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incluyendo el d&#237;a de ingreso que se inicia cada t&#233;cnica y la duraci&#243;n de la misma&#46;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Para la valoraci&#243;n de la funci&#243;n renal se utilizaron los valores de las mediciones repetidas de creatinina en sangre y la diuresis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">El da&#241;o renal se defini&#243; y categoriz&#243; siguiendo la adaptaci&#243;n pedi&#225;trica de los criterios RIFLE &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; El filtrado glomerular se estim&#243; con la f&#243;rmula de Schwartz&#58; FGe<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>K<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>talla &#40;cm&#41;&#47;creatinina &#40;mg&#47;dL&#41;&#46; Los valores de K dependen de la edad&#58; 0&#44;45 en<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>12 meses&#44; 0&#44;55 entre uno y 12 a&#241;os&#44; 057 en mujeres<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>de 12 a&#241;os y 0&#44;70 en varones<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>12 a&#241;os&#46; Se utilizaron las 3 primeras categor&#237;as de gravedad&#44; obvi&#225;ndose las categor&#237;as &#171;L&#187; y &#171;E&#187; por hacer referencia al resultado final m&#225;s que a un cambio agudo&#46; Se consideraron DRA grave aquellas situaciones que cumplieron los criterios de las categor&#237;as &#171;I&#187; o &#171;F&#187; de la clasificaci&#243;n pRIFLE&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Cuando no se dispon&#237;a de un valor de creatinina basal sobre el que evaluar los cambios evolutivos para la categorizaci&#243;n del DRA&#44; se procedi&#243; de la siguiente manera&#58; si el paciente dispon&#237;a de un valor de creatinina en los 6 meses previos al ingreso se utiliz&#243; este&#44; siempre y cuando no se tratase del primer mes de vida&#44; y si no exist&#237;a una creatinina conocida&#44; se recurri&#243; a los valores de referencia recientes para lactantes y ni&#241;os<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Asimismo&#44; se determin&#243; el momento de inicio del da&#241;o renal y la duraci&#243;n del mismo&#46; Se defini&#243; DRA precoz como el que se iniciaba en las primeras 72<span class="elsevierStyleHsp" style=""></span>h de ingreso en UCIP &#40;probablemente relacionado con la enfermedad que motiv&#243; el ingreso&#41; y tard&#237;o el que se present&#243; posteriormente &#40;que puede estar m&#225;s relacionado con complicaciones de la enfermedad inicial o del ingreso prolongado en la UCIP&#41;&#46; Se consider&#243; da&#241;o prerrenal cuando se resolvi&#243; antes de las 72<span class="elsevierStyleHsp" style=""></span>h&#44; y da&#241;o renal prolongado si la duraci&#243;n era mayor o igual a 72<span class="elsevierStyleHsp" style=""></span>h<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Para la valoraci&#243;n de la morbilidad se analiz&#243; la necesidad y duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#44; la duraci&#243;n del ingreso en la UCIP y en el hospital&#44; y la mortalidad&#46; Se consider&#243; ingreso prolongado en UCIP aquel con una duraci&#243;n superior a 12 d&#237;as<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a>&#44; y como hospitalario prolongado el superior a 28 d&#237;as&#46; Asimismo se defini&#243; como ventilaci&#243;n mec&#225;nica prolongada la recibida durante m&#225;s de 7 d&#237;as&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Los ni&#241;os que fallecieron fueron excluidos del an&#225;lisis de la duraci&#243;n de la estancia y de la ventilaci&#243;n mec&#225;nica&#46; En los 5 ni&#241;os que presentaron una ventilaci&#243;n mec&#225;nica superior a 42 d&#237;as se les asign&#243; el valor de 1&#46;000<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Los datos fueron procesados con el programa SPSS<span class="elsevierStyleSup">&#174;</span> 18&#46;0&#46; Se comprob&#243; la distribuci&#243;n normal de las variables cuantitativas con el test de Kolmogorov-Smirnov&#46; Los datos se presentan en medianas &#40;P25-P75&#41; y frecuencias y porcentajes&#46; Las comparaciones de las variables cualitativas se realizaron con el test de la Chi-cuadrado y el test exacto de Fisher si era necesario&#44; y la de las cuantitativas&#44; con el test U de Mann-Whitney&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La asociaci&#243;n del DRA con la morbimortalidad se comprob&#243; con regresi&#243;n log&#237;stica univariante y multivariante&#44; construy&#233;ndose modelos ajustados por edad&#44; diagn&#243;stico y duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#44; y para el an&#225;lisis de la duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#44; modelos ajustados por edad y diagn&#243;stico&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="par0100" class="elsevierStylePara elsevierViewall">Durante el per&#237;odo de estudio ingresaron 320 pacientes mayores de un mes en la UCIP&#44; de los que 5 se excluyeron por haber sido sometidos a trasplante renal&#44; quedando 315 pacientes para el estudio&#46; Las caracter&#237;sticas demogr&#225;ficas se presentan en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">La enfermedad m&#225;s frecuente que motiv&#243; el ingreso fue el postoperatorio de cirug&#237;a card&#237;aca &#40;134 ni&#241;os&#44; 42&#44;5&#37;&#41;&#46; Como puede verse en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#44; 148 ni&#241;os &#40;47&#37;&#41; precisaron ventilaci&#243;n mec&#225;nica&#44; con una duraci&#243;n de 48<span class="elsevierStyleHsp" style=""></span>h &#40;13-192&#41;&#46; La estancia en la UCIP fue de 4 d&#237;as &#40;3-8&#41;&#44; mientras que la duraci&#243;n total del ingreso hospitalario fue de 11 d&#237;as &#40;8-22&#41;&#46; Cincuenta y nueve ni&#241;os &#40;18&#44;7&#37;&#41; carec&#237;an de creatinina basal conocida y para ellos se utiliz&#243; un valor de creatinina de referencia adecuado a su edad&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">De los 315 ni&#241;os&#44; el 40&#44;6&#37; &#40;128 ni&#241;os&#41; sufrieron DRA en alg&#250;n momento de su ingreso&#44; de los que 107 &#40;83&#44;6&#37;&#41; presentaron un DRA precoz</p><p id="par0115" class="elsevierStylePara elsevierViewall">En relaci&#243;n con el diagn&#243;stico&#44; el DRA fue m&#225;s frecuente en los ni&#241;os sometidos a cirug&#237;a card&#237;aca&#44; produci&#233;ndose en 78 &#40;58&#44;2&#37;&#41; de ellos &#40;lo que supone el 60&#44;9&#37; del total de casos de DRA&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Los pacientes con DRA precisaron ventilaci&#243;n mec&#225;nica con una frecuencia significativamente mayor &#40;61&#44;7&#37;&#41; que el resto de los ni&#241;os ingresado en la UCIP&#44; y la duraci&#243;n de la misma tambi&#233;n fue mayor&#46; Igualmente&#44; la necesidad de oxigenaci&#243;n por membrana extracorp&#243;rea fue superior &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Los ni&#241;os que desarrollaron DRA tuvieron una estancia significativamente m&#225;s prolongada&#44; tanto en la UCIP como en el hospital&#44; y tambi&#233;n una asociaci&#243;n con mayor mortalidad &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a> muestra la categorizaci&#243;n del DRA seg&#250;n el momento de inicio&#44; la gravedad y la duraci&#243;n&#46; El 58&#44;6&#37; de los pacientes presentaron un DRA prerrenal&#46; Se encontr&#243; relaci&#243;n entre la gravedad y la duraci&#243;n del DRA&#44; existiendo un mayor n&#250;mero de casos en la categor&#237;a m&#225;s leve en el DRA prerrenal&#44; mientras que los casos de categor&#237;as m&#225;s graves se asociaron con una mayor duraci&#243;n del