Original article
Unexplained pulmonary hypertension in peritoneal dialysis and hemodialysis patients
Hipertensão pulmonar inexplicável em doentes com diálise peritoneal e hemodiálise
J. Etemadia, H. Zolfagharib, R. Firoozic, M.R. Ardalana, M. Toufanc, M.M. Shojad, K. Ghabilie,
Corresponding author
a Department of Nephrology, Dialysis and Transplantation, Tabriz University of Medical Sciences, Tabriz, Iran
b Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
c Department of Cardiology, Tabriz University of Medical Sciences, Tabriz, Iran
d Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
e Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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"apellidos" => "Etemadi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "H." "apellidos" => "Zolfaghari" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "R." "apellidos" => "Firoozi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M.R." "apellidos" => "Ardalan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Toufan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "M.M." 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"apellidos" => "Ghabili" "email" => array:1 [ 0 => "kghabili@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Department of Nephrology, Dialysis and Transplantation, Tabriz University of Medical Sciences, Tabriz, Iran" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Cardiology, Tabriz University of Medical Sciences, Tabriz, Iran" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Hipertensão pulmonar inexplicável em doentes com diálise peritoneal e hemodiálise" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1778 "Ancho" => 2924 "Tamanyo" => 237193 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Study flowchart.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary arterial hypertension (PAH) is a newly recognized disease in patients with renal disease.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In clinical practice, shunting of blood from the left to the right side of the heart and increased cardiac output and pulmonary blood flow are common medical conditions resulting in PAH.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, Yigla et al. first noted unexplained PAH in some long-term hemodialysis (HD) patients during an epidemiologic study.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> They attributed both end stage renal disease (ESRD) and long-term HD therapy via an arteriovenous (AV) access to the pathogenesis of PAH in these patients.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> On the other hand, the prevalence of PAH in patients on peritoneal dialysis (PD) is still a matter of debate.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> The information in the literature regarding unexplained or primary PAH in ESRD patients especially PD patients is limited. Therefore, the aim of the present study was to compare the prevalence of unexplained PAH in HD and PD patients. In addition, we aimed to compare laboratory parameters between patients with unexplained PAH and those with normal pulmonary artery pressure (PAP).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Materials and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">We retrospectively reviewed the medical records of 278 chronic HD and 145 chronic PD patients treated at the hospitals affiliated to the university in Tabriz, Iran between May 2008 and January 2010. The patients’ data including age, sex, co-morbidities, medications, tobacco use, etiology of renal failure, vascular access type, and duration of dialysis therapy were recorded. Laboratory findings including hemoglobin, calcium, phosphorus, alkaline phosphatase, albumin, parathyroid hormone (PTH) level, serum iron, total iron binding capacity, ferritin, creatinine and blood urea nitrogen were documented. The results of transthoracic Doppler echocardiography were used to determine the pulmonary artery pressure, expiratory and inspiratory inferior vena cava (IVC) diameters and percent collapse, left ventricular ejection fraction, presence of valvular diseases, etc. PAH was defined as a systolic pulmonary artery pressure (SPAP) ≥35<span class="elsevierStyleHsp" style=""></span>mmHg.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Patients with cardiac disease, pulmonary disease, collagen vascular disease, volume overload at the time of echocardiography (<50% collapsibility in IVC diameter) and positive human immunodeficiency virus (HIV) test were excluded. Additionally, patients treated with dialysis <3 months or >7 years were not included in the present study.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Data were presented as median (interquartile range). All statistical analyses were performed with Statistical Package of Social Science (SPSS Inc., Chicago, IL) for Windows version 16. The Mann–Whitney <span class="elsevierStyleItalic">U</span> test, chi-square test and Fisher's exact test were used wherever appropriate. A <span class="elsevierStyleItalic">P</span>-value <0.05 was considered statistically significant.