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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Renal function is a powerful predictor of prognosis in patients with chronic<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and acute<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> heart failure &#40;HF&#41;&#46; In acute decompensated heart failure episodes&#44; a decrease in glomerular filtration rate &#40;GFR&#41; is frequently observed&#44; which confers a worse prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> The definition and diagnostic criteria of acute kidney injury &#40;AKI&#41; and worsening renal function &#40;WRF&#41; are subject to debate&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Some experts believe that the period of time it takes for creatinine concentrations to increase must be taken into account in order to classify it as AKI or WRF&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> When creatinine increases above certain limits soon before or during hospitalization&#44; the term used to define this scenario is AKI&#46; On the contrary&#44; when the increase in more prolonged&#8212;over weeks or months&#8212;and occurs in patients with chronic HF&#44; it is more appropriate to call it WRF&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Currently&#44; there are two sets of criteria used to define AKI&#46; The <span class="elsevierStyleItalic">Risk&#44; Injury&#44; Failure&#44; Loss</span>&#44; <span class="elsevierStyleItalic">End-stage</span> &#40;RIFLE&#41; functional criteria<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> evaluate changes in serum creatinine and&#47;or diuresis&#46; The RIFLE criteria include a decrease in GFR &#40;&#62;50&#37;&#41;&#44; a relative increase in serum creatinine with respect to baseline levels &#40;&#62;50&#37;&#41;&#44; and an absolute reduction in diuresis &#40;&#60;0&#46;5<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;hour for more than six hours&#41; for seven days&#46; The Acute Kidney Injury Network &#40;AKIN&#41; criteria<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> arose as an adaptation of the RIFLE criteria due to evidence that small increases in serum creatinine concentrations greater than 26<span class="elsevierStyleHsp" style=""></span>mmol&#47;L &#40;0&#46;29<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; during the first 48<span class="elsevierStyleHsp" style=""></span>h of hospitalization have been associated with an 80&#37; increase in mortality&#46; However&#44; both sets of criteria are mostly based on studies specifically on kidney injury &#40;for example&#44; contrast toxicity or surgical bypass&#41; in which the intensity of the aggression and&#44; especially&#44; the moment when it begins are easily recognizable&#44; which simplifies diagnosis of AKI&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In the specific context of HF&#44; these two aspects are neither explicit nor measurable&#44; which explains why the outcomes of studies on the incidence or prognostic impact of AKI are more heterogeneous and not always definitive&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;9&#44;10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Some studies show that in the specific context of decompensated HF&#44; the relationship between renal function and prognosis is more complex than previously thought&#46; It has been found that small increases in creatinine concentration during hospitalization for any cause can affect long-term prognosis&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> that small variations &#40;trajectories&#41; in creatinine in the short-term during hospitalization for HF are associated with differences in risk of death&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and that the role and prognostic data provided by renal function differ among subjects in the community and patients hospitalized for HF&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this study&#44; we aimed to analyze the validity of the AKIN and RIFLE criteria for the diagnosis of AKI in the specific context of patients hospitalized for HF&#44; the relationship of the criteria to prognosis&#44; and the significance of small increases in creatinine concentration and its residual elevation following discharge&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0025" class="elsevierStylePara elsevierViewall">Between February 2013 and December 2014&#44; 204 patients who were consecutively admitted to the Internal Medicine Department of a tertiary university hospital for acute decompensated heart failure &#40;ADHF&#41; were selected&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The inclusion criteria were&#58; 1&#41; patients admitted with a diagnosis of ADHF &#40;defined as rapid or gradual onset of the signs and symptoms of HF leading to an unplanned hospitalization&#41;&#59; 2&#41; patients over 18 years of age&#59; 3&#41; dyspnea and presence of the Framingham criteria&#59;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> 4&#41; an N-amino terminal fragment of the prohormone B-type natriuretic peptide &#40;NT-proBNP&#41; level over 300<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#59; and 5&#41; clinical signs and x-ray findings compatible with a diagnosis of HF&#46; Patients with either new-onset ADHF or acute decompensation of chronic HF were eligible for inclusion&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The exclusion criteria were&#58; 1&#41; patients who did not wish to participate in the study&#59; 2&#41; patients with stage 4&#8211;5 chronic kidney disease &#40;CKD&#41;&#59; 3&#41; patients with cardiogenic shock&#59; 4&#41; need for inotropic agents during the hospitalization&#59; 5&#41; patients with a life expectancy of less than three months&#59; 6&#41; advanced