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ORIGINAL
Características basales de los pacientes nonagenarios ingresados por fracaso renal agudo en comparación con otros grupos etarios
Baseline characteristics of nonagenarians hospitalised due to acute kidney injury compared to other age groups
Begoña Santosa, Marta Sanza, Patricia Muñoz Ramosa, Noemi Gilabertb, Ramón Costab, Silvia Oterob, Patricia Carlesb, Pablo Ruanob, Borja Quirogaa,
Autor para correspondencia
borjaqg@gmail.com

Autor para correspondencia.
a Servicio de Nefrología, Hospital Universitario de La Princesa, Madrid, España
b Servicio de Medicina Interna, Hospital Universitario de La Princesa, 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">El aumento en la esperanza de vida global condiciona que el perfil de pacientes que ingresan en los hospitales haya variado en las &#250;ltimas d&#233;cadas&#44; situ&#225;ndose en 2018 en 83&#44;19 a&#241;os seg&#250;n datos del Instituto Nacional de Estad&#237;stica<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a>&#46; La edad por s&#237; misma es un condicionante pron&#243;stico para cualquier hospitalizaci&#243;n&#44; pero otras comorbilidades pueden agravar determinadas situaciones&#44; como por ejemplo&#44; un fracaso renal agudo &#40;FRA&#41;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2-4</span></a>&#46; El simple desarrollo de un FRA durante una hospitalizaci&#243;n predice un peor pron&#243;stico&#44; tanto a corto como a largo plazo&#44; y los pacientes de mayor edad se encuentran en una situaci&#243;n de riesgo m&#225;s evidente para ello<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Por otro lado&#44; el manejo del FRA cl&#225;sicamente se ha podido ver condicionado por la edad del paciente&#46; Sin embargo&#44; esta situaci&#243;n presenta cambios emergentes en el que se tienen en cuenta factores diferentes a la edad&#44; como por ejemplo&#44; la situaci&#243;n mental&#44; la robustez o la ausencia de comorbilidades importantes&#44; as&#237; como el deseo expreso de los pacientes para el manejo m&#225;s o menos conservador<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Hasta la fecha muy pocos estudios sobre FRA han sido capaces de incluir a pacientes de edad muy avanzada &#40;por encima de los 85 a&#241;os&#41;&#44; por lo que los datos disponibles son realmente escasos<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; Adem&#225;s&#44; apenas existen series en los que la inclusi&#243;n de pacientes nonagenarios sea relevante o en los que se realicen suban&#225;lisis de esta poblaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El presente estudio tiene como objetivo analizar las caracter&#237;sticas de los pacientes nonagenarios que sufren FRA durante un ingreso hospitalario y comparar las mismas con otros grupos etarios&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se trata de un estudio transversal que incluy&#243; a todos los pacientes hospitalizados en nuestro centro &#40;Hospital Universitario de La Princesa&#44; Madrid&#41; durante los a&#241;os 2013 y 2014&#44; con codificaci&#243;n al alta de FRA&#44; independientemente del desenlace del ingreso&#46; Se excluyeron aquellos que presentaban una codificaci&#243;n incorrecta&#44; que no tuvieran criterios cl&#237;nicos de FRA o que no dispusieran de datos de funci&#243;n renal durante el ingreso&#46; FRA se defini&#243; siguiendo las gu&#237;as KDIGO que establecen un incremento de la creatinina s&#233;rica &#8805;&#160;0&#44;3&#160;mg&#47;dL en 48 horas o un aumento de 1&#44;5 a 1&#44;9 veces respecto a la creatinina basal<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a>&#46; Este se pod&#237;a producir durante la hospitalizaci&#243;n y al ingreso bas&#225;ndonos en esta definici&#243;n&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">De cada paciente se recogi&#243; basalmente edad&#44; sexo&#44; motivo de ingreso&#44; servicio de ingreso&#44; fecha de ingreso&#44; comorbilidad cardiovascular &#40;presencia de diabetes <span class="elsevierStyleItalic">mellitus</span>&#44; hipertensi&#243;n arterial&#44; cardiopat&#237;a isqu&#233;mica&#44; insuficiencia cardiaca&#44; enfermedad vascular perif&#233;rica&#44; accidente cerebrovascular&#44; dislipemia&#41; y neoplasia<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12-14</span></a>&#46; En aquellos pacientes en los que estaba disponible&#44; se registraron los datos de ecocardiograma reciente &#40;menos de seis meses&#41; tales como disfunci&#243;n sist&#243;lica&#44; diast&#243;lica&#44; hipertrofia de