Treatment of Chronic Heart Failure in Advanced Chronic Kidney Disease: The HAKA Multicenter Retrospective Real-World Study.

INTRODUCTION: Chronic heart failure (HF) has high rates of mortality and hospitalization in patients with advanced chronic kidney disease (aCKD). However, randomized clinical trials have systematically excluded aCKD population. We have investigated current HF therapy in patients receiving clinical care in specialized aCKD units. METHODS: The Heart And Kidney Audit (HAKA) was a cross-sectional and retrospective real-world study including outpatients with aCKD and HF from 29 Spanish centers. The objective was to evaluate how the treatment of HF in patients with aCKD complied with the recommendations of the European Society of Cardiology Guidelines for the diagnosis and treatment of HF, especially regarding the foundational drugs: renin-angiotensin system inhibitors (RASi), angiotensin receptor blocker/neprilysin inhibitors (ARNI), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2i). RESULTS: Among 5,012 aCKD patients, 532 (13%) had a diagnosis of HF. Of them, 20% had reduced ejection fraction (HFrEF), 13% mildly reduced EF (HFmrEF), and 67% preserved EF (HFpEF). Only 9.3% of patients with HFrEF were receiving quadruple therapy with RASi/ARNI, BB, MRA, and SGLT2i, but the majority were not on the maximum recommended doses. None of the patients with HFrEF and CKD G5 received quadruple therapy. Among HFmrEF patients, approximately half and two-thirds were receiving RASi and/or BB, respectively, while less than 15% received ARNI, MRA, or SGLT2i. Less than 10% of patients with HFpEF were receiving SGLT2i. CONCLUSIONS: Under real-world conditions, HF in aCKD patients is sub-optimally treated. Increased awareness of current guidelines and pragmatic trials specifically enrolling these patients represent unmet medical needs.

Prescribing the dialysis dose and treatment frequency in home haemodialysis.

BACKGROUND: There is growing interest in home haemodialysis (HHD) performed with low-flow dialysate devices and variable treatment schedules. The target standard Kt/V (stdKt/V) should be 2.3 volumes/week, according to KDOQI guidelines (2015). The current formula for stdKt/V does not help prescribe the dialysis dose (eKt/V) and treatment frequency (TF). The aim of this study was to obtain a formula for stdKt/V that is able to define the minimum required values of eKt/V and TF to achieve the targeted stdKtV. METHODS: Thirty-eight prevalent patients on HHD were enrolled. A total of 231 clinical datasets were available for urea modelling using the Solute-Solver software (SS), recommended by KDOQI guidelines. A new formula (stdKt/V = a + b × Kru + c × eKt/V) was obtained from multivariable regression analysis of stdKt/V vs eKt/V and residual kidney urea clearance (Kru). The values of coefficients a, b and c depend on the treatment schedules and the day of the week of blood sampling for the kinetic study (labdayofwk) and then vary for each of their foreseen 62 combinations. For practical purposes, we used only seven combinations, assuming Monday as a labdayofwk for each of the most common schedules of the 7 days of the week. RESULTS: The stdKt/V values obtained with SS were compared with the paired ones obtained with the formula. The mean ± standard deviation stdKt/V values obtained with SS and the formula were 3.043 ± 0.530 and 2.990 ± 0.553, respectively, with 95% confidence interval +0.15 to -0.26. A 'prescription graph' was built using the formula to draw lines expressing the relationship between Kru and required eKt/V for each TF. Using this graph, TF could have been reduced from the delivered 5.8 ± 0.8 to 4.8 ± 0.8 weekly sessions. CONCLUSIONS: The new formula for stdKtV is reliable and can support clinicians to prescribe the dialysis dose and TF in patients undergoing HHD.

Validation of formulas calculating normalized protein catabolic rate in patients undergoing home hemodialysis.