DRA &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">El criterio de oliguria se encontr&#243; en muy pocos pacientes&#58; un paciente con SHU que present&#243; anuria desde el ingreso junto a una creatinina de 4&#44;09<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;cumple ambos criterios de Failure&#41; y en 2 ni&#241;os con disfunci&#243;n card&#237;aca grave que requirieron tratamiento con oxigenaci&#243;n por membrana extracorp&#243;rea&#44; y seguidamente tuvieron depuraci&#243;n extrarrenal&#46; En otros 20 ni&#241;os en los que se inici&#243; depuraci&#243;n extrarrenal por sobrecarga h&#237;drica con alteraci&#243;n de la creatinina y del filtrado glomerular se alcanz&#243; el criterio de oliguria&#44; pero estando ya con la depuraci&#243;n&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Veinticuatro ni&#241;os &#40;18&#44;7&#37; de los pacientes con DRA&#41; precisaron t&#233;cnicas de depuraci&#243;n extrarrenal &#40;23&#44; t&#233;cnicas de depuraci&#243;n extrarrenal continuas&#44; y uno&#44; di&#225;lisis peritoneal&#41;&#46; La mortalidad de los pacientes con DRA grave &#40;Injury o Failure&#41; fue del 23&#44;7&#37;&#44; mucho mayor que la de los que presentaron DRA leve &#40;Risk&#41;&#44; que fue del 2&#44;7&#37;&#44; y la de los ni&#241;os sin DRA&#44; del 0&#44;5&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Se encontr&#243; una asociaci&#243;n muy significativa del DRA con una estancia prolongada en UCIP y en el hospital y la necesidad de una ventilaci&#243;n mec&#225;nica prolongada&#46; Esta asociaci&#243;n fue independiente de la edad y enfermedad de los pacientes&#44; tras controlar estas variables en la regresi&#243;n log&#237;stica multivariante &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46; Adem&#225;s&#44; se encontr&#243; un aumento paralelo de la morbimortalidad con la mayor gravedad del DRA &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">Posteriormente estudiamos de forma separada los ni&#241;os que presentaron un DRA prerrenal de aquellos que presentaron un DRA m&#225;s prolongado &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">tabla 6</a>&#41;&#46; Los ni&#241;os que presentaron un DRA prerrenal tuvieron una estancia m&#225;s prolongada en la UCIP y en el hospital que los que no tuvieron DRA&#44; aunque no fue diferente la utilizaci&#243;n y duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#46; Como se muestra en la <a class="elsevierStyleCrossRef" href="#tbl0030">tabla 6</a>&#44; los ni&#241;os con DRA establecido eran m&#225;s peque&#241;os y tuvieron mayor morbimortalidad que los ni&#241;os sin DRA y que aquellos con DRA prerrenal&#46; Se encontr&#243; una asociaci&#243;n muy significativa del DRA establecido con una estancia prolongada en UCIP y en el hospital y la necesidad de una ventilaci&#243;n mec&#225;nica prolongada&#44; que fue independiente de la edad y enfermedad de los pacientes &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">tabla 7</a>&#41;&#46; No pudo establecerse esta asociaci&#243;n para los ni&#241;os que tuvieron un DRA prerrenal&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discusi&#243;n</span><p id="par0155" class="elsevierStylePara elsevierViewall">Los resultados encontrados en este estudio demuestran una importante asociaci&#243;n entre el desarrollo de DRA y la morbimortalidad de los ni&#241;os que ingresan en la UCIP&#46; Asimismo&#44; muestra como el riesgo aumenta con la gravedad del DRA&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Hay pocos estudios publicados que eval&#250;en la repercusi&#243;n del DRA en ni&#241;os<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; En una reciente revisi&#243;n sistem&#225;tica<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> se encontr&#243; una falta de concordancia en los resultados publicados en los diferentes estudios&#44; atribuida&#44; en parte&#44; a la aplicaci&#243;n de una forma heterog&#233;nea de los criterios de DRA y en los criterios de inclusi&#243;n y exclusi&#243;n utilizados y el tipo de pacientes estudiados<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#8211;25</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">La utilizaci&#243;n homog&#233;nea de unos criterios uniformes y comunes para la definici&#243;n de DRA en la poblaci&#243;n pedi&#225;trica deber&#237;a permitir la comparaci&#243;n de resultados de diferentes estudios&#46; Los criterios pRIFLE pueden servir para este fin&#44; pero su aplicaci&#243;n de una forma heterog&#233;nea en los estudios publicados hasta ahora no ha permitido alcanzar este objetivo<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">En nuestro estudio hemos incluido a todos los ni&#241;os en estado cr&#237;tico que requirieron asistencia en UCIP&#44; independientemente del tipo de enfermedad y de si el ingreso fue urgente o programado&#44; lo que nos permite obtener una mejor aproximaci&#243;n a la magnitud del problema que representa el desarrollo de DRA sobre la morbimortalidad en la poblaci&#243;n general pedi&#225;trica&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Otra limitaci&#243;n de los estudios son las variaciones en el m&#233;todo para determinar el valor de la creatinina s&#233;rica de referencia cuando esta es desconocida&#44; y en algunos no se especifica<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#8211;28</span></a>&#46; En el presente estudio un gran n&#250;mero de pacientes dispon&#237;an de valores previos&#44; y para el resto se utilizaron valores de referencia publicados recientemente<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">El criterio de oliguria no se ha utilizado en los principales estudios que se han llevado a cabo sobre el DRA en ni&#241;os<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;24&#44;29</span></a>&#46; En nuestro trabajo el criterio de oliguria se cumpli&#243; en pocas ocasiones&#46; Probablemente influye que un mismo valor de diuresis &#40;ml&#47;kg&#47;h&#41; para definir oliguria es un criterio mucho m&#225;s severo cuanto m&#225;s peque&#241;o es el paciente&#44; dado que el aporte de agua que recibe el ni&#241;o en relaci&#243;n con su peso es mucho mayor cuanto m&#225;s peque&#241;o es&#46; Una valoraci&#243;n en ml&#47;m<span class="elsevierStyleSup">2</span> de superficie corporal o ml&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> obviar&#237;a probablemente este problema&#46; Tambi&#233;n puede influir en la evaluaci&#243;n de la oliguria la dificultad para cuantificar la diuresis en ni&#241;os no sondados&#44; m&#225;s a&#250;n si se realiza de forma retrospectiva&#46; Adem&#225;s&#44; la utilizaci&#243;n de diur&#233;ticos&#44; que es frecuente en los ni&#241;os ingresados en la UCI&#44; influida por el alto porcentaje de ni&#241;os con cardiopat&#237;as &#40;53&#37; en nuestro estudio&#41;&#44; puede contribuir a que se cumpla menos la oliguria&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">De los 12 art&#237;culos publicados que tratan de relacionar el desarrollo de DRA con la morbimortalidad&#44; tan solo dos de ellos aportan datos suficientes para verificar que las medidas empleadas para definir la presencia de da&#241;o renal corresponden a una correcta aplicaci&#243;n de los criterios pRIFLE<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;20</span></a>&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Varios estudios han hallado una relaci&#243;n entre la existencia de DRA y la mortalidad<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21&#44;29</span></a>&#44; al igual que ocurri&#243; en nuestro estudio&#46; De los 4 trabajos que analizaron la mortalidad con el grado de severidad seg&#250;n el estadio pRIFLE<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;20&#44;21&#44;29</span></a>&#44; solo 