ventr&#237;culo izquierdo y fracci&#243;n de eyecci&#243;n de ventr&#237;culo izquierdo<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a>&#46; Como escala de dependencia se utiliz&#243; el &#237;ndice de mini-Barthel que se codific&#243; en funci&#243;n de la capacidad del paciente para&#58; la alimentaci&#243;n &#40;10 puntos si es independiente&#44; 5 si necesita ayuda y 0 si es dependiente&#41;&#44; ba&#241;o &#40;5 puntos si es independiente y 0 si es dependiente&#41;&#44; vestirse &#40;10 puntos si es independiente&#44; 5 si necesita ayuda y 0 si es dependiente&#41;&#44; arreglarse &#40;10 puntos si es independiente y 0 si es dependiente&#41; y realizar deposici&#243;n &#40;10 puntos si es continente&#44; 5 si tiene incontinencia ocasional y 0 si es incontinente&#41;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">16&#44;17</span></a>&#46; Se recogi&#243; la presencia de deterioro cognitivo que se defini&#243; con los criterios del grupo de estudio de demencias y trastornos de la conducta de la Sociedad Espa&#241;ola de Neurolog&#237;a<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a>&#46; En cuanto a la funci&#243;n renal&#44; se evalu&#243; la presencia de enfermedad renal cr&#243;nica &#40;ERC&#41; de base&#44; la creatinina basal&#44; el filtrado glomerular estimado por MDRD y CKD-EPI con base en la creatinina s&#233;rica y la proteinuria basal &#40;en mg en 24 horas&#41;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">19&#44;20</span></a>&#46; Adem&#225;s&#44; se recogi&#243; basalmente si dentro de su medicaci&#243;n habitual recib&#237;an metformina&#44; diur&#233;ticos o f&#225;rmacos bloqueantes del sistema renina-angiotensina-aldosterona &#40;BSRAA&#41;&#44; que son f&#225;rmacos que pueden contribuir al desarrollo de un FRA si se dan determinadas circunstancias relacionadas con la disminuci&#243;n de la perfusi&#243;n renal&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En el momento del ingreso se recogi&#243; el motivo de este &#40;FRA&#44; cardiovascular&#44; infeccioso&#44; neoplasia <span class="elsevierStyleItalic">de&#160;novo</span>&#44; otros&#41; y el tipo de FRA &#40;funcional&#44; obstructivo&#44; necrosis tubular aguda&#44; nefritis intersticial aguda&#44; causa glomerular&#44; vascular o no filiado&#41;&#46; Para la definici&#243;n de la etiolog&#237;a se utilizaron criterios cl&#237;nicos que se revisaron por los investigadores y biopsia renal si &#233;sta se encontraba disponible&#46; En caso de duda diagn&#243;stica se incluy&#243; en el grupo de no filiado&#46; Se ha utilizado la escala AKIN para determinar la severidad del FRA&#44; de manera que el estadio 1 supone un aumento de la creatinina s&#233;rica de un 150 a 199&#37;&#44; el estadio 2 de 200&#37; a 299&#37; y el estadio 3 m&#225;s de 300&#37;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a>&#46; Se recogi&#243; la necesidad de di&#225;lisis durante el ingreso&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">El estudio cumple la normativa vigente de protecci&#243;n de datos&#44; as&#237; como los principios &#233;ticos&#44; y ha sido aprobado por el Comit&#233; &#201;tico del Hospital Universitario de La Princesa &#40;referencia 3447&#44; 11&#47;2018&#41;&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">An&#225;lisis estad&#237;stico</span><p id="par0045" class="elsevierStylePara elsevierViewall">Las variables se expresan como media &#40;desviaci&#243;n est&#225;ndar&#41; si siguen una distribuci&#243;n normal &#40;seg&#250;n el test de Kolmogorov-Smirnov&#41; o como mediana &#40;rango intercuart&#237;lico&#41; en caso contrario&#46; Dividimos a los pacientes en funci&#243;n de su edad en los siguientes grupos&#58; menos de 65 a&#241;os&#44; de 65 a 89 y m&#225;s de 89&#46; Comparamos las diferentes caracter&#237;sticas recogidas en los grupos etarios usando los test de inferencia estad&#237;stica &#967;<span class="elsevierStyleSup">2</span>&#44; t de Student o ANOVA dependiendo del tipo de variable utilizada &#40;cualitativa o cuantitativa&#41;&#46; Todos los an&#225;lisis estad&#237;sticos se realizaron con el programa SPSS&#174; &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#41; versi&#243;n 22&#46;0&#46; Una p&#160;&#60;&#160;0&#44;05 se consider&#243; estad&#237;sticamente significativa&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">Se incluy&#243; y analiz&#243; a 1&#46;733 pacientes&#44; de los que 926 &#40;53&#37;&#41; eran varones&#44; con una edad media de 77 &#40;15&#41; a&#241;os&#46; Las comorbilidades m&#225;s frecuentes fueron la