Depner and Daugirdas developed a simplified formula to estimate the normalized protein catabolic rate in patients on twice- or thrice-weekly hemodialysis (JASN, 1996). The aim of our work was to establish formulas in more frequent schedules and validate them in home-based hemodialysis patients. We realized that the structure of Depner and Daugirdas' normalized protein catabolic rate formulas has a general meaning and can be expressed as PCRn = C0/[a + b*(Kt/V) + c/(Kt/V)] + d, where C0 is pre-dialysis blood urea nitrogen, Kt/V is dialysis dose, a, b, c, d are the specific coefficients for each combination of home-based hemodialysis schedules and the day of blood sampling. The same applies to the formula that adjusts C0 (C'0) for residual kidney clearance of blood water urea (Kru) and urea distribution volume (V): C'0 = C0*[1 + (a1 + b1/(Kt/V))*Kru/V]. On this basis, we computed the six coefficients (a, b, c, d, a1, b1) for each of the 50 possible combinations and simulated a total of 24,000 weekly dialysis cycles using the Daugirdas Solute Solver software recommended by the KDOQI 2015 guidelines. From the associated statistical analyses we obtained 50 sets of coefficient values, which were validated comparing the paired normalized protein catabolic rate values (i.e., those estimated with our formulas with those modeled with Solute Solver) in 210 datasets of 27 patients on home-based hemodialysis. The mean values ± SD were 1.06 ± 0.262 and 1.07 ± 0.283 g/kg/day, respectively, with a mean difference of 0.004 ± 0.034 g/kg/day (p = 0.11). The paired values were highly correlated (R2 = 0.99). In conclusion, even if the coefficient values were validated in a relatively small sample of patients, they allow an accurate estimation of normalized protein catabolic rate in home-based hemodialysis patients.

¿Es adecuada la diálisis peritoneal para pacientes mayores de 65 años? Estudio multicéntrico prospectivo / Is peritoneal dialysis suitable technique CKD patients over 65 years? A prospective multicenter study

Escenario: La prevalencia de enfermedad renal crónica (ERC) aumenta en población mayor de 65años y asocia morbilidad, dependencia y fragilidad. La diálisis peritoneal (DP) se ha considerado una técnica de paciente joven y vida activa. Hipótesis: La DP puede ser adecuada en pacientes de edad avanzada. Buscamos resultados desfavorables que contravengan esta hipótesis. Objetivo: Describir el tratamiento con DP en mayores de 65años, evaluar su evolución clínica comparada con los menores de 65 e identificar áreas de mejora asistencial. Estudio: Prospectivo, observacional y multicéntrico en incidentes en DP, seguimiento hasta evento o fin del estudio (ene-2003 a ene-2018).Resultados: Se incluyen 2.435 pacientes; el 31,9% (777) eran mayores de 65 años. El tiempo medio de seguimiento fue de 2,1años para ambos grupos. El grupo de edad avanzada era 25años mayor, con más comorbilidad: diabetes (29,5% vs. 17,2%; p<0,001), evento CV previo (34,5% vs. 14,0%; p<0,001) e índice de Charlson sin edad (3,8 vs. 3,0; p<0,001). No encontramos diferencias en cumplimiento de objetivos intermedios de eficacia de DP, control de anemia o hipertensión durante el seguimiento. La tasa de peritonitis fue mayor en la cohorte mayor de 65años (0,65 vs. 0,45 episodios/paciente-año; p<0,001), aunque la distribución gérmenes, tasa de ingreso y evolución final fue similar en ambos grupos. Lógicamente, registramos mayor mortalidad en el grupo mayor de 65años (28,4% vs. 9,4%), aunque el tiempo de permanencia en DP fue similar (2,1años). La principal causa de salida fue el trasplante renal en jóvenes (48,3%), mientras que en los pacientes de mayor edad fue el paso a hemodiálisis, principalmente por cansancio de cuidador/autocuidado (20,2%) y no por fallo de la técnica (7,3%). (AU)

Background: Chronic kidney disease (CKD) is increasing in patients older than 65years and is related to morbidity, frailty, and dependence. Peritoneal dialysis (PD) has classically been associated with young patients with an active life. Hypothesis: PD should be offered to patients over 65years. We search for any unfavorable results that may advice not to recommend PD therapy for this group. Objective: To describe PD treatment and outcomes in patients >65years, to compare their results with patients <65years and to identify areas with room for improvement in a real-life study. Study: Prospective, observational, and multicenter study performed in incident PD patients, from January 2003 until January 2018. Results: We included 2,435 PD patients, 31.9% were older than 65years; there was a difference of 25years between both groups. Median follow up was 2.1years. Older than 65years group had more comorbidity: Diabetes (29.5% vs 17.2%; p<0.001), previous CV events 34.5% vs 14.0%; p<0.001), Charlson index (3.8 vs 3.0; p<0.001). We did not find differences in efficacy and PD adequacy objectives fulfillment, anaemia management or blood pressure during follow-up. Peritonitis rate was higher in older 65years group (0.65 vs 0.45 episodes/patient/year; p<0.001), but there was not differences in germs, admission rate and follow up. Mortality was higher in older 65years group (28.4% vs 9.4%) as expected. PD permanence probability was similar (2.1years). The main cause of PD withdrawal was transplant in group <65years (48.3%) and transfer to HD in group >65years. The main reason was caregiver or patient fatigue (20.2%), and not technique failure (7.3%). (AU)

