nuestro estudio mostro que la ausencia de correcci&#243;n de la hiponatremia a las 72-96<span class="elsevierStyleHsp" style=""></span>horas del ingreso hospitalario fue un factor de riesgo independiente de incremento de mortalidad en pacientes con COVID-19&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Nuestro estudio present&#243; las siguientes limitaciones&#58; dada la excesiva carga asistencial que gener&#243; la necesidad de manejo e ingreso hospitalario de los pacientes con COVID-19&#44; coincidiendo con la primera ola de la pandemia&#44; solo se pudieron obtener los datos para determinar la etiolog&#237;a de la hiponatremia en los casos graves&#46; En el resto de pacientes no fue posible obtener datos cl&#237;nicos ni anal&#237;ticos complementarios para realizar un diagn&#243;stico fiable de la hiponatremia&#46; En segundo lugar&#44; por su dise&#241;o retrospectivo y observacional&#44; los resultados solo reflejan la asociaci&#243;n de la hiponatremia grave con muerte intrahospitalaria en la COVID-19&#44; pero no se infiere una relaci&#243;n causal&#46; Aunque se intent&#243; ajustar la asociaci&#243;n a diferentes covariables al ingreso hospitalario&#44; como cambios din&#225;micos de la hiponatremia durante toda la hospitalizaci&#243;n&#44; no se pudo determinar la cronicidad o etiolog&#237;a de la hiponatremia en casos leves y moderados&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Nuestra principal fortaleza fue comparar la correcci&#243;n de la hiponatremia a las 72 a 96<span class="elsevierStyleHsp" style=""></span>horas del ingreso entre el grupo de supervivientes y fallecidos&#46; A nuestro entender este es el primer estudio que eval&#250;a la hiponatremia mantenida como un factor de mal pron&#243;stico en pacientes con diagn&#243;stico de COVID-19 y&#44; por lo tanto&#44; a&#241;ade una valiosa informaci&#243;n a la literatura&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusiones</span><p id="par0145" class="elsevierStylePara elsevierViewall">Concluimos que la hiponatremia mantenida en las primeras 72 a 96<span class="elsevierStyleHsp" style=""></span>horas del ingreso hospitalario estuvo asociada a mayor mortalidad en los pacientes con COVID-19&#46; Creemos que los resultados de nuestra revisi&#243;n retrospectiva ayudar&#225;n a aumentar la conciencia cl&#237;nica de los profesionales implicados en el tratamiento de los pacientes con COVID-19 sobre un aspecto en ocasiones no bien manejado&#44; especialmente ahora que el mundo est&#225; inmerso en una pandemia todav&#237;a en curso&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Financiaci&#243;n</span><p id="par0150" class="elsevierStylePara elsevierViewall">Los autores declaran no contar con ning&#250;n tipo de financiaci&#243;n para el estudio&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicto de intereses</span><p id="par0155" class="elsevierStylePara elsevierViewall">Los autores declaran no tener conflicto de intereses&#46;</p></span></span>"
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            0 => "S&#237;ndrome respiratorio agudo grave del coronavirus 2"
            1 => "Enfermedad del coronavirus 2019"
            2 => "Hiponatremia y mortalidad"
          ]
        ]
      ]
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1535271"
          "palabras" => array:3 [
            0 => "Severe acute respiratory syndrome coronavirus 2"
            1 => "Coronavirus disease 2019"
            2 => "Hyponatremia and mortality"
          ]
        ]
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    "resumen" => array:2 [
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La infecci&#243;n por el coronavirus del s&#237;ndrome respiratorio agudo grave de tipo 2 &#40;SARS-CoV-2&#41; se asocia con frecuencia con hiponatremia &#40;sodio plasm&#225;tico<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>135<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#41;&#44; relacion&#225;ndose con peor pron&#243;stico&#46; La incidencia de la hiponatremia se estima en 20-37&#37; seg&#250;n las series&#44; pero no existen datos sobre el pron&#243;stico tras la correcci&#243;n de la hiponatremia&#46; Por ello&#44; nuestros objetivos fueron&#58; analizar la incidencia y gravedad de la hiponatremia al ingreso hospitalario y determinar la asociaci&#243;n de dicha hiponatremia con el pron&#243;stico de la enfermedad por coronavirus de 2019 &#40;COVID-19&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohorte observacional y retrospectivo&#46; Se incluyeron pacientes que ingresaron con diagn&#243;stico de infecci&#243;n por COVID-19 e hiponatremia en el periodo marzo-mayo de 2020&#46; Registramos variables epidemiol&#243;gicas&#44; demogr&#225;ficas&#44; cl&#237;nicas&#44; anal&#237;ticas y radiol&#243;gicas de la infecci&#243;n por SARS-CoV-2 e hiponatremia en el momento del diagn&#243;stico y durante la hospitalizaci&#243;n&#46; El seguimiento cl&#237;nico comprendi&#243; desde el ingreso hasta el exitus o el alta&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Noventa y un pacientes &#40;21&#44;8&#37;&#41; de los 414 ingresados por infecci&#243;n del SARS-CoV-2 presentaron hiponatremia &#40;81&#44;32&#37; hiponatremia leve&#44; 9&#44;89&#37; moderada y 8&#44;79&#37; grave&#41;&#46; La ausencia de correcci&#243;n de la hiponatremia a las 72-96<span class="elsevierStyleHsp" style=""></span>horas del ingreso hospitalario estuvo asociado a mayor mortalidad en los pacientes con COVID-19 &#40;<span class="elsevierStyleItalic">odds ratio</span> 0&#44;165&#59; 95&#37; intervalo de confianza&#58; 0&#44;018-0&#44;686&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;011&#41;&#46; Fallecieron 19 pacientes &#40;20&#44;9&#37;&#41;&#46; Se observ&#243; un aumento de la mortalidad en pacientes con hiponatremia grave en comparaci&#243;n con hiponatremia moderada y leve durante el ingreso &#40;37&#44;5&#37; versus 11&#44;1&#37; versus 8&#44;1&#37;&#44; respectivamente&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La persistencia de la hiponatremia tras las primeras 72-96<span class="elsevierStyleHsp" style=""></span>horas del ingreso hospitalario se asoci&#243; a mayor mortalidad en los pacientes con SARS-CoV-2&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material y m&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">SARS-CoV-2 infection is frequently associated with hyponatremia &#40;plasma sodium<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>135<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41;&#44; being associated with a worse prognosis&#46; The incidence of hyponatremia is estimated to be 20&#8211;37&#37; according to the series&#44; but there are no data on the prognosis after correction of hyponatremia&#46; Therefore&#44; our objectives were&#58; to analyze the incidence and severity of hyponatremia at hospital admission&#44; and to determine the association of this hyponatremia with the prognosis of COVID-19&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Observational and retrospective cohort study&#46; Patients who were admitted with a diagnosis of COVID-19 infection and hyponatremia&#44; in the period March&#8211;May 2020&#44; were included&#46; We recorded epidemiological&#44; demographic&#44; clinical&#44; biochemical&#44; and radiological variables of SARS-CoV-2 infection and