2 de ellos mostraron una relaci&#243;n significativa<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;29</span></a>&#46; Probablemente estas diferencias se deban al peque&#241;o tama&#241;o de la poblaci&#243;n de los estudios publicados y la baja incidencia de mortalidad en las UCIP&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">La mayor morbilidad asociada al DRA&#44; valorada como una duraci&#243;n mayor del ingreso en la UCIP&#44; ingreso en el hospital y duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#44; ha sido mostrada en estudios realizados en adultos<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10&#44;12&#44;13</span></a> y ni&#241;os<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;20&#8211;22&#44;27&#44;29&#44;30</span></a>&#46; En estudios en adultos se encontr&#243;&#44; adem&#225;s&#44; un riesgo creciente con la mayor gravedad del DRA seg&#250;n los criterios RIFLE&#44; datos que coinciden con nuestros resultados&#46; Sin embargo&#44; esta asociaci&#243;n no hab&#237;a sido descrita en las series previamente publicadas en ni&#241;os&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Adem&#225;s&#44; hemos analizado separadamente los ni&#241;os con DRA prerrenal de aquellos con un DRA establecido&#44; para comprobar el efecto de la disfunci&#243;n pasajera frente al de un DRA establecido sobre la morbilidad&#46; Como era de esperar&#44; se demuestra que los ni&#241;os que tienen un DRA establecido presentan mayor morbilidad que los que presentan un DRA prerrenal&#46; Adem&#225;s&#44; pudo establecerse una asociaci&#243;n independiente del DRA establecido con los par&#225;metros de morbilidad estudiados&#46; La ausencia de esta asociaci&#243;n en nuestro estudio con los ni&#241;os que tuvieron DRA prerrenal pudo verse influida por cumplirse los criterios de morbilidad estudiados en pocos de estos ni&#241;os &#40;5 tuvieron ventilaci&#243;n mec&#225;nica durante m&#225;s de 7 d&#237;as&#44; 10 una estancia en UCIP superior a 12 d&#237;as y 10 ingreso en el hospital mayor de 28 d&#237;as&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Dada la gran morbimortalidad asociada al desarrollo de DRA en los ni&#241;os en estado grave&#44; la utilizaci&#243;n precoz de medidas que disminuyan la incidencia y&#47;o la gravedad del DRA podr&#237;an mejorar la evoluci&#243;n de estos ni&#241;os&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Este estudio presenta una serie de limitaciones&#58; 1&#41; estudio retrospectivo y unic&#233;ntrico&#59; 2&#41; n&#250;mero peque&#241;o de pacientes incluidos&#59; 3&#41; el filtrado glomerular estimado basal de una parte de los ni&#241;os tuvo que extrapolarse desde valores de creatinina adecuados a la edad del ni&#241;o publicados en tablas de referencia&#59; 4&#41; el criterio de oliguria no pudo evaluarse de forma adecuada en todos los pacientes por no estar todos los ni&#241;os sondados&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusiones</span><p id="par0215" class="elsevierStylePara elsevierViewall">El desarrollo de DRA en los ni&#241;os ingresados en la UCIP se asocia a una mayor morbimortalidad&#46; La categorizaci&#243;n del DRA con los criterios pRIFLE y la utilizaci&#243;n de definiciones y criterios bien definidos permiten una adecuada identificaci&#243;n del riesgo de morbimortalidad asociada y puede detectar de forma precoz a los pacientes con riesgo de presentar un DRA y aplicar medidas para disminuir la incidencia y la gravedad de este s&#237;ndrome&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicto de intereses</span><p id="par0220" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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    "fechaRecibido" => "2013-04-24"
    "fechaAceptado" => "2013-07-17"
    "PalabrasClave" => array:2 [
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec350538"
          "palabras" => array:4 [
            0 => "Da&#241;o renal agudo"
            1 => "Pediatr&#237;a"
            2 => "Cuidados Intensivos"
            3 => "Morbilidad"
          ]
        ]
      ]
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec350539"
          "palabras" => array:4 [
            0 => "Acute kidney injury"
            1 => "Pediatrics"
            2 => "Intensive Care"
            3 => "Morbidity"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar la morbimortalidad asociada a da&#241;o renal agudo &#40;DRA&#41; definido por los criterios RIFLE adaptados a Pediatr&#237;a en los ni&#241;os que ingresan en la Unidad de Cuidados Intensivos Pedi&#225;tricos &#40;UCIP&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de cohorte&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">&#193;mbito</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">UCIP de un hospital terciario&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Pacientes o participantes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Trescientos veinte ni&#241;os ingresados en la UCIP en el a&#241;o 2011&#46; Se excluyeron los neonatos y los trasplantados renales&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Variables principales El DRA fue definido con los criterios RIFLE adaptados a Pediatr&#237;a&#46; Para la valoraci&#243;n de la morbimortalidad se utiliz&#243; la duraci&#243;n de las estancias en la UCIP y en el hospital&#44; la necesidad de ventilaci&#243;n mec&#225;nica y la mortalidad&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Resultados</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se estudiaron 315 ni&#241;os&#44; con una mediana de edad de 19 meses &#40;6-72&#41;&#46; Presentaron DRA 128 ni&#241;os &#40;40&#44;6&#37;&#41; &#40;73 en la categor&#237;a de Risk &#91;riesgo&#93; y 55 en las categor&#237;as Injury &#91;da&#241;o&#93; y Failure &#91;fallo&#93;&#41;&#46; Los ni&#241;os con DRA presentaron mayor mortalidad &#40;11&#44;7&#37;&#41; que el resto de pacientes &#40;0&#44;5&#37;&#41;&#44; una estancia m&#225;s prolongada en UCIP &#40;6&#44;0 &#91;4&#44;0-12&#44;5&#93; frente a 3&#44;5 &#91;2&#44;0-7&#44;0&#93; d&#237;as&#41; y en el hospital &#40;17 &#40;10-32&#41; frente a 10 &#40;7-15&#93; d&#237;as&#41; y m&#225;s ni&#241;os precisaron ventilaci&#243;n mec&#225;nica &#40;61&#44;7 frente a 36&#44;9&#37;&#41;&#46; El desarrollo de DRA fue un factor independiente de morbilidad&#44; asociado a una mayor estancia en UCIP y hospitalaria y a una ventilaci&#243;n mec&#225;nica m&#225;s prolongada&#44; increment&#225;ndose esta morbilidad de forma paralela a la gravedad del da&#241;o renal&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0035">Conclusi&#243;n</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El desarrollo de DRA en ni&#241;os en estado cr&#237;tico se asocia a un incremento en la morbimortalidad&#44; que es directamente proporcional a la magnitud de la gravedad del da&#241;o renal&#46;</p>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0045">Aim</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">To describe the morbimortality associated to the development of acute kidney injury &#40;AKI&#41; defined by the pediatric adaptation of the RIFLE criteria in a Pediatric Intensive Care Unit &#40;PICU&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Design</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A retrospective cohort study was carried out&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Setting</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Children admitted to a PICU in a tertiary care hospital&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Patients or participants A total of 320 children admitted to a tertiary care hospital PICU during the year 2011&#46; Neonates and renal