Análisis de las infecciones del orificio de salida del catéter peritoneal. Efectividad de un protocolo basado en la aplicación de mupirocina tópica diaria / Analysis of peritoneal catheter exit-site infections. Effectiveness of a protocol based on daily topical mupirocin application

Objetivos: Analizar las infecciones del orificio de salida del catéter peritoneal, identificando los principales factores relacionados con las mismas; asimismo se ha comparado la efectividad de un protocolo basado en la utilización diaria de mupirocina tópica en la cura del orificio de salida frente a la utilización suero salino.Material y Método:Estudio observacional, retrospectivo. Recogimos variables demográficas, clínicas, la etiología y evolución de los episodios de infección del orificio en un periodo de 2 años. Utilizamos un protocolo de profilaxis con suero fisiológico y con mupirocina crema al 2%.Resultados:Estudiamos 75 pacientes, edad media 60,3±13,9 años, 66,7% varones, mediana de tiempo en diálisis peritoneal 24,3 meses (rango intercuartílico 11-48,7). La incidencia de infección del orificio de salida fue del 26,7%, el 77% fueron originadas por microorganismos de piel y mucosas. La infección del orificio de salida se relacionó con el estado portador nasal de Staphylococcus aureus (p=0,048) y la extrusión del dacron externo (p=0,004). De los 4 pacientes que presentaron una peritonitis secundaria a la infección del orificio de salida, 3 fueron trasferidos a hemodiálisis (p=0,025). Con el protocolo de antibioterapia tópica diaria se redujo un 68% la tasa de infecciones.Conclusiones:La exteriorización del anillo externo del catéter peritoneal es un factor predisponente de infecciones. La aplicación diaria de mupirocina es una estrategia efectiva para reducir la incidencia de infección del orificio y peritonitis. La erradicación de portadores nasales de Staphylococcus aureus puede contribuir a reducir la pérdida del catéter y la transferencia a hemodiálisis. (AU)

Objectives: To analyze the characteristics of catheter related exit-site infections, identifying the main related factors. Likewise, the effectiveness of a protocol based on the daily use of topical mupirocin in the exit site prophylaxis strategy has been compared with the use of saline solution.Material and Method: Observational retrospective study. Demographic and clinical variables, the etiology and evolution of the episodes of infection of the orifice in a period of 2 years were collected. A prophylaxis protocol with saline solution and 2% mupirocin cream was used.Results:We recruited 75 patients, mean age 60.3±13.9 years, 66.7% male, median time on peritoneal dialysis 24.3 months (interquartile range 11-48.7). The incidence of exit site infection was 26.7%, 77% were produced by skin and mucous microorganisms. The exit site infection was associated to Staphylococcus aureus nasal carriage (p=0.048) and the superficial cuff extrusion (p=0.004). 4 of the patients who presented peritonitis secondary to exit site infection, 3 were switch to hemodialysis (p=0.025). Daily topical antibiotic therapy protocol reduced the exit site infection rate by 68%.Conclusions:The superficial cuff externalization is a predisposing factor for infections. Daily application of mupirocin is an effective strategy in reducing the incidence of exit site infections and peritonitis. The eradication of nasal carriers of Staphylococcus aureus can help reduce catheter loss and transfer to hemodialysis. (AU)

Is peritoneal dialysis suitable technique CKD patients over 65 years? A prospective multicenter study.