hipertensi&#243;n arterial&#44; que se registr&#243; en 1&#46;290 pacientes &#40;75&#37;&#41;&#44; la dislipemia que presentaron 728 pacientes &#40;42&#37;&#41;&#44; la enfermedad renal cr&#243;nica presente en 728 &#40;43&#37;&#41; y la diabetes <span class="elsevierStyleItalic">mellitus</span> registrada en 509 de ellos &#40;29&#37;&#41;&#46; El resto de las caracter&#237;sticas basales se recogen en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; En cuanto a la distribuci&#243;n por servicios&#44; el 34&#37; de los pacientes ingresaron en Medicina Interna&#44; el 14&#37; en Cirug&#237;a&#44; el 11&#37; en Nefrolog&#237;a&#44; el 8&#37; en Cardiolog&#237;a y el 8&#37; en la Unidad de Cuidados Intermedios&#46; El restante 25&#37; se reparti&#243; entre el resto de servicios del centro&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Del total de pacientes&#44; 264 &#40;15&#37;&#41; ten&#237;an una edad igual o superior a 90 a&#241;os&#44; 1&#46;180 &#40;68&#37;&#41; ten&#237;an entre 65 y 89 a&#241;os y 289 &#40;16&#37;&#41; ten&#237;an menos de 65 a&#241;os&#46; Realizamos una comparaci&#243;n entre los diferentes grupos etarios y encontramos diferencias significativas en el sexo&#44; en la prevalencia de hipertensi&#243;n arterial&#44; de enfermedad renal cr&#243;nica&#44; de insuficiencia cardiaca&#44; fibrilaci&#243;n auricular&#44; de ictus&#44; de deterioro cognitivo y de dependencia &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> se muestra la comparaci&#243;n entre las variables en los mayores y menores de 90 a&#241;os&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Analizamos los par&#225;metros ecocardiogr&#225;ficos de aquellos pacientes que ten&#237;an un ecocardiograma disponible como m&#225;ximo seis meses antes del ingreso &#40;854 pacientes &#91;49&#37;&#93;&#41; y encontramos diferencias significativas en la funci&#243;n sist&#243;lica y en la hipertensi&#243;n pulmonar en los diferentes grupos de edad &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">El motivo principal de ingreso fue infecci&#243;n &#40;32&#44;8&#37;&#41;&#44; seguido de patolog&#237;a cardiovascular &#40;21&#44;2&#37;&#41; y neoplasia &#40;20&#44;9&#37;&#41;&#46; Encontramos diferencias en la distribuci&#243;n del motivo de ingreso en los diferentes grupos etarios como se muestra en las <a class="elsevierStyleCrossRefs" href="#tbl0010">tablas 2 y 3</a>&#44; predominando la infecci&#243;n en los pacientes mayores de 90 a&#241;os y el FRA en los menores de 65 &#40;p&#160;&#60;&#160;0&#44;001&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">El 71&#44;1&#37; de los pacientes ten&#237;a como etiolog&#237;a del FRA la causa funcional&#44; seguida de no filiado &#40;13&#44;2&#37;&#41;&#44; obstructivo &#40;6&#44;2&#37;&#41; y necrosis tubular aguda &#40;NTA&#41; &#40;4&#44;6&#37;&#41;&#46; La distribuci&#243;n por grupos etarios present&#243; diferencias estad&#237;sticamente significativas&#44; como se muestra en las <a class="elsevierStyleCrossRefs" href="#tbl0010">tablas 2 y 3</a> &#40;p&#160;&#60;&#160;0&#44;001 y p&#160;&#61;&#160;0&#44;005&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Respecto a la severidad del FRA&#44; 1&#46;147 pacientes &#40;66&#37;&#41; presentaban un AKIN-1&#44; 331 &#40;19&#37;&#41; un AKIN-2 y 255 &#40;15&#37;&#41; un AKIN-3&#46; Los diferentes grupos etarios tuvieron una distribuci&#243;n distinta de la severidad del FRA&#44; como se muestra en las <a class="elsevierStyleCrossRefs" href="#tbl0010">tablas 2 y 3</a>&#46; Ciento veintiocho pacientes &#40;7&#44;3&#37;&#41; precisaron terapia renal sustitutiva&#44; de los que solo dos &#40;0&#44;1&#37;&#41; eran mayores de 90 a&#241;os &#40;p&#160;&#60;&#160;0&#44;001 respecto al resto de grupos etarios&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discusi&#243;n</span><p id="par0080" class="elsevierStylePara elsevierViewall">El envejecimiento progresivo de la poblaci&#243;n condiciona un cambio en las caracter&#237;sticas epidemiol&#243;gicas y cl&#237;nicas de los pacientes hospitalizados y&#44; concretamente&#44; en aquellos que sufren un FRA durante el ingreso&#46; Dentro de las caracter&#237;sticas de nuestro estudio&#44; que incluy&#243; todos los FRA hospitalizados&#44; destaca en general una poblaci&#243;n envejecida con importante carga cardiovascular &#40;elevada prevalencia de hipertensi&#243;n arterial&#44; ERC y eventos cardiovasculares previos&#41; y un elevado porcentaje de pacientes con deterioro cognitivo&#44; que pudiera estar en relaci&#243;n con la propia afectaci&#243;n vascular