transplant patients were excluded&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Primary endpoints AKI was defined and classified according to the pediatric adaptation to the RIFLE criteria&#46; PICU and hospital stays&#44; use of mechanical ventilation and mortality were used to evaluate morbimortality&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Results</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">A total of 315 children met the inclusion criteria&#44; with a median age of 19 months &#40;range 6-72&#41;&#46; Of these patients&#44; 128 presented AKI &#40;73 reached the Risk category and 55 reached the Injury and Failure categories&#41;&#46; Children with AKI presented a longer PICU stay &#40;6&#46;0 &#91;4&#46;0-12&#46;5&#93; vs&#46; 3&#46;5 &#91;2&#46;0-7&#46;0&#93; days&#41; and hospital stay &#40;17 &#91;10-32&#93; vs&#46; 10 &#91;7-15&#93; days&#41;&#44; and a greater need for mechanical ventilation &#40;61&#46;7 vs&#46; 36&#46;9&#37;&#41;&#46; The development of AKI was an independent factor of morbidity&#44; associated with a longer PICU and hospital stay&#44; and with a need for longer mechanical ventilation&#44; with a proportional relationship between increasing morbidity and the severity of AKI&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0065">Conclusion</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The development of AKI in critically ill children is associated with increased morbimortality&#44; which is proportional to the severity of renal injury&#46;</p>"
      ]
    ]
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">FGe&#58; filtrado glomerular estimado&#46;</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"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Creatinina s&#233;rica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Diuresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Risk&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">Aumento<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#44;5-2 o descenso FGe<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Injury&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">Aumento<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2-3 o descenso FGe<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>16<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Failure&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">Aumento<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3 veces o descenso FGe<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>75&#37; o FGe<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;3<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>24<span class="elsevierStyleHsp" style=""></span>h o anuria<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "es" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Criterios RIFLE adaptados a Pediatr&#237;a de da&#241;o renal agudo</p>"
        ]
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Cr&#58; creatinina&#46;</p>"
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              "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"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Creatinina s&#233;rica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Diuresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Estadio 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aumento<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#44;5-2 o aumento<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span> 6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Estadio 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aumento<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2-3 veces&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Estadio 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aumento<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3 veces o Cr<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;con un incremento agudo<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;3<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>24<span class="elsevierStyleHsp" style=""></span>h o anuria durante 12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Criterios AKIN de da&#241;o renal agudo</p>"
        ]
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Cr&#58; creatinina&#59; DRA&#58; da&#241;o renal agudo&#59; ECMO&#58; oxigenaci&#243;n por membrana extracorp&#243;rea&#59; PO&#58; postoperatorio&#59; IRA&#58; insuficiencia respiratoria aguda&#59; UCIP&#58; Unidad de Cuidados Intensivos Pedi&#225;tricos&#59; VMC&#58; ventilaci&#243;n mec&#225;nica&#46;</p>"
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              "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"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Todos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Con DRA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sin DRA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">N &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">315&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">128 &#40;40&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">187 &#40;59&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otras cardiopat&#237;as &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Duraci&#243;n VMC</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">&#40;horas&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cr basal</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">&#40;mg&#47;dl&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia UCIP</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">&#40;d&#237;as&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia total</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">&#40;d&#237;as&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;7-15&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;8&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">34 &#40;91&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;13&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">19 &#40;86&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Total DRA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">128&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">75 &#40;58&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">53 &#40;41&#44;4&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">107&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">62 &#40;57&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Distribuci&#243;n del da&#241;o renal agudo seg&#250;n su gravedad&#44; momento de inicio y duraci&#243;n</p>"
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          "leyenda" => "<p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">DRA&#58; da&#241;o renal agudo&#59; OR&#58; odds ratio&#59; UCIP&#58; Unidad de Cuidados Intensivos Pedi&#225;tricos&#59; VMC&#58; ventilaci&#243;n mec&#225;nica&#46;</p><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Regresi&#243;n log&#237;stica&#44; odds ratio &#40;IC 95&#37;&#41;&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Estancia UCIP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>12 d&#237;as<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PO cirug&#237;a card&#237;aca &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">36 &#40;26&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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Original
Morbimortalidad asociada al daño renal agudo en pacientes ingresados en unidades de cuidados intensivos pediátricos
Morbimortality associated to acute kidney injury in patients admitted to pediatric intensive care units
J.C. Gómez Polo, A.J. Alcaraz Romero
Autor para correspondencia
aaromero@um.es

Autor para correspondencia.