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">Data from 66 patients were analyzed: 34 in group HD and 32 in group PD (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The median age of the study population was 57 (45–68) years. The median duration of dialysis was 102 (54.25–161) weeks in HD group and 44 (24.5–82) weeks in PD group (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001, Mann–Whitney <span class="elsevierStyleItalic">U</span> test). Among HD group, 18 patients (53%) had proximal and 16 patients (47%) had distal arteriovenous fistula (AVF). However, none of the patients in PD group had functional AVF; 28 patients were primarily in PD group and 4 patients had primary nonfunctional AVF.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The median SPAP value in patients with PAH was 37.5 (35–45)<span class="elsevierStyleHsp" style=""></span>mmHg. According to the echocardiographic findings, PAH was detected in 20 (30.3%) patients: 14 (41.1%) patients in HD group and 6 (18.7%) patients in PD group (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.04, Fisher's exact test). Among HD patients with PAH, vascular access type was proximal and distal AVF in 8 (57.1%) and 6 (42.9%) patients, respectively. None of the PD patients with PAH had vascular access. There were no differences in gender, age, weight, duration of dialysis, calcium, phosphorus, alkaline phosphatase, albumin, parathyroid hormone level, total iron binding capacity, ferritin, creatinine and blood urea nitrogen between the patients with PAH and those with normal PAP (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05). The median serum iron was significantly lower in patients with PAH (47<span class="elsevierStyleHsp" style=""></span>μg/dL) compared to that in patients with normal PAP (71.5<span class="elsevierStyleHsp" style=""></span>μg/dL, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001, <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The median hemoglobin of patients with normal PAP was not comparable to that of PAH patients (11.3<span class="elsevierStyleHsp" style=""></span>mg/dL vs. 9.9<span class="elsevierStyleHsp" style=""></span>mg/dL, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.004, <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">The present study revealed that PAH was more frequent in patients undergoing HD (41.1%) than in patients of PD group (18.7%). Previous studies have mostly reported the prevalence of PAH in HD patients, but not in PD patients. Amin et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Yigla et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and Tarrass et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> concluded that there was a high prevalence of PAH among patients with ESRD receiving long-term HD with surgical AV access. The two latter studies differed with regard to the type of PAH; primary and secondary PAH in the former and primary PAH in the latter. Nakhoul and colleagues<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and Havlucu et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> found PAH in approximately half of the HD patients. Nakhoul et al. noted a significant decrease in PAP following successful kidney transplants and temporary closure of AV access in some PAH patients.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Kumbar et al. detected PAH (primary and secondary) in 42% of patients on PD.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In a recent study on HD and PD patients, Bozbas and co-workers found a higher PAH ratio in HD compared to that in the PD group (18.8% vs. 5.9%). Patients with secondary PAH were not excluded in their study.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Furthermore, the duration of dialysis in the HD group was longer than that in the PD group. This may account for the differing incidence of PAH between the two groups. However, previous studies have highlighted no difference in the duration of HD therapy between patients with PAH and those without PAH.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In recent studies numerous parameters have been compared between patients with PAH and those with normal PAP. In a study on HD patients, Abassi et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and Yigla et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> found that those with elevated PAP had significantly lower hemoglobin and hematocrit levels. Similarly, we observed significantly lower hemoglobin levels in PAH patients in the present study. In contrast, other researchers have failed to detect any difference in hemoglobin and hematocrit levels between the two groups.