cerebral&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Abordando la poblaci&#243;n nonagenaria encontramos diferencias llamativas respecto al resto de grupos etarios en algunas patolog&#237;as como por ejemplo la diabetes <span class="elsevierStyleItalic">mellitus</span>&#44; la dislipemia o las neoplasias&#46; As&#237;&#44; por ejemplo&#44; menos del 20&#37; de los pacientes presentan diabetes <span class="elsevierStyleItalic">mellitus</span> y solo el 8&#37; de los nonagenarios ten&#237;an prescrita metformina&#46; A pesar de que con el aumento de la edad se incrementa la prevalencia de hipertensi&#243;n arterial&#44; en las etapas vitales m&#225;s avanzadas el riesgo cardiovascular sin&#233;rgico con la diabetes y dislipemia se aten&#250;a&#44; favoreciendo un perfil m&#225;s favorable de comorbilidades y&#44; por tanto&#44; un aumento de la supervivencia<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">22&#44;23</span></a>&#46; De hecho&#44; los pacientes m&#225;s ancianos presentan menos antecedentes de eventos cardiovasculares&#44; como por ejemplo ictus o insuficiencia cardiaca&#44; de acuerdo con la literatura publicada<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">24&#44;25</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Disponemos adem&#225;s de datos ecocardiogr&#225;ficos en el 49&#37; de los pacientes que demuestran que los pacientes nonagenarios presentaban menos disfunci&#243;n diast&#243;lica e hipertensi&#243;n pulmonar&#46; Ambas situaciones condicionan una elevada mortalidad precoz &#40;que muchas veces pasa inadvertida por ser asintom&#225;tica en estadios iniciales&#41; y son los pacientes que carecen de ellas los que tienen oportunidad de alcanzar etapas m&#225;s avanzadas de la vida<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">El 50&#37; de los nonagenarios ingresados por FRA ten&#237;an ERC&#46; Este es un dato interesante ya que la presencia de ERC se asocia al desarrollo de FRA&#44; como se ha demostrado en numerosos trabajos como&#44; por ejemplo&#44; el recientemente publicado por He et al&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a>&#46; Esta condici&#243;n obedece a numerosas causas&#44; como las caracter&#237;sticas proinflamatorias y oxidativas de la ERC&#44; a la disminuci&#243;n de la reserva funcional renal &#40;m&#225;s frecuente en ancianos&#41; y la alteraci&#243;n de los mecanismo reparadores que dificultan o agravan un FRA<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a>&#46; Sin embargo&#44; la estimaci&#243;n del filtrado glomerular usando f&#243;rmulas basadas en creatinina &#40;enzima de origen muscular&#41; y que incluyen la edad supone que este par&#225;metro se deba interpretar con cautela en pacientes ancianos y muy ancianos y no etiquetar precozmente de ERC a pacientes con poco riesgo de progresar<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a>&#46; Actualmente en algunos centros se dispone de la cistatina C como estimador del filtrado glomerular&#44; que tiene como ventaja la independencia de la masa muscular<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">La toma de ciertas decisiones cl&#237;nicas&#44; sobre todo si implican procedimientos o intervenciones&#44; con objeto de evitar la futilidad&#44; obedecen en parte a la situaci&#243;n basal del paciente<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a>&#46; Nuestros datos revelan&#44; como era de esperar&#44; que la edad aumenta el riesgo de presentar deterioro cognitivo severo y empeora las actividades de la vida diaria &#40;que en nuestro estudio se ha evaluado mediante un test de Barthel modificado&#41;&#46; Estas dos situaciones se asocian con un peor pron&#243;stico global y del FRA&#44; tal y como se ha publicado previamente<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a>&#46; Adem&#225;s&#44; sumado a lo anterior&#44; la fragilidad se ha propuesto en algunos estudios como un factor de riesgo para presentar deterioro de funci&#243;n renal<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a>&#46; Aunque en nuestro estudio carecemos de informaci&#243;n acerca de la fragilidad&#44; se deben establecer estrategias en esa poblaci&#243;n para disminuir FRA o evitar su progresi&#243;n&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">En cuanto a los datos relacionados con el episodio del FRA&#44; los nonagenarios presentan predominantemente una etiolog&#237;a funcional del mismo&#46; El manejo de la volemia es de vital importancia para prevenir o al menos mitigar este tipo de episodios&#46; Abordar la volemia