, M.A. Gil-Ruíz Gil-Esparza, J. López-Herce Cid, M. García San Prudencio, S.N. Fernández Lafever, Á. Carrillo Álvarez
Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">El da&#241;o renal agudo &#40;DRA&#41; en el paciente pedi&#225;trico es una entidad cl&#237;nica importante&#44; especialmente en aquellos en estado grave que requieren ingreso en las Unidades de Cuidados Intensivos Pedi&#225;tricos &#40;UCIP&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El DRA es un s&#237;ndrome cl&#237;nico caracterizado por una p&#233;rdida o disminuci&#243;n brusca de la funci&#243;n renal&#44; acompa&#241;ada o no de oligoanuria&#44; con unas manifestaciones cl&#237;nicas inespec&#237;ficas&#44; que pueden incluir desequilibrios hidroelectrol&#237;ticos<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La incidencia y gravedad son muy variables debido a la falta de criterios diagn&#243;sticos universalmente aceptados<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#44; existiendo hasta 30 definiciones distintas de DRA&#46; Este hecho influye en las enormes diferencias descritas en la incidencia en las UCIP&#44; que oscila entre el 2&#44;5 y el 24&#37;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;Todo ello supone una dificultad a la hora de comparar la incidencia y la morbilidad asociada al DRA<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En los &#250;ltimos a&#241;os ha mejorado la estandarizaci&#243;n del diagn&#243;stico de DRA en el paciente pedi&#225;trico&#44; estableci&#233;ndose como definici&#243;n principal los criterios pRIFLE<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#44; obtenidos mediante una leve modificaci&#243;n de los criterios RIFLE descritos para el adulto<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; La aplicaci&#243;n de los posteriores criterios AKIN<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41; no ha mostrado ninguna diferencia relevante con respecto a la de los pRIFLE<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">En pacientes adultos se ha demostrado&#44; tanto con los criterios RIFLE como con los posteriores AKIN<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;13</span></a>&#44; una relaci&#243;n entre el desarrollo de DRA y la morbimortalidad&#44; directamente proporcional al grado de severidad del da&#241;o renal&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Sin embargo&#44; en el paciente pedi&#225;trico&#44; esta relaci&#243;n no se ha demostrado de forma consistente&#44; probablemente influida por el escaso n&#250;mero de estudios y el peque&#241;o tama&#241;o muestral de los mismos&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El objetivo principal de este estudio es valorar la morbimortalidad de los ni&#241;os ingresados en UCIP que desarrollan DRA&#44; definido y clasificado con la utilizaci&#243;n de los criterios pRIFLE&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Material y m&#233;todos</span><p id="par0040" class="elsevierStylePara elsevierViewall">Estudio de dise&#241;o observacional retrospectivo de cohorte mediante revisi&#243;n de historias cl&#237;nicas&#44; en el que se incluyeron todos los pacientes mayores de un mes y menores de 15 a&#241;os que ingresaron en la UCIP del Hospital General Universitario Gregorio Mara&#241;&#243;n durante el a&#241;o 2011&#46; Fueron excluidos los reci&#233;n nacidos y aquellos que ingresaron a consecuencia del postoperatorio de un trasplante renal&#46; El estudio fue aprobado por el Comit&#233; &#201;tico de Investigaci&#243;n Cl&#237;nica del hospital&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se recogieron las siguientes variables&#58; edad&#44; sexo&#44; peso y diagn&#243;stico que motiv&#243; el ingreso&#44; que se agrup&#243; en postoperatorio de cirug&#237;a card&#237;aca&#44; descompensaci&#243;n de cardiopat&#237;a no relacionada con la cirug&#237;a&#44; postoperatorios de otras cirug&#237;as&#44; insuficiencia respiratoria aguda y otros&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Como indicadores de morbilidad se consideraron la necesidad de ventilaci&#243;n mec&#225;nica invasiva y duraci&#243;n de la misma&#44; la estancia tanto en la UCIP como la hospitalaria total&#44; y la mortalidad&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Tambi&#233;n se recogi&#243; la asistencia con oxigenaci&#243;n por membrana extracorp&#243;rea&#44; y la depuraci&#243;n extrarrenal &#40;di&#225;lisis peritoneal o depuraci&#243;n extrarrenal continua&#41;&#44; incluyendo el d&#237;a de ingreso que se inicia cada t&#233;cnica y la duraci&#243;n de la misma&#46;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Para la valoraci&#243;n de la funci&#243;n renal se utilizaron los valores de las mediciones repetidas de creatinina en sangre y la diuresis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">El da&#241;o renal se defini&#243; y categoriz&#243; siguiendo la adaptaci&#243;n pedi&#225;trica de los criterios RIFLE &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; El filtrado glomerular se estim&#243; con la f&#243;rmula de Schwartz&#58; FGe<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>K<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>talla &#40;cm&#41;&#47;creatinina &#40;mg&#47;dL&#41;&#46; Los valores de K dependen de la edad&#58; 0&#44;45 en<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>12 meses&#44; 0&#44;55 entre uno y 12 a&#241;os&#44; 057 en mujeres<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>de 12 a&#241;os y 0&#44;70 en varones<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>12 a&#241;os&#46; Se utilizaron las 3 primeras categor&#237;as de gravedad&#44; obvi&#225;ndose las categor&#237;as &#171;L&#187; y &#171;E&#187; por hacer referencia al resultado final m&#225;s que a un cambio agudo&#46; Se consideraron DRA grave aquellas situaciones que cumplieron los criterios de las categor&#237;as &#171;I&#187; o &#171;F&#187; de la clasificaci&#243;n pRIFLE&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Cuando no se dispon&#237;a de un valor de creatinina basal sobre el que evaluar los cambios evolutivos para la categorizaci&#243;n del DRA&#44; se procedi&#243; de la siguiente manera&#58; si el paciente dispon&#237;a de un valor de creatinina en los 6 meses previos al ingreso se utiliz&#243; este&#44; siempre y cuando no se tratase del primer mes de vida&#44; y si no exist&#237;a una creatinina conocida&#44; se recurri&#243; a los valores de referencia recientes para lactantes y ni&#241;os<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Asimismo&#44; se determin&#243; el momento de inicio del da&#241;o renal y la duraci&#243;n del mismo&#46; Se defini&#243; DRA precoz como el que se iniciaba en las primeras 72<span class="elsevierStyleHsp" style=""></span>h de ingreso en UCIP &#40;probablemente relacionado con la enfermedad que motiv&#243; el ingreso&#41; y tard&#237;o el que se present&#243; posteriormente &#40;que puede estar m&#225;s relacionado con complicaciones de la enfermedad inicial o del ingreso prolongado en la UCIP&#41;&#46; Se consider&#243; da&#241;o prerrenal cuando se resolvi&#243; antes de las 72<span class="elsevierStyleHsp" style=""></span>h&#44; y da&#241;o renal prolongado si la duraci&#243;n era mayor o igual a 72<span class="elsevierStyleHsp" style=""></span>h<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Para la valoraci&#243;n de la morbilidad se analiz&#243; la necesidad y duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#44; la duraci&#243;n del ingreso en la UCIP y en el hospital&#44; y la mortalidad&#46; Se consider&#243; ingreso prolongado en UCIP aquel con una duraci&#243;n superior a 12 d&#237;as<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a>&#44; y como hospitalario prolongado el superior a 28 d&#237;as&#46; Asimismo se defini&#243; como ventilaci&#243;n mec&#225;nica prolongada la recibida durante m&#225;s de 7 d&#237;as&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Los ni&#241;os que fallecieron fueron excluidos del an&#225;lisis de la duraci&#243;n de la estancia y de la ventilaci&#243;n mec&#225;nica&#46; En los 5 ni&#241;os que presentaron una ventilaci&#243;n mec&#225;nica superior a 42 d&#237;as se les asign&#243; el valor de 1&#46;000<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Los datos fueron procesados con el programa SPSS<span class="elsevierStyleSup">&#174;</span> 18&#46;0&#46; Se comprob&#243; la distribuci&#243;n normal de las variables cuantitativas con el test de Kolmogorov-Smirnov&#46; Los