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6,9,10</span></a> In addition, we found lower serum iron levels in patients with PAH compared to those in normal PAP group. This finding has not been previously reported in patients undergoing HD and/or PD. In a recent study, Ruiter et al. interestingly revealed that iron deficiency was common in idiopathic PAH.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The present study's findings are consistent with previous studies which found that PTH level and calcium–phosphorus product did not differ.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5,7,9,12</span></a> However, Havlucu and colleagues reported higher calcium–phosphorus production and PTH levels in patients with PAH.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Although we failed to find a significant difference in ferritin levels between PAH and normal PAP groups, Kumbar et al. disclosed lower ferritin levels in patients with PAH.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">There is not yet a clear explanation for the high prevalence of PAH in ESRD. In HD patients, numerous hormonal and metabolic disorders have been attributed to vasoconstriction of pulmonary vessels and pulmonary artery calcification.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,12,14</span></a> However, Amin et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and Yigla et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> did not confirm the role of secondary hyperparathyroidism and pulmonary calcification as the etiology of PAH in ESRD patients. Later, Nakhoul et al. studied the role of two endothelial-derived molecules, endothelin-1 and nitric oxide (NO), in the pathogenesis of PAH in HD patients via AV access.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Although impaired NO production and reduced sensitivity to NO have already been described in patients with chronic renal failure,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Nakhoul et al. first demonstrated a link between impaired NO production and PAH in uremic patients receiving chronic HD therapy via AV access.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This finding may be also generalized to the patients on PD therapy; NO deficiency has been described in PD patients.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Along with high cardiac output resulting from the AV access, such an endothelial dysfunction may reduce the capability of the pulmonary vasculature to maintain the raised cardiac output and may subsequently contribute to the development of PAH in ESRD patients.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,18</span></a> An increase in the cardiac output and pulmonary blood flow due to the AV access may change shear stress.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This may alter endothelial function or release of mediators through induction of gene expression patterns.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Moreover, a venous torrent of microbubbles stemming from tubing or dialyzer has been proposed as a potential etiological factor in the development of PAH in this population. These microbubbles obstruct capillaries in the lungs, which may cause tissue ischemia, an inflammatory response and complement activation.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This study has certain limitations. The retrospective observational design of the study might be considered a weakness in this work. Moreover, PAP was measured by a non-invasive method, Doppler echocardiography, without obtaining direct invasive measurements (e.g. right heart catheterization). However, measurements of PAP by the applied Doppler echocardiographic method have been reported to have a good correlation with measurements obtained by invasive methods in some studies.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,21,22</span></a> This method of PAP measurement has been widely applied in previous studies on PAH in patients on HD or PD.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4–11,15</span></a> In addition, doses of erythropoiesis-stimulating agent (ESA) were not available in either group. Higher doses of ESA in either group might be a confounding factor and interesting to observe. Furthermore, the effect of the duration of dialysis on the incidence of PAH was not addressed in the present study.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, unexplained PAH seems to be more frequent in patients undergoing HD than patients in the PD group. Moreover, among numerous laboratory parameters, hemoglobin and serum iron levels are lower in patients with PAH compared to those in normal PAP group. Due to the high importance of PAH in ESRD patients receiving both HD and PD therapy, the present findings need to be further explored in larger studies.