desde un punto de vista menos estricto evitando la hipoperfusi&#243;n renal probablemente podr&#237;a ayudar a prevenir episodios de FRA<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">34&#44;35</span></a>&#46; De hecho&#44; las gu&#237;as actuales de hipertensi&#243;n arterial recomiendan un objetivo m&#225;s conservador &#40;aunque individualizable&#41; en cuanto a las cifras de presi&#243;n arterial<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a>&#46; Pese a ello&#44; m&#225;s de la mitad de los nonagenarios ten&#237;an prescrito diur&#233;ticos y&#47;o BSRAA&#44; f&#225;rmacos que contribuyen a empeorar un FRA en determinadas circunstancias&#46; Por ello es importante el manejo de la polifarmacia en pacientes ancianos y evitar la inercia en un objetivo en la prevenci&#243;n de complicaciones derivadas de su uso<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">37&#44;38</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Dentro de la etiolog&#237;a es destacable como el FRA obstructivo se presenta con mayor frecuencia en los pacientes m&#225;s j&#243;venes de nuestro estudio&#46; Hipotetizamos que pueda deberse al inicio de patolog&#237;a prost&#225;tica en edades m&#225;s tempranas de la vida y que en los pacientes nonagenarios hayan podido ser resueltas previamente mediante cirug&#237;a o descongestionantes prost&#225;ticos&#46; Tambi&#233;n la alta incidencia de neoplasias &#40;urol&#243;gicas o metast&#225;sicas&#41; en los menores de 90 a&#241;os son una causa frecuente de obstrucci&#243;n urinaria&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">El presente estudio no est&#225; exento de limitaciones&#44; como por ejemplo&#44; la naturaleza transversal y retrospectiva del mismo con los sesgos que ello supone&#46; Por otro lado&#44; la ausencia de seguimiento de los pacientes nos impide obtener conclusiones pron&#243;sticas&#44; aunque establecer un perfil de pacientes ingresados mayores de 89 a&#241;os y su especial situaci&#243;n parecen de relevancia con el avance de la esperanza de vida&#46; Sin embargo&#44; el tama&#241;o muestral y las comorbilidades recogidas son fortalezas que apoyan los resultados obtenidos y permiten establecer un patr&#243;n caracter&#237;stico de los pacientes nonagenarios&#46; Por otro lado&#44; en cuanto a la funci&#243;n renal no disponemos de datos urinarios en muchos pacientes y cuando dispusimos de proteinuria &#233;sta no era selectiva&#46; Tampoco disponemos de datos hidroelectrol&#237;ticos&#44; aunque en este caso no son de gran importancia para el objetivo del estudio&#46; Asimismo&#44; el volumen de diuresis no ha sido considerado&#44; por lo que la definici&#243;n de FRA se basa en la variaci&#243;n de la creatinina s&#233;rica&#46; Finalmente&#44; la fragilidad no se ha podido medir siendo una importante caracter&#237;stica de los pacientes ancianos&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Como conclusiones podemos determinar que los pacientes mayores de 90 a&#241;os suponen un elevado porcentaje de los pacientes ingresados por FRA&#46; Estos pacientes presentan una mayor incidencia de FRA funcional&#44; siendo el motivo predominante del ingreso el infeccioso&#46; En cuanto a las comorbilidades&#44; los nonagenarios que ingresan por FRA tienen m&#225;s HTA&#44; ERC&#44; ICC&#44; dependencia y deterioro cognitivo en comparaci&#243;n con el resto de los grupos etarios&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicto de intereses</span><p id="par0125" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Antecedentes y objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">El aumento en la esperanza de vida ha generado hospitalizaciones de pacientes con edades muy avanzadas&#46; El objetivo de este trabajo es estudiar las caracter&#237;sticas de la poblaci&#243;n de m&#225;s de 90 a&#241;os que ingresa por fracaso renal agudo &#40;FRA&#41; en comparaci&#243;n con otros grupos etarios&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materiales y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal que incluy&#243; a todos los pacientes hospitalizados entre 2013 y 2014 cuya codificaci&#243;n al alta era de FRA&#46; Recogimos caracter&#237;sticas epidemiol&#243;gicas&#44; comorbilidad&#44; medicaci&#243;n y datos anal&#237;ticos basales&#46; Analizamos y comparamos los datos de los mayores de 90 a&#241;os con los menores de dicha edad&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 1&#46;733 pacientes&#46; Del total de pacientes&#44; 264 &#40;15&#37;&#41; ten&#237;an una edad superior a 90 