BACKGROUND: Chronic kidney disease (CKD) is increasing in patients older than 65 years and is related to morbidity, frailty, and dependence. Peritoneal dialysis (PD) has classically been associated with young patients with an active life. HYPOTHESIS: PD should be offered to patients over 65 years. We search for any unfavorable results that may advice not to recommend PD therapy for this group. OBJECTIVE: To describe PD treatment and outcomes in patients > 65 years, to compare their results with patients < 65 years and to identify areas with room for improvement in a real-life study. STUDY: Prospective, observational, and multicenter study performed in incident PD patients, from January 2003 until January 2018. RESULTS: We included 2,435 PD patients, 31.9% were older than 65 years; there was a difference of 25 years between both groups. Median follow up was 2.1 years. Older than 65 years group had more comorbidity: Diabetes (29.5% vs 17.2%; p < 0.001), previous CV events 34.5% vs 14.0%; p < 0.001), Charlson index (3.8 vs 3.0; p < 0.001). We did not find differences in efficacy and PD adequacy objectives fulfillment, anaemia management or blood pressure during follow-up. Peritonitis rate was higher in older 65 years group (0.65 vs 0.45 episodes/patient/year; p < 0.001), but there was not differences in germs, admission rate and follow up. Mortality was higher in older 65 years group (28.4% vs 9.4%) as expected. PD permanence probability was similar (2.1 years). The main cause of PD withdrawal was transplant in group < 65 years (48.3%) and transfer to HD in group > 65 years. The main reason was caregiver or patient fatigue (20.2%), and not technique failure (7.3%). Multivariate Cox regression analysis showed a relation (HR [95%CI]) between mortality and age > 65 years 2.4 [1.9-3.0]; DM 1.6 [1.3-2.1]; CV events 2.1 [1.7-2.7]. Multivariate Cox regression analysis identify a relation between technique failure and age > 65 years 1.5 [1.3-1.9]; DM 1.6 [1.3-1.9] and previous transplant 1.5 [1.2-2.0]. CONCLUSION: Patients older than 65 years fulfilled PD adequacy criteria during the follow up. We believe PD is a valid option for patients older 65 years. It is necessary to try to prevent infections and patient/caregiver fatigue, to avoid HD transfer for reasons not related to technique failure.

Informe de un caso de diálisis peritoneal no asistida en personas con déficit visual grave: ¿Es posible? / Report of a case of unassisted peritoneal dialysis in people with severe visual impairment: is it possible?

DESCRIPCIÓN DEL CASO: Presentamos un informe de un caso sobre entrenamiento en diálisis peritoneal automatizada no asistida en una paciente con una deficiencia visual adquirida grave, cuya pérdida de visión se produjo de forma rápida y progresiva una vez elegida la técnica dialítica. DESCRIPCIÓN DEL PLAN DE CUIDADOS: Se identificaron 5 diagnósticos enfermeros: Conocimientos deficientes: Tratamiento, dieta, higiene en Diálisis Peritoneal; disposición para mejorar el manejo del régimen terapéutico; trastorno de la percepción sensorial visual y auditiva; riesgo de cansancio en el desempeño del rol cuidador; temor y riesgo de infección. Se diseñó un plan de cuidados que incluía un plan de entrenamiento adaptado. EVALUACIÓN DEL PLAN: se logró un adecuado manejo de la técnica y de los problemas detectados, con un cambio positivo en todos los NOC establecidos en el plan: Conocimiento: Procedimientos terapéuticos; Preparación para el alta: Vida independiente; Conducta de cumplimiento; Orientación cognitiva; Conducta de compensación auditiva y visual; Bienestar del cuidador familiar; Conocimiento: Conductas sanitarias; Control del miedo; Integridad del acceso de DP y Control del riesgo. CONCLUSIONES: En nuestra experiencia, la diálisis peritoneal con un entrenamiento dirigido constituye una opción de tratamiento renal sustitutivo eficaz y seguro para personas con deficiencia visual o ceguera. La suma de pequeñas contribuciones nos permitirá aunar esfuerzos que nos ayuden a estandarizar protocolos para la capacitación de pacientes en situaciones especiales

CASE DESCRIPTION: A case report on unassisted automated peritoneal dialysis training in a patient with a severe acquired visual impairment is presented. Loss of vision occurred rapidly and progressively once the dialysis technique was chosen. DESCRIPTION OF THE CARE PLAN: Five nursing diagnoses were identified: Deficient knowledge: Treatment, diet, hygiene in Peritoneal Dialysis; willingness to improve the management of the therapeutic regimen; visual and auditory sensory perception disorder; risk of fatigue in the performance of the caregiver role; fear and risk of infection. A care plan that included an adapted training plan was designed. EVALUATION OF THE PLAN: An adequate management of the technique and the problems detected was achieved, achieving a positive change in all the NOCs established in the plan: Knowledge: Therapeutic procedures; Preparation for discharge: Independent living; Compliance behavior; Cognitive orientation; Hearing and visual compensation behavior; Well-being of the family caregiver; Knowledge: Health behaviors; Control of fear; Integrity of the peritoneal dialysis access and Risk control. CONCLUSIONS: In our experience, peritoneal dialysis with targeted training constitutes an effective and safe renal replacement treatment option for people with visual impairment or blindness. The sum of small contributions will allow us to join forces that will help standardize protocols for the training of patients in special situations