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres547614" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objectives" 2 => "Methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec565495" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres547615" "titulo" => array:5 [ 0 => "Resumo" 1 => "Objetivos" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusão" ] ] 3 => array:2 [ "identificador" => "xpalclavsec565494" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-01-29" "fechaAceptado" => "2011-07-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec565495" "palabras" => array:3 [ 0 => "Unexplained pulmonary hypertension" 1 => "Peritoneal dialysis" 2 => "Hemodialysis" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec565494" "palabras" => array:3 [ 0 => "Hipertensão arterial pulmonar inexplicável" 1 => "Diálise peritoneal" 2 => "Hemodiálise" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span><span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To compare the prevalence of unexplained pulmonary artery hypertension (PAH) in hemodialysis (HD) and peritoneal dialysis (PD) patients and to compare laboratory parameters between patients with unexplained PAH and those with normal pulmonary artery pressure (PAP).</p></span> <span><span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We retrospectively reviewed the medical records of 278 chronic HD and 145 chronic PD patients. Laboratory findings including hemoglobin, calcium, phosphorus, alkaline phosphatase, albumin, parathyroid hormone level, serum iron, total iron binding capacity, ferritin, creatinine and blood urea nitrogen were documented. The results of transthoracic Doppler echocardiography were used to determine the pulmonary artery pressure (PAP). PAH was defined as a systolic pulmonary artery pressure (SPAP) ≥35<span class="elsevierStyleHsp" style=""></span>mmHg. To rule out secondary PAH, patients with cardiac disease, pulmonary disease, collagen vascular disease, volume overload at the time of echocardiography and positive human immunodeficiency virus test were excluded.</p></span> <span><span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Data from 34 patients in group HD and 32 individuals in group PD were analyzed. The median age of the study population was 57 (45–68) years. The median SPAP value in patients with PAH was 37.5 (35–45)<span class="elsevierStyleHsp" style=""></span>mmHg. According to the echocardiographic findings, PAH was found in 14 (41.1%) patients of HD group and in 6 (18.7%) patients of PD group (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.04). The median serum iron and hemoglobin was significantly lower in patients with PAH compared to those in patients with normal PAP (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05).</p></span> <span><span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Unexplained PAH seems to be more frequent in patients undergoing HD than patients in PD group. Moreover, hemoglobin and serum iron levels are lower in patients with PAH compared to those in normal PAP group.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span><span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Comparar a prevalência de hipertensão arterial pulmonar (PAH) inexplicável em doentes sob hemodiálise (HD) e diálise peritoneal (PD) e comparar os parâmetros laboratoriais entre doentes com PAH inexplicável e aqueles com pressão arterial pulmonar normal (PAP).</p></span> <span><span class="elsevierStyleSectionTitle">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revimos, de forma retrospetiva, os registos médicos de 278 doentes com HD crónica e 145 com PD crónica. Dos dados laboratoriais foram registadas hemoglobina, cálcio, fósforo, fosfatase alcalina, albumina, nível de paratormona, ferro sérico, capacidade total de ligação de ferro, ferritina, creatinina e nitrogénio ureico no sangue. Os resultados do ecocardiograma doppler <span class="elsevierStyleItalic">transtorácico</span> foram utilizados para determinar a pressão arterial pulmonar (PAP). A PAH foi definida como uma pressão arterial pulmonar sistólica (SPAP) ≥35<span class="elsevierStyleHsp" style=""></span>mmHg. Para excluir a PAH secundária, foram excluídos os pacientes com problemas cardíacos, doenças pulmonares, doenças vasculares do colagénio, excesso de volume na altura do ecocardiograma e vírus de imunodeficiência humana positivo.</p></span> <span><span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Foram analisados dados de 34 pacientes no HD e 32 indivíduos no grupo PD. A mediana de idade da população estudada foi de 57 (45–68) anos. O valor médio de SPAP em doentes com PAH foi de 37,5 (35–45) mmHg. De acordo com os resultados do ecocardiograma, a PAH foi registada em 14 (41,1%) pacientes do grupo HD e em 6 (18,7%) pacientes do grupo PD (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,04). A mediana do ferro sérico médio e da hemoglobina estavam significativamente mais baixos em pacientes com PAH em comparação com os pacientes com PAP normal (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,05).