datos se presentan en medianas &#40;P25-P75&#41; y frecuencias y porcentajes&#46; Las comparaciones de las variables cualitativas se realizaron con el test de la Chi-cuadrado y el test exacto de Fisher si era necesario&#44; y la de las cuantitativas&#44; con el test U de Mann-Whitney&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La asociaci&#243;n del DRA con la morbimortalidad se comprob&#243; con regresi&#243;n log&#237;stica univariante y multivariante&#44; construy&#233;ndose modelos ajustados por edad&#44; diagn&#243;stico y duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#44; y para el an&#225;lisis de la duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#44; modelos ajustados por edad y diagn&#243;stico&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="par0100" class="elsevierStylePara elsevierViewall">Durante el per&#237;odo de estudio ingresaron 320 pacientes mayores de un mes en la UCIP&#44; de los que 5 se excluyeron por haber sido sometidos a trasplante renal&#44; quedando 315 pacientes para el estudio&#46; Las caracter&#237;sticas demogr&#225;ficas se presentan en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">La enfermedad m&#225;s frecuente que motiv&#243; el ingreso fue el postoperatorio de cirug&#237;a card&#237;aca &#40;134 ni&#241;os&#44; 42&#44;5&#37;&#41;&#46; Como puede verse en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#44; 148 ni&#241;os &#40;47&#37;&#41; precisaron ventilaci&#243;n mec&#225;nica&#44; con una duraci&#243;n de 48<span class="elsevierStyleHsp" style=""></span>h &#40;13-192&#41;&#46; La estancia en la UCIP fue de 4 d&#237;as &#40;3-8&#41;&#44; mientras que la duraci&#243;n total del ingreso hospitalario fue de 11 d&#237;as &#40;8-22&#41;&#46; Cincuenta y nueve ni&#241;os &#40;18&#44;7&#37;&#41; carec&#237;an de creatinina basal conocida y para ellos se utiliz&#243; un valor de creatinina de referencia adecuado a su edad&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">De los 315 ni&#241;os&#44; el 40&#44;6&#37; &#40;128 ni&#241;os&#41; sufrieron DRA en alg&#250;n momento de su ingreso&#44; de los que 107 &#40;83&#44;6&#37;&#41; presentaron un DRA precoz</p><p id="par0115" class="elsevierStylePara elsevierViewall">En relaci&#243;n con el diagn&#243;stico&#44; el DRA fue m&#225;s frecuente en los ni&#241;os sometidos a cirug&#237;a card&#237;aca&#44; produci&#233;ndose en 78 &#40;58&#44;2&#37;&#41; de ellos &#40;lo que supone el 60&#44;9&#37; del total de casos de DRA&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Los pacientes con DRA precisaron ventilaci&#243;n mec&#225;nica con una frecuencia significativamente mayor &#40;61&#44;7&#37;&#41; que el resto de los ni&#241;os ingresado en la UCIP&#44; y la duraci&#243;n de la misma tambi&#233;n fue mayor&#46; Igualmente&#44; la necesidad de oxigenaci&#243;n por membrana extracorp&#243;rea fue superior &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Los ni&#241;os que desarrollaron DRA tuvieron una estancia significativamente m&#225;s prolongada&#44; tanto en la UCIP como en el hospital&#44; y tambi&#233;n una asociaci&#243;n con mayor mortalidad &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a> muestra la categorizaci&#243;n del DRA seg&#250;n el momento de inicio&#44; la gravedad y la duraci&#243;n&#46; El 58&#44;6&#37; de los pacientes presentaron un DRA prerrenal&#46; Se encontr&#243; relaci&#243;n entre la gravedad y la duraci&#243;n del DRA&#44; existiendo un mayor n&#250;mero de casos en la categor&#237;a m&#225;s leve en el DRA prerrenal&#44; mientras que los casos de categor&#237;as m&#225;s graves se asociaron con una mayor duraci&#243;n del DRA &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">El criterio de oliguria se encontr&#243; en muy pocos pacientes&#58; un paciente con SHU que present&#243; anuria desde el ingreso junto a una creatinina de 4&#44;09<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;cumple ambos criterios de Failure&#41; y en 2 ni&#241;os con disfunci&#243;n card&#237;aca grave que requirieron tratamiento con oxigenaci&#243;n por membrana extracorp&#243;rea&#44; y seguidamente tuvieron depuraci&#243;n extrarrenal&#46; En otros 20 ni&#241;os en los que se inici&#243; depuraci&#243;n extrarrenal por sobrecarga h&#237;drica con alteraci&#243;n de la creatinina y del filtrado glomerular se alcanz&#243; el criterio de oliguria&#44; pero estando ya con la depuraci&#243;n&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Veinticuatro ni&#241;os &#40;18&#44;7&#37; de los pacientes con DRA&#41; precisaron t&#233;cnicas de depuraci&#243;n extrarrenal &#40;23&#44; t&#233;cnicas de depuraci&#243;n extrarrenal continuas&#44; y uno&#44; di&#225;lisis peritoneal&#41;&#46; La mortalidad de los pacientes con DRA grave &#40;Injury o Failure&#41; fue del 23&#44;7&#37;&#44; mucho mayor que la de los que presentaron DRA leve &#40;Risk&#41;&#44; que fue del 2&#44;7&#37;&#44; y la de los ni&#241;os sin DRA&#44; del 0&#44;5&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Se encontr&#243; una asociaci&#243;n muy significativa del DRA con una estancia prolongada en UCIP y en el hospital y la necesidad de una ventilaci&#243;n mec&#225;nica prolongada&#46; Esta asociaci&#243;n fue independiente de la edad y enfermedad de los pacientes&#44; tras controlar estas variables en la regresi&#243;n log&#237;stica multivariante &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46; Adem&#225;s&#44; se encontr&#243; un aumento paralelo de la morbimortalidad con la mayor gravedad del DRA &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">Posteriormente estudiamos de forma separada los ni&#241;os que presentaron un DRA prerrenal de aquellos que presentaron un DRA m&#225;s prolongado &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">tabla 6</a>&#41;&#46; Los ni&#241;os que presentaron un DRA prerrenal tuvieron una estancia m&#225;s prolongada en la UCIP y en el hospital que los que no tuvieron DRA&#44; aunque no fue diferente la utilizaci&#243;n y duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#46; Como se muestra en la <a class="elsevierStyleCrossRef" href="#tbl0030">tabla 6</a>&#44; los ni&#241;os con DRA establecido eran m&#225;s peque&#241;os y tuvieron mayor morbimortalidad que los ni&#241;os sin DRA y que aquellos con DRA prerrenal&#46; Se encontr&#243; una asociaci&#243;n muy significativa del DRA establecido con una estancia prolongada en UCIP y en el hospital y la necesidad de una ventilaci&#243;n mec&#225;nica prolongada&#44; que fue independiente de la edad y enfermedad de los pacientes &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">tabla 7</a>&#41;&#46; No pudo establecerse esta asociaci&#243;n para los ni&#241;os que tuvieron un DRA prerrenal&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discusi&#243;n</span><p id="par0155" class="elsevierStylePara elsevierViewall">Los resultados encontrados en este estudio demuestran una importante asociaci&#243;n entre el desarrollo de DRA y la morbimortalidad de los ni&#241;os que ingresan en la UCIP&#46; Asimismo&#44; muestra como el riesgo aumenta con la gravedad del DRA&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Hay pocos estudios publicados que eval&#250;en la repercusi&#243;n del DRA en ni&#241;os<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; En una reciente revisi&#243;n sistem&#225;tica<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> se encontr&#243; una falta de concordancia en los resultados publicados en los diferentes estudios&#44; atribuida&#44; en parte&#44; a la aplicaci&#243;n de una forma heterog&#233;nea de los criterios de DRA y en los criterios de inclusi&#243;n y exclusi&#243;n utilizados y el tipo de pacientes estudiados<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#8211;25</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">La utilizaci&#243;n homog&#233;nea de unos criterios uniformes y comunes para la definici&#243;n de DRA en la poblaci&#243;n pedi&#225;trica deber&#237;a permitir la comparaci&#243;n de resultados de diferentes estudios&#46; Los criterios pRIFLE pueden servir para este fin&#44; pero su aplicaci&#243;n de una forma heterog&#233;nea en los estudios publicados hasta ahora no ha permitido alcanzar este objetivo<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">En nuestro estudio hemos incluido a todos los ni&#241;os en estado cr&#237;tico que requirieron asistencia en UCIP&#44; independientemente del tipo de enfermedad y de si el ingreso fue urgente o programado&#44; lo que nos permite