a&#241;os y se encontr&#243; una proporci&#243;n significativamente mayor de mujeres&#46; La causa m&#225;s frecuente del FRA en los pacientes mayores de 90 a&#241;os fue la funcional &#40;81&#37;&#41; &#40;p&#160;&#60;&#160;0&#44;001 respecto al resto de grupos etarios&#41;&#46; La principal causa de ingreso fue la infecciosa&#46; En el grupo de m&#225;s de 90 a&#241;os&#44; encontramos mayor prevalencia de hipertensi&#243;n arterial &#40;HTA&#41; &#40;p&#160;&#61;&#160;0&#44;005&#41;&#44; enfermedad renal cr&#243;nica &#40;ERC&#41; &#40;p&#160;&#61;&#160;0&#44;014&#41;&#44; insuficiencia cardiaca congestiva &#40;I<span class="elsevierStyleSmallCaps">CC</span>&#41; &#40;p&#160;&#61;&#160;0&#44;006&#41; y deterioro cognitivo &#40;p&#160;&#60;&#160;0&#44;0001&#41;&#46; El filtrado glomerular basal por CKD-EPI fue inferior en el grupo de mayores de 90 a&#241;os &#40;p&#160;&#60;&#160;0&#44;0001&#41;&#46; Los pacientes hospitalizados por FRA menores de 90 a&#241;os ten&#237;an mayor prevalencia de diabetes <span class="elsevierStyleItalic">mellitus</span> &#40;p&#160;<span class="elsevierStyleItalic">&#60;</span>&#160;0&#44;001&#41;&#44; dislipemia &#40;p&#160;&#60;&#160;0&#44;001&#41; y antecedente de neoplasia &#40;p&#160;&#60;&#160;0&#44;001&#41;&#44; y un &#237;ndice de Barthel superior &#40;p&#160;&#60;&#160;0&#44;0001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La causa m&#225;s frecuente de FRA en nonagenarios es la funcional&#44; presentando los pacientes m&#225;s HTA&#44; ERC&#44; ICC&#44; mayor dependencia y deterioro cognitivo frente al resto de grupos etarios&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The increase in life expectancy leads to higher hospitalisation rates in elderly patients&#46; The aim of this work is to study the characteristics of the population over 90 years of age that are admitted due to acute kidney injury &#40;AKI&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A cross-sectional study was conducted that included all patients admitted to hospital with AKI in the years 2013 and 2014&#46; Epidemiological characteristics&#44; comorbidity&#44; medication and baseline analytical data were collected&#44; and a comparison was made between patients with age over 90 years-old and the others&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 1733 patients were included&#44; of whom 264 &#40;15&#37;&#41; were over 90 years-old&#46; A significantly higher proportion of these patients were women&#46; The most frequent cause of AKI in patients older than 90 years was functional &#40;81&#37;&#41; &#40;p&#160;&#60;&#160;0&#46;001 compared to other age groups&#41;&#46; The main cause of hospital admission was infection&#46; In the group of over 90 years of age&#44; a higher prevalence was found for arterial hypertension &#40;p&#160;&#61;&#160;0&#46;005&#41;&#44; chronic kidney disease &#40;p &#61; 0&#46;014&#41;&#44; congestive heart failure &#40;p&#160;&#61;&#160;0&#46;006&#41;&#44; and cognitive impairment &#40;p &#60; 0&#46;0001&#41;&#46; The baseline glomerular filtration rate by CKD-EPI was lower in the group of patients older than 90 years &#40;p&#160;&#60;&#160;0&#46;0001&#41;&#46; Patients under 90 years admitted to hospital due to AKI&#44; had a higher prevalence of diabetes <span class="elsevierStyleItalic">mellitus</span> &#40;p &#60; 0&#46;001&#41;&#44; dyslipidaemia &#40;p &#60; 0&#46;001&#41;&#44; history of neoplasia &#40;p &#60; 0&#46;001&#41;&#44; and a higher Barthel index &#40;p &#60; 0&#46;0001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nonagenarians admitted due to AKI have functional aetiology as the most common factor&#46; These patients have a higher prevalence of hypertension&#44; heart failure&#44; chronic kidney disease&#44; low functional status&#44; and more cognitive impairment&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material and methods"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusions"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">De 65 a 89 a&#241;os &#40;n&#160;&#61;&#160;1180&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">84 &#40;32&#37;&#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"><span class="elsevierStyleItalic">Enfermedad renal cr&#243;nica &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Creatinina basal &#40;mg&#47;dL&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&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"><span class="elsevierStyleHsp" style=""></span>CKD-EPI &#40;mL&#47;min&#47;1&#44;73 m<span class="elsevierStyleSup">2</span>&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&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"><span class="elsevierStyleHsp" style=""></span>Creatinina basal &#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