</p></span> <span><span class="elsevierStyleSectionTitle">Conclusão</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A PAH inexplicável parece ser mais frequente em pacientes com HD do que em pacientes no grupo de PD. Além disso, os níveis de hemoglobina e ferro sérico são inferiores em pacientes com PAH comparando com os do grupo de PAP normal.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1778 "Ancho" => 2924 "Tamanyo" => 237193 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Study flowchart.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">PAP, pulmonary artery pressure; TIBC, total iron binding capacity; BUN, blood urea nitrogen.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Normal PAP (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>46) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Elevated PAP (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>20) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gender (male:female) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22:24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8:12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.79 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.5 (39.75–68.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 (53.75–67.75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Weight (kg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.5 (54–75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.5 (53.25–69.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Duration of dialysis (weeks) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 (27.75–140) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77 (44.5–171) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.32 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hemoglobin (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.3 (9.95–12.05) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.9 (9.5–10.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.004<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Calcium (Ca) (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.8 (8.17–9.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.35 (7.82–9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Phosphorus (P) (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.45 (4.37–6.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.11 (4.57–7.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ca.P product \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.2 (39.35–56.22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.13 (38.2–61.37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Alkaline phosphatase (IU/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">249 (193.75–297) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">215 (174–312.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Albumin (g/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.1 (3.6–4.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.8 (3.62–4.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Parathyroid hormone (pg/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">197 (71–412) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">213 (172–509) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.32 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Serum iron (SI) (μg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71.5 (58.5–98.25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 (31.5–63) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">TIBC (μg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">291.5 (240.75–333) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">295 (231.5–329.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.98 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SI/TIBC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.25 (0.19–0.32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.16 (0.14–0.21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.002<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ferritin (ng/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">305 (148–682) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">410 (223.9–721) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Creatinine (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.75 (5.05–9.85) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.6 (6.57–9.07) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.77 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">BUN (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 (45.12–77.37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.5 (55.5–84.62) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab884582.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara">Statistically significant (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05).</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patients’ demographic data and laboratory parameters (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>number of patients).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The long-term effects of arteriovenous fistula creation on the development of 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 8 | 15 |