obtener una mejor aproximaci&#243;n a la magnitud del problema que representa el desarrollo de DRA sobre la morbimortalidad en la poblaci&#243;n general pedi&#225;trica&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Otra limitaci&#243;n de los estudios son las variaciones en el m&#233;todo para determinar el valor de la creatinina s&#233;rica de referencia cuando esta es desconocida&#44; y en algunos no se especifica<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#8211;28</span></a>&#46; En el presente estudio un gran n&#250;mero de pacientes dispon&#237;an de valores previos&#44; y para el resto se utilizaron valores de referencia publicados recientemente<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">El criterio de oliguria no se ha utilizado en los principales estudios que se han llevado a cabo sobre el DRA en ni&#241;os<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;24&#44;29</span></a>&#46; En nuestro trabajo el criterio de oliguria se cumpli&#243; en pocas ocasiones&#46; Probablemente influye que un mismo valor de diuresis &#40;ml&#47;kg&#47;h&#41; para definir oliguria es un criterio mucho m&#225;s severo cuanto m&#225;s peque&#241;o es el paciente&#44; dado que el aporte de agua que recibe el ni&#241;o en relaci&#243;n con su peso es mucho mayor cuanto m&#225;s peque&#241;o es&#46; Una valoraci&#243;n en ml&#47;m<span class="elsevierStyleSup">2</span> de superficie corporal o ml&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> obviar&#237;a probablemente este problema&#46; Tambi&#233;n puede influir en la evaluaci&#243;n de la oliguria la dificultad para cuantificar la diuresis en ni&#241;os no sondados&#44; m&#225;s a&#250;n si se realiza de forma retrospectiva&#46; Adem&#225;s&#44; la utilizaci&#243;n de diur&#233;ticos&#44; que es frecuente en los ni&#241;os ingresados en la UCI&#44; influida por el alto porcentaje de ni&#241;os con cardiopat&#237;as &#40;53&#37; en nuestro estudio&#41;&#44; puede contribuir a que se cumpla menos la oliguria&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">De los 12 art&#237;culos publicados que tratan de relacionar el desarrollo de DRA con la morbimortalidad&#44; tan solo dos de ellos aportan datos suficientes para verificar que las medidas empleadas para definir la presencia de da&#241;o renal corresponden a una correcta aplicaci&#243;n de los criterios pRIFLE<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;20</span></a>&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Varios estudios han hallado una relaci&#243;n entre la existencia de DRA y la mortalidad<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21&#44;29</span></a>&#44; al igual que ocurri&#243; en nuestro estudio&#46; De los 4 trabajos que analizaron la mortalidad con el grado de severidad seg&#250;n el estadio pRIFLE<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;20&#44;21&#44;29</span></a>&#44; solo 2 de ellos mostraron una relaci&#243;n significativa<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;29</span></a>&#46; Probablemente estas diferencias se deban al peque&#241;o tama&#241;o de la poblaci&#243;n de los estudios publicados y la baja incidencia de mortalidad en las UCIP&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">La mayor morbilidad asociada al DRA&#44; valorada como una duraci&#243;n mayor del ingreso en la UCIP&#44; ingreso en el hospital y duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#44; ha sido mostrada en estudios realizados en adultos<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10&#44;12&#44;13</span></a> y ni&#241;os<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;20&#8211;22&#44;27&#44;29&#44;30</span></a>&#46; En estudios en adultos se encontr&#243;&#44; adem&#225;s&#44; un riesgo creciente con la mayor gravedad del DRA seg&#250;n los criterios RIFLE&#44; datos que coinciden con nuestros resultados&#46; Sin embargo&#44; esta asociaci&#243;n no hab&#237;a sido descrita en las series previamente publicadas en ni&#241;os&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Adem&#225;s&#44; hemos analizado separadamente los ni&#241;os con DRA prerrenal de aquellos con un DRA establecido&#44; para comprobar el efecto de la disfunci&#243;n pasajera frente al de un DRA establecido sobre la morbilidad&#46; Como era de esperar&#44; se demuestra que los ni&#241;os que tienen un DRA establecido presentan mayor morbilidad que los que presentan un DRA prerrenal&#46; Adem&#225;s&#44; pudo establecerse una asociaci&#243;n independiente del DRA establecido con los par&#225;metros de morbilidad estudiados&#46; La ausencia de esta asociaci&#243;n en nuestro estudio con los ni&#241;os que tuvieron DRA prerrenal pudo verse influida por cumplirse los criterios de morbilidad estudiados en pocos de estos ni&#241;os &#40;5 tuvieron ventilaci&#243;n mec&#225;nica durante m&#225;s de 7 d&#237;as&#44; 10 una estancia en UCIP superior a 12 d&#237;as y 10 ingreso en el hospital mayor de 28 d&#237;as&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Dada la gran morbimortalidad asociada al desarrollo de DRA en los ni&#241;os en estado grave&#44; la utilizaci&#243;n precoz de medidas que disminuyan la incidencia y&#47;o la gravedad del DRA podr&#237;an mejorar la evoluci&#243;n de estos ni&#241;os&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Este estudio presenta una serie de limitaciones&#58; 1&#41; estudio retrospectivo y unic&#233;ntrico&#59; 2&#41; n&#250;mero peque&#241;o de pacientes incluidos&#59; 3&#41; el filtrado glomerular estimado basal de una parte de los ni&#241;os tuvo que extrapolarse desde valores de creatinina adecuados a la edad del ni&#241;o publicados en tablas de referencia&#59; 4&#41; el criterio de oliguria no pudo evaluarse de forma adecuada en todos los pacientes por no estar todos los ni&#241;os sondados&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusiones</span><p id="par0215" class="elsevierStylePara elsevierViewall">El desarrollo de DRA en los ni&#241;os ingresados en la UCIP se asocia a una mayor morbimortalidad&#46; La categorizaci&#243;n del DRA con los criterios pRIFLE y la utilizaci&#243;n de definiciones y criterios bien definidos permiten una adecuada identificaci&#243;n del riesgo de morbimortalidad asociada y puede detectar de forma precoz a los pacientes con riesgo de presentar un DRA y aplicar medidas para disminuir la incidencia y la gravedad de este s&#237;ndrome&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicto de intereses</span><p id="par0220" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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    "fechaRecibido" => "2013-04-24"
    "fechaAceptado" => "2013-07-17"
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    "resumen" => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar la morbimortalidad asociada a da&#241;o renal agudo &#40;DRA&#41; definido por los criterios RIFLE adaptados a Pediatr&#237;a en los ni&#241;os que ingresan en la Unidad de Cuidados Intensivos Pedi&#225;tricos &#40;UCIP&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de cohorte&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">&#193;mbito</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">UCIP de un hospital terciario&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Pacientes o participantes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Trescientos veinte ni&#241;os ingresados en la UCIP en el a&#241;o 2011&#46; Se excluyeron los neonatos y los trasplantados renales&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Variables principales El DRA fue definido con los criterios RIFLE adaptados a Pediatr&#237;a&#46; Para la valoraci&#243;n de la morbimortalidad se utiliz&#243; la duraci&#243;n de las estancias en la UCIP y en el hospital&#44; la necesidad de ventilaci&#243;n mec&#225;nica y la mortalidad&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Resultados</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se estudiaron 315 ni&#241;os&#44; con una mediana de edad de 19 meses &#40;6-72&#41;&#46; Presentaron DRA 128 ni&#241;os &#40;40&#44;6&#37;&#41; &#40;73 en la categor&#237;a de Risk &#91;riesgo&#93; y 55 en las categor&#237;as Injury &#91;da&#241;o&#93; y Failure &#91;fallo&#93;&#41;&#46; Los ni&#241;os con DRA presentaron mayor mortalidad &#40;11&#44;7&#37;&#41; que el resto de pacientes &#40;0&#44;5&#37;&#41;&#44; una estancia m&#225;s prolongada en UCIP &#40;6&#44;0 &#91;4&#44;0-12&#44;5&#93; frente a 3&#44;5 &#91;2&#44;0-7&#44;0&#93; d&#237;as&#41; y en el hospital &#40;17 &#40;10-32&#41; frente a 10 &#40;7-15&#93; d&#237;as&#41; y m&#225;s ni&#241;os precisaron ventilaci&#243;n mec&#225;nica &#40;61&#44;7 frente a 36&#44;9&#37;&#41;&#46; El desarrollo de DRA fue un factor independiente de morbilidad&#44; asociado a una mayor estancia en UCIP y hospitalaria y a una ventilaci&#243;n mec&#225;nica m&#225;s prolongada&#44; increment&#225;ndose esta morbilidad de forma paralela a la gravedad del da&#241;o renal&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0035">Conclusi&#243;n</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El desarrollo de DRA en ni&#241;os en estado cr&#237;tico se asocia a un incremento en la morbimortalidad&#44; que es directamente proporcional a la magnitud de la gravedad del da&#241;o renal&#46;</p>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0045">Aim</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">To describe the morbimortality associated to the development of acute kidney injury &#40;AKI&#41; defined by the pediatric adaptation of the RIFLE criteria in a Pediatric Intensive Care Unit &#40;PICU&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Design</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A retrospective cohort study was carried out&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Setting</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Children admitted to a PICU in a tertiary care hospital&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Patients or participants A total of 320 children admitted to a tertiary care hospital PICU during the year 2011&#46; Neonates and renal transplant patients were excluded&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Primary endpoints AKI was defined and classified according to the pediatric adaptation to the RIFLE criteria&#46; PICU and hospital stays&#44; use of mechanical ventilation and mortality were used to evaluate morbimortality&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Results</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">A total of 315 children met the inclusion criteria&#44; with a median age of 19 months &#40;range 6-72&#41;&#46; Of these patients&#44; 128 presented AKI &#40;73 reached the Risk category and 55 reached the Injury and Failure categories&#41;&#46; Children with AKI presented a longer PICU stay &#40;6&#46;0 &#91;4&#46;0-12&#46;5&#93; vs&#46; 3&#46;5 &#91;2&#46;0-7&#46;0&#93; days&#41; and hospital stay &#40;17 &#91;10-32&#93; vs&#46; 10 &#91;7-15&#93; days&#41;&#44; and a greater need for mechanical ventilation &#40;61&#46;7 vs&#46; 36&#46;9&#37;&#41;&#46; The development of AKI was an independent factor of morbidity&#44; associated with a longer PICU and hospital stay&#44; and with a need for longer mechanical ventilation&#44; with a proportional relationship between increasing morbidity and the severity of AKI&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0065">Conclusion</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The development of AKI in critically ill children is associated with increased morbimortality&#44; which is proportional to the severity of renal injury&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Estadio 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aumento<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#44;5-2 o aumento<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span> 6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Estadio 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aumento<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2-3 veces&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Estadio 3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aumento<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3 veces o Cr<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;con un incremento agudo<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;3<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>24<span class="elsevierStyleHsp" style=""></span>h o anuria durante 12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otras cardiopat&#237;as &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IRA &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otros &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17 &#40;35&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">VMC &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total DRA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">128&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">75 &#40;58&#44;6&#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="char" valign="\n
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                  \t\t\t\t">53 &#40;41&#44;4&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">107&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="char" valign="\n
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                  \t\t\t\t">62 &#40;57&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">45 &#40;42&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TDE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">12&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="char" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
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                  """
              ]
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                0 => "xTab560626.png"
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Distribuci&#243;n del da&#241;o renal agudo seg&#250;n su gravedad&#44; momento de inicio y duraci&#243;n</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Tabla 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">DRA&#58; da&#241;o renal agudo&#59; OR&#58; odds ratio&#59; UCIP&#58; Unidad de Cuidados Intensivos Pedi&#225;tricos&#59; VMC&#58; ventilaci&#243;n mec&#225;nica&#46;</p><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Regresi&#243;n log&#237;stica&#44; odds ratio &#40;IC 95&#37;&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Estancia UCIP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>12 d&#237;as<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">OR no ajustada&#46; DRA categor&#237;a Injury&nbsp;\t\t\t\t\t\t\n
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                  """
              ]
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                0 => "xTab560621.png"
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          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0010"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">OR &#40;IC 95&#37;&#41; ajustada para edad&#44; diagn&#243;stico y uso de VMC&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">OR &#40;IC 95&#37;&#41; ajustada para edad y diagn&#243;stico&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">No significativo &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Asociaci&#243;n entre morbilidad y desarrollo de da&#241;o renal agudo de cualquier grado o de las formas graves &#40;categor&#237;as Injury y Failure&#41;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0030"
        "etiqueta" => "Tabla 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">Cr&#58; creatinina&#59; DRA&#58; da&#241;o renal agudo&#59; ECMO&#58; oxigenaci&#243;n por membrana extracorp&#243;rea&#59; PO&#58; postoperatorio&#59; IRA&#58; insuficiencia respiratoria aguda&#59; UCIP&#58; Unidad de Cuidados Intensivos Pedi&#225;tricos&#59; VMC&#58; ventilaci&#243;n mec&#225;nica&#46;</p>"
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                  \t\t\t\t">24 &#40;8-72&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otras cardiopat&#237;as &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">VMC &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Duraci&#243;n VMC</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">&#40;horas&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">ECMO &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cr basal</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">&#40;mg&#47;dl&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;904&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia UCIP</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">&#40;d&#237;as&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia total</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">&#40;d&#237;as&#41;</span>&nbsp;\t\t\t\t\t\t\n
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ISSN: 02105691
Idioma original: Español
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