hyponatremia at the time of diagnosis and during hospitalization&#46; The clinical follow-up ranged from admission to death or discharge&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">91 patients &#40;21&#46;8&#37;&#41; of the 414 admitted for SARS-CoV-2 infection presented hyponatremia &#40;81&#46;32&#37; mild hyponatremia&#44; 9&#46;89&#37; moderate and 8&#46;79&#37; severe&#41;&#46; The absence of correction of hyponatremia 72&#8211;96<span class="elsevierStyleHsp" style=""></span>h after hospital admission was associated with higher mortality in patients with COVID-19 &#40;Odds Ratio &#46;165&#59; 95&#37; confidence interval&#58; &#46;018-&#46;686&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;011&#41;&#46; 19 patients &#40;20&#46;9&#37;&#41; died&#46; An increase in mortality was observed in patients with severe hyponatremia compared with moderate and mild hyponatremia during hospital admission &#40;37&#46;5&#37; versus 11&#46;1&#37; versus 8&#46;1&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;041&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">We conclude that persistence of hyponatremia at 72&#8211;96<span class="elsevierStyleHsp" style=""></span>h of hospital admission was associated with higher mortality in patients with SARS-CoV-2&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material and method"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusions"
          ]
        ]
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        "etiqueta" => "Tabla 1"
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          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">ARA-II&#58; antagonista del receptor de angiotensina <span class="elsevierStyleSmallCaps">ii</span>&#59; DE&#58; desviaci&#243;n est&#225;ndar&#59; DM <span class="elsevierStyleSmallCaps">2</span>&#58; diabetes mellitus tipo 2&#59; EPOC&#58; enfermedad pulmonar obstructiva cr&#243;nica&#59; ERC&#58; enfermedad renal cr&#243;nica clasificaci&#243;n seg&#250;n la clasificaci&#243;n de la <span class="elsevierStyleItalic">Kidney Improving Global Outcomes</span> &#40;KIDGO&#41;&#59; HTA&#58; hipertensi&#243;n arterial&#59; IECA&#58; inhibidor de la enzima conversora de angiotensina&#59; n&#58; n&#250;mero de pacientes&#59; &#37;&#58; porcentaje&#46;</p>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t" scope="col">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">Total&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>91&#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
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Concentraci&#243;n de sodio</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" 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="" 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">130-135<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>74&#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">126-129<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#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
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#60;<span class="elsevierStyleHsp" style=""></span>125<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#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
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Valor de p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Sexo<span class="elsevierStyleItalic">&#44;</span> n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Varones&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">64 &#40;70&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">54 &#40;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 &#40;66&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">-&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 ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Edad &#40;media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DE&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">68&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;1&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">67&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;1&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">72&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;8&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">0&#44;399&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  " rowspan="14" align="left" valign="\n
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                  \t\t\t\t">Comorbilidades&#44; n &#40;&#37;&#41;</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">ERC&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">11 &#40;12&#44;1&#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">7 &#40;9&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 &#40;33&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;116&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">3a&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">2 &#40;2&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;1&#44;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;029&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">7 &#40;7&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obesidad&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">DM 2&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">Dislipidemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">C&#225;ncer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">EPOC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;4&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Tabaquismo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">SAHOS&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">Uropat&#237;a obstructiva&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">0&#44;791&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">Tratamiento previo&#44; n &#40;&#37;&#41;</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">IECA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;17&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;22&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5 &#40;62&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#44;014&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">ARA-II&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">13 &#40;14&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11 &#40;14&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;11&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;944&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas epidemiol&#243;gicas&#44; comorbilidades y tratamiento antihipertensivo de los pacientes estratificados por 3 niveles diferentes de sodio s&#233;rico</p>"
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      1 => array:8 [
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        "etiqueta" => "Tabla 2"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at2"
            "detalle" => "Tabla "