| 2024 October | 35 | 45 | 80 |
| 2024 September | 33 | 24 | 57 |
| 2024 August | 55 | 40 | 95 |
| 2024 July | 45 | 31 | 76 |
| 2024 June | 48 | 37 | 85 |
| 2024 May | 62 | 31 | 93 |
| 2024 April | 47 | 41 | 88 |
| 2024 March | 34 | 23 | 57 |
| 2024 February | 27 | 19 | 46 |
| 2024 January | 29 | 24 | 53 |
| 2023 December | 18 | 19 | 37 |
| 2023 November | 32 | 32 | 64 |
| 2023 October | 23 | 42 | 65 |
| 2023 September | 20 | 28 | 48 |
| 2023 August | 26 | 16 | 42 |
| 2023 July | 32 | 27 | 59 |
| 2023 June | 20 | 13 | 33 |
| 2023 May | 34 | 33 | 67 |
| 2023 April | 33 | 22 | 55 |
| 2023 March | 60 | 17 | 77 |
| 2023 February | 39 | 24 | 63 |
| 2023 January | 23 | 22 | 45 |
| 2022 December | 36 | 17 | 53 |
| 2022 November | 82 | 34 | 116 |
| 2022 October | 47 | 25 | 72 |
| 2022 September | 26 | 31 | 57 |
| 2022 August | 33 | 32 | 65 |
| 2022 July | 51 | 51 | 102 |
| 2022 June | 33 | 34 | 67 |
| 2022 May | 41 | 36 | 77 |
| 2022 April | 38 | 28 | 66 |
| 2022 March | 40 | 51 | 91 |
| 2022 February | 38 | 31 | 69 |
| 2022 January | 41 | 33 | 74 |
| 2021 December | 26 | 39 | 65 |
| 2021 November | 39 | 30 | 69 |
| 2021 October | 39 | 51 | 90 |
| 2021 September | 18 | 31 | 49 |
| 2021 August | 30 | 22 | 52 |
| 2021 July | 26 | 15 | 41 |
| 2021 June | 19 | 31 | 50 |
| 2021 May | 30 | 23 | 53 |
| 2021 April | 48 | 82 | 130 |
| 2021 March | 73 | 16 | 89 |
| 2021 February | 53 | 23 | 76 |
| 2021 January | 28 | 21 | 49 |
| 2020 December | 33 | 11 | 44 |
| 2020 November | 48 | 24 | 72 |
| 2020 October | 35 | 26 | 61 |
| 2020 September | 89 | 37 | 126 |
| 2020 August | 92 | 31 | 123 |
| 2020 July | 131 | 35 | 166 |
| 2020 June | 95 | 27 | 122 |
| 2020 May | 118 | 21 | 139 |
| 2020 April | 76 | 6 | 82 |
| 2020 March | 72 | 15 | 87 |
| 2020 February | 82 | 18 | 100 |
| 2020 January | 110 | 20 | 130 |
| 2019 December | 90 | 20 | 110 |
| 2019 November | 102 | 16 | 118 |
| 2019 October | 97 | 25 | 122 |
| 2019 September | 90 | 17 | 107 |
| 2019 August | 277 | 16 | 293 |
| 2019 July | 277 | 15 | 292 |
| 2019 June | 313 | 15 | 328 |
| 2019 May | 289 | 19 | 308 |
| 2019 April | 273 | 19 | 292 |
| 2019 March | 359 | 16 | 375 |
| 2019 February | 344 | 8 | 352 |
| 2019 January | 349 | 22 | 371 |
| 2018 December | 249 | 6 | 255 |
| 2018 November | 78 | 1 | 79 |
| 2018 October | 79 | 7 | 86 |
| 2018 September | 40 | 6 | 46 |
| 2018 August | 47 | 31 | 78 |
| 2018 July | 44 | 21 | 65 |
| 2018 June | 81 | 21 | 102 |
| 2018 May | 111 | 18 | 129 |
| 2018 April | 121 | 22 | 143 |
| 2018 March | 63 | 15 | 78 |
| 2018 February | 26 | 12 | 38 |
| 2018 January | 42 | 19 | 61 |
| 2017 December | 60 | 16 | 76 |
| 2017 November | 39 | 14 | 53 |
| 2017 October | 26 | 16 | 42 |
| 2017 September | 31 | 15 | 46 |
| 2017 August | 40 | 18 | 58 |
| 2017 July | 21 | 21 | 42 |
| 2017 June | 43 | 24 | 67 |
| 2017 May | 32 | 17 | 49 |
| 2017 April | 19 | 5 | 24 |
| 2017 March | 16 | 6 | 22 |
| 2017 February | 15 | 7 | 22 |
| 2017 January | 14 | 2 | 16 |
| 2016 December | 20 | 20 | 40 |
| 2016 November | 22 | 12 | 34 |
| 2016 October | 22 | 18 | 40 |
| 2016 September | 30 | 9 | 39 |
| 2016 August | 10 | 4 | 14 |
| 2016 July | 7 | 9 | 16 |
| 2016 June | 0 | 9 | 9 |
| 2016 May | 3 | 9 | 12 |
| 2016 April | 61 | 3 | 64 |
| 2016 March | 49 | 19 | 68 |
| 2016 February | 80 | 21 | 101 |
| 2016 January | 47 | 16 | 63 |
| 2015 December | 48 | 15 | 63 |
| 2015 November | 60 | 15 | 75 |
| 2015 October | 33 | 25 | 58 |
| 2015 September | 51 | 13 | 64 |
| 2015 August | 44 | 11 | 55 |
| 2015 July | 61 | 8 | 69 |
| 2015 June | 42 | 3 | 45 |
| 2015 May | 52 | 15 | 67 |
| 2015 April | 96 | 9 | 105 |
| 2015 March | 90 | 4 | 94 |
| 2015 February | 109 | 7 | 116 |
| 2015 January | 95 | 14 | 109 |
| 2014 December | 104 | 16 | 120 |
| 2014 November | 113 | 11 | 124 |
| 2014 October | 115 | 20 | 135 |
| 2014 September | 115 | 12 | 127 |
| 2014 August | 112 | 9 | 121 |
| 2014 July | 101 | 13 | 114 |
| 2014 June | 107 | 12 | 119 |
| 2014 May | 136 | 11 | 147 |
| 2014 April | 116 | 12 | 128 |
| 2014 March | 116 | 14 | 130 |
| 2014 February | 126 | 5 | 131 |
| 2014 January | 123 | 12 | 135 |
| 2013 December | 174 | 26 | 200 |
| 2013 November | 423 | 13 | 436 |
| 2013 October | 99 | 15 | 114 |
| 2013 September | 87 | 15 | 102 |
| 2013 August | 95 | 19 | 114 |
| 2013 July | 110 | 21 | 131 |
| 2013 June | 82 | 24 | 106 |
| 2013 May | 94 | 18 | 112 |
| 2013 April | 99 | 35 | 134 |
| 2013 March | 91 | 17 | 108 |
| 2013 February | 82 | 30 | 112 |
| 2013 January | 82 | 25 | 107 |
| 2012 December | 64 | 18 | 82 |
| 2012 November | 70 | 24 | 94 |
| 2012 October | 27 | 11 | 38 |
| 2012 September | 13 | 16 | 29 |
| 2012 January | 314 | 0 | 314 |
Show all