Survival and renal recovery after acute kidney injury requiring dialysis outside of intensive care units.

BACKGROUND: The incidence of acute kidney injury requiring dialysis (AKI-D) is increasing globally and it is usually associated to chronic kidney disease (CKD) and high mortality. Literature is lacking in short- and intermediate-term data on recovery of renal function after acute kidney injury (AKI). OBJECTIVES: The objective was to evaluate the overall survival and renal recovery after an episode of AKI requiring dialysis out of intensive care units (ICUs). MATERIALS AND METHODS: Retrospective study including patients admitted in two nephrology units along a period of 2 years. Patients admitted to ICUs and renal transplant patients were excluded. Baseline renal function, mortality and glomerular filtration rate (GFR) improvement were evaluated. RESULTS: 151 consecutive adult patients with AKI requiring renal replacement therapy (RRT) were included. Mean age was 70.5 ± 15.2 years, 60.3% were males. Median baseline creatinine (bCr) and baseline GFR (bGFR) were 1.4 mg/dL and 46 mL/min/1.73 m2, respectively. After 1 year of follow-up, we completed the monitoring of 94 patients: 64.9% had died, 10.6% were alive on dialysis and 24.5% were alive without need for RRT. Patients with bGFR > 60 mL/min/1.73 m2 prior to AKI episode had a slower but sustained GFR improvement through the follow-up in comparison with patients with bGFR < 60 mL/min/1.73 m2 whose recovery was incomplete. CONCLUSIONS: Patients with AKI requiring RRT have high short- and intermediate-term mortality and some require maintenance dialysis. Patients with GFR > 60 mL/min/1.73 m2 prior to AKI had a renal recovery closer to the basal renal function than in patients with a previously diminished GFR.

The role of an electronic alert system to detect acute kidney injury in hospitalized patients: DETECT-H Project / Utilidad de un sistema de alerta electrónica para la detección de fracaso renal agudo en pacientes hospitalizados. Proyecto DETECT-HP

BACKGROUND AND AIMS: Acute kidney injury (AKI) is associated with higher mortality and length of stay (LOS) for hospitalized patients. To improve outcomes, an electronic detection system could be a useful tool for early diagnosis. METHODS: A fully automated real-time system for detecting decreased glomerular filtration rate in adult patients was developed in our hospital, DETECT-H project. AKI was established according to KDIGO guidelines. RESULTS: In six months, 1241 alerts from 11,022 admissions were issued. Overall incidence of AKI was 7.7%. Highest AKI stage reached was: stage 1 (49.8%), 2 (24.5%) and 3 (25.8%), in-hospital mortality was 10.9%, 22.7%, 33.9% respectively and 57.1% in AKI requiring dialysis; mortality in stable CKD was 4.3%. Median LOS was 8 days versus 5 days for all patients. AKI was associated with a mortality of 3.18 (95% CI 1.80-5.59) and a LOS 1.52 (1.11-2.08) times as high as that for admissions without AKI. Multivariate analysis indicated that a LOS higher than 8 days was associated with AKI. Previous CKD was noted in 31.9% and AKI in 45.3% at discharge. As compared to the use of the detect system, only one third of CKD patients and half of AKI episodes were identified. CONCLUSIONS: CKD and in-hospital AKI are under-recognized entities. Mortality and LOS are increased in-hospital patients with renal dysfunction. AKI severity was associated with higher mortality and LOS. An automated electronic detection system for identifying renal dysfunction would be a useful tool to improve renal outcomes