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                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-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t" scope="col">Total &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>91&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">130-135<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">125-129<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#60;<span class="elsevierStyleHsp" style=""></span>125<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#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="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Na<span class="elsevierStyleSup">&#43;</span> &#40;mmol&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">131&#44;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">132&#44;68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">127&#44;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Na<span class="elsevierStyleSup">&#43;</span> ajustado a glucosa &#40;mmol&#47;l&#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">131&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&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">133&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;4&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">127&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#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">121&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&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">Glucosa &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">154&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>91&#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">162&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>97&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">130&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>57&#44;1&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">114&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;265&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
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">55&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>48&#44;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>43&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;392&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">0&#44;355&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">Cl&#237;nica&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">25 &#40;27&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;24&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;44&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;37&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severidad COVID-19&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leve&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">12 &#40;13&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;13&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;11&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderado&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">14 &#40;15&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;18&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " 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
                  \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">Grave&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">54 &#40;59&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43 &#40;58&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;88&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;37&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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
                  \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">Cr&#237;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;12&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;9&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cl&#237;nica&#44; n &#40;&#37;&#41;</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">Neumon&#237;a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87 &#40;95&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;88&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;62&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&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>Infiltrados unilaterales&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">7 &#40;7&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;6&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;11&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&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>Infiltrados bilaterales&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80 &#40;87&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69 &#40;93&#44;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;77&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diarrea&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">23 &#40;25&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">19 &#40;25&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;11&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;37&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;450&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reingresos</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&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">77 &#40;84&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">63 &#40;85&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;77&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;87&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;274&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">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;10&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;11&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas cl&#237;nicas y grados de severidad de la enfermedad por coronavirus de 2019 en los pacientes estratificados por 3 niveles diferentes de sodio s&#233;rico</p>"
        ]
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      3 => array:8 [
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        "tipo" => "MULTIMEDIATABLA"
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          0 => array:3 [
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        "tabla" => array:2 [
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Ritonavir&#47;lopinavir&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">34 &#40;37&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;33&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;064&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Esteroides&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">6 &#40;66&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Ciclosporina&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">9 &#40;9&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;9&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Interfer&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;48&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;22&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Heparina&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  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cotrimoxazol&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">Ceftriaxona&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;440&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "es" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Tratamiento recibido de pacientes con enfermedad por coronavirus de 2019 estratificados por 3 niveles de sodio s&#233;rico</p>"
        ]
      ]
      4 => array:8 [