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                  \t\t\t\t">1&#44;2 &#40;0&#44;8&#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">1&#44;4 &#40;1&#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
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                  \t\t\t\t">1&#44;3 &#40;0&#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&#44;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Enfermedad vascular perif&#233;rica &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Antecedente de neoplasia &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Mini-Barthel &#40;puntuaci&#243;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">F&#225;rmacos &#40;&#37;&#41;</span></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">Bloqueantes del SRAA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Diur&#233;ticos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diur&#233;ticos del asa<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;&#42;</span></a>&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">Metformina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Motivo de ingreso &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">FRA&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">Infecci&#243;n&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">Neoplasia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiovascular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Otros&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"><span class="elsevierStyleItalic">Tipo de FRA &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Funcional&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">164 &#40;57&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">865 &#40;74&#37;&#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"><span class="elsevierStyleHsp" style=""></span>Obstructivo&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">27 &#40;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">70 &#40;6&#37;&#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"><span class="elsevierStyleHsp" style=""></span>NTA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">54 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intersticial&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;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11 &#40;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#37;&#41;&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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diur&#233;ticos del asa<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Metformina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Motivo de ingreso &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neoplasia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cardiovascular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Funcional&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obstructivo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>NTA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intersticial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Glomerular&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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;04&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"><span class="elsevierStyleHsp" style=""></span>AKIN-1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AKIN-2&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\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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Levemente deprimida<a class="elsevierStyleCrossRef" href="#tblfn0025">&#42;</a>&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\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>Severamente deprimida<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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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">5 &#40;5&#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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Disfunci&#243;n diast&#243;lica</span>&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\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Hipertensi&#243;n pulmonar</span>&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\ttable-entry\n
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