INTRODUCCIÓN Y OBJETIVOS: El fracaso renal agudo (FRA) aumenta la mortalidad y la estancia hospitalarias (EH). El empleo de sistemas de detección electrónica podría ser una herramienta beneficiosa para mejorar estos resultados. MÉTODOS: Se desarrolló un sistema de detección automático a tiempo real de pacientes ingresados con función renal alterada, denominado proyecto DETECT-H. El FRA se estableció de acuerdo con las guías KDIGO. RESULTADOS: En 6 meses, 1.241 alertas fueron recogidas de 11.022 ingresos. La incidencia global del FRA fue del 7,7%. La distribución en función del estadio máximo del FRA alcanzado fue: estadio 1: 49,8%, estadio 2: 24,5% y estadio 3: 25,8%; con una mortalidad hospitalaria del 10,9, 22,7 y 33,9%, respectivamente. En el caso del FRA con necesidad de diálisis fue del 57,1%. La mortalidad en pacientes con enfermedad renal crónica (ERC) estable fue del 4,3%. La mediana de EH en pacientes detectados fue 8 vs. 5 días para todos los pacientes hospitalizados. El FRA se asoció con una mortalidad 3,18 (1,8-5,59) y una EH 1,52 (1,11-2,08) veces superior que aquellos ingresos sin FRA. El análisis multivariante indicó que el FRA se asociaba con la EH > 8 días. En los informes de alta, la presencia de ERC previa solo fue registrada en el 31,9% de los pacientes con ERC y el FRA hospitalario en el 45,3%. Conclusiones : La ERC y el FRA intrahospitalario son entidades infradiagnosticadas. La mortalidad y la EH están aumentadas en pacientes con disfunción renal. La gravedad del FRA se asoció con mayor mortalidad y EH. Un sistema de detección automático para identificarlos podría ser útil para mejorar estos resultados

Evolocumab para el tratamiento de la hipercolesterolemia familiar heterocigota en enfermedad renal crónica avanzada y diálisis / Evolocumab for the treatment of heterozygous familial hypercholesterolemia in end-stage chronic kidney disease and dialysis

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The role of an electronic alert system to detect acute kidney injury in hospitalized patients: DETECT-H Project.

BACKGROUND AND AIMS: Acute kidney injury (AKI) is associated with higher mortality and length of stay (LOS) for hospitalized patients. To improve outcomes, an electronic detection system could be a useful tool for early diagnosis. METHODS: A fully automated real-time system for detecting decreased glomerular filtration rate in adult patients was developed in our hospital, DETECT-H project. AKI was established according to KDIGO guidelines. RESULTS: In six months, 1241 alerts from 11,022 admissions were issued. Overall incidence of AKI was 7.7%. Highest AKI stage reached was: stage 1 (49.8%), 2 (24.5%) and 3 (25.8%), in-hospital mortality was 10.9%, 22.7%, 33.9% respectively and 57.1% in AKI requiring dialysis; mortality in stable CKD was 4.3%. Median LOS was 8 days versus 5 days for all patients. AKI was associated with a mortality of 3.18 (95% CI 1.80-5.59) and a LOS 1.52 (1.11-2.08) times as high as that for admissions without AKI. Multivariate analysis indicated that a LOS higher than 8 days was associated with AKI. Previous CKD was noted in 31.9% and AKI in 45.3% at discharge. As compared to the use of the detect system, only one third of CKD patients and half of AKI episodes were identified. CONCLUSIONS: CKD and in-hospital AKI are under-recognized entities. Mortality and LOS are increased in-hospital patients with renal dysfunction. AKI severity was associated with higher mortality and LOS. An automated electronic detection system for identifying renal dysfunction would be a useful tool to improve renal outcomes.

Brote de bacteriemia por Serratia marcescens en hemodiálisis. Comentario a «Brote de bacteriemia por Serratia marcescens en pacientes portadores de catéteres tunelizados en hemodiálisis secundario a colonización de la solución antiséptica. Experiencia en 4 centros» / Serratia marcescens bacteraemia outbreak in hemodialysis. Comment on «Serratia marcescensbacteraemia outbreak in haemodialysis patients with tunnelled catheters due to colonisation of antiseptic solution. Experience from 4 hospitals»

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Amiloidosis secundaria (AA) a infecciones de repetición en el síndrome de hipergammaglobulinemia IgE / AA amyloidosis associated with recurrent infections in the hyperimmunoglobulin E syndrome

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Cetoacidosis diabética asociada a canagliflozina en diabetes mellitus tipo 2 / Diabetic ketoacidosis associated to canagliflozin in type 2 diabetes

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