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">DE&#58; desviaci&#243;n est&#225;ndar&#59; n&#58; n&#250;mero de pacientes&#59; &#37;&#58; porcentaje&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Concentraci&#243;n de sodio</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;11&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;041&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Tras el ingreso&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">9 &#40;9&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;9&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1 &#40;11&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;955&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">Supervivencia en d&#237;as &#40;media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DE&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Mortalidad de los pacientes con enfermedad por coronavirus de 2019 estratificados por 3 niveles de sodio s&#233;rico</p>"
        ]
      ]
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">HR&#58; <span class="elsevierStyleItalic">hazard ratio</span>&#59; IC&#58; intervalo de confianza&#59; Na<span class="elsevierStyleSup">&#43;</span>&#58; sodio plasm&#225;tico&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&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" scope="col">Valor de p&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" scope="col">HR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#44;0&#37; IC para HR</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="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><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
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Inferior&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Superior&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
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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">Correcci&#243;n del Na&#43; a las 72-96<span class="elsevierStyleHsp" style=""></span>horas&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">0&#44;019&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">0&#44;149&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">0&#44;030&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;735&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">Sexo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;728&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;335&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;262&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">6&#44;798&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">Edad al ingreso&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;903&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;997&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;948&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;048&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Creatinina s&#233;rica&#59; mg&#47;dl&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;233&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;258&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;863&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">1&#44;833&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">D&#237;mero-D&#59; ng&#47;ml&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">0&#44;010&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">1&#44;000&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">1&#44;000&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">1&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "es" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Modelo de ajuste multivariante mediante regresi&#243;n de Cox de la correcci&#243;n de la natremia a las 72-96<span class="elsevierStyleHsp" style=""></span>horas ajustada por edad&#44; sexo&#44; creatinina basal y d&#237;mero-D</p>"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical features of patients infected with 2019 novel coronavirus in Wuhan&#44; China"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Huang"
                            1 => "Y&#46; Wang"
                            2 => "X&#46; Li"
                            3 => "L&#46; Ren"
                            4 => "J&#46; Zhao"
                            5 => "Y&#46; Hu"
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                      ]
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                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(20)30183-5"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pathophysiology&#44; transmission&#44; diagnosis&#44; and treatment of coronavirus disease 2019 &#40;COVID-19&#41;&#58; A review"
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                        0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Hyponatraemia in patients with community-acquired pneumonia&#59; prevalence and aetiology&#44; and natural history of SIAD"
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                          "etal" => true
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                            0 => "M&#46; Cuesta"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "V&#46; Nair"
                            1 => "M&#46;S&#46; Niederman"
                            2 => "N&#46; Masani"
                            3 => "S&#46; Fishbane"
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                    0 => array:2 [
                      "doi" => "10.1159/000100866"
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                        "fecha" => "2007"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Upadhyay"
                            1 => "B&#46;L&#46; Jaber"
                            2 => "N&#46;E&#46; Madias"
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjmed.2006.05.005"
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                        "fecha" => "2006"
                        "volumen" => "119"
                        "numero" => "7 Suppl 1"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hyponatremia and anti-diuretic hormone in Legionnaires&#8217; disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Schuetz"
                            1 => "S&#46; Haubitz"
                            2 => "M&#46; Christ-Crain"
                            3 => "W&#46;C&#46; Albrich"
                            4 => "W&#46; Zimmerli"
                            5 => "B&#46; Mueller"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1471-2334-13-585"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Infect Dis"
                        "fecha" => "2013"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24330484"
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                        "volumen" => "34"
                        "paginaInicial" => "991"
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                          "etal" => true
                          "autores" => array:6 [
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                            2 => "J&#46; Huang"
                            3 => "A&#46; Lewis"
                            4 => "A&#46;S&#46; Lord"
                            5 => "T&#46; Zhou"
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Información del artículo
ISSN: 00257753
Idioma original: Español
DOI:10.1016/j.medcli.2021.07.006
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