dementia&#59; and 7&#41; allergy or intolerance to diuretics&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Laboratory measurements</span><p id="par0040" class="elsevierStylePara elsevierViewall">During the first two hours after the initial evaluation in the Emergency Department&#44; a blood test was performed that included urea&#44; creatinine&#44; and electrolytes&#46; Then&#44; another blood test was performed during the first 48<span class="elsevierStyleHsp" style=""></span>h from admission and again 24<span class="elsevierStyleHsp" style=""></span>h prior to discharge&#46; It included urea&#44; creatinine&#44; cystatin C&#44; and NT-proBNP &#40;Elecsys&#174;&#44; Roche Diagnostics GmbH&#44; Mannheim&#44; Germany&#41;&#46; Other additional blood tests were performed during the hospitalization as per the judgment of the attending physician&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The estimated glomerular filtration rate &#40;eGFR&#41; was calculated using equations based on creatinine&#58; Modification of Diet in Renal Disease-4 &#40;MDRD-4&#41; and Chronic Kidney Disease Epidemiology Collaboration &#40;CKD-EPI&#41;&#44; including cystatin C concentrations as well&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">AKI was diagnosed when serum creatinine levels increased at least 50&#37; above baseline in seven days &#40;RIFLE criteria&#41; or increased &#62;0&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in 48<span class="elsevierStyleHsp" style=""></span>h &#40;AKIN criteria&#41;&#44; both during the hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Pursuant to the criteria proposed by Sheerin et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> we also compared baseline serum creatinine &#40;measured within the three months prior to the ADHF episode&#41; with its concentration one month after discharge in order to search for potential residual worsening in renal function after the ADHF episode&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The relationship between changes in creatinine concentration and the appearance of end points was also analyzed&#46; The primary endpoints were all-cause mortality and mortality due to HF that occurred during follow-up&#46; Two periods of time were considered in order to observe creatinine variations during the hospitalization and&#44; secondly&#44; changes in creatinine values between the last available record in the three months prior to admission and the first visit one month after discharge&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Follow-up</span><p id="par0065" class="elsevierStylePara elsevierViewall">Patient follow-up took place in a specialized HF clinic and lasted 12 months&#46; All patients had an appointment scheduled for one month after discharge&#46; At that time&#44; another blood test was performed&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">An echocardiogram was performed on all patients prior to discharge from the hospital or in the first outpatient visit&#46; In patients who were readmitted&#44; the discharge summaries were carefully reviewed in order to identify causes of the readmission&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">Descriptive statistics&#58; the distribution frequency of qualitative variables was calculated for each category&#46; Quantitative variables were analyzed for normal distribution using the Kolmogorov-Smirnov test&#46; In terms of normality&#44; indicators of central tendency &#40;mean or median&#41; and dispersion &#40;standard deviation or interquartile range&#41; were determined&#46; A two-tailed <span class="elsevierStyleItalic">p</span> value of &#46;05 was considered statistically significant&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Comparisons were made using a contrast hypothesis&#44; comparing the percentages of qualitative variables &#40;chi-square test&#44; Fisher&#8217;s exact test&#41; or using a comparison of means of quantitative variables &#40;Student&#8217;s <span class="elsevierStyleItalic">t</span>-test or ANOVA&#41;&#46; The Mann-Whitney U test or the Kruskal-Wallis test were used for comparisons between groups when distribution was not normal&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The analysis was completed with a linear regression model &#40;for continuous variables&#41; or a logistic regression model &#40;for categorical variables&#41;&#46; To evaluate cumulative survival&#44; the Kaplan-Meier method was used without events with a log-rank test at 12 months of follow-up&#46; The all-cause total mortality and 12-month mortality study was carried out using a multivariate Cox regression model&#46; Once the initially identified predictors of all-cause mortality were corrected&#44; the multivariate-adjusted hazard ratios for mortality were calculated in terms of exponentiation of the B coefficient &#40;Exp&#40;B&#41;&#41; and odds ratio &#40;OR&#41;&#46; Variables regarding the candidate were selected based on clinical relevance and the available literature and included&#58; age&#44; sex&#44; length of hospital stay&#44; ejection fraction &#40;EF&#41;&#44; plasma urea and creatinine&#44; NT-proBNP&#44; cystatin C&#44; and well-known risk factors &#40;hypertension&#44; ischemia&#44; cardiomyopathy&#44; diabetes mellitus&#44; CKD&#44; and anemia&#41;&#46; Variables that were not normal were included in the multivariate regression expressed in logarithmic form &#40;Ln&#41;&#46; The analysis was carried out using the SPSS&#174; statistical software package&#44; version 22&#46;0 &#40;IBM&#44; Chicago&#44; Illinois&#44; USA&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical considerations</span><p id="par0090" class="elsevierStylePara elsevierViewall">All patients who agreed to participate in the study signed an informed consent form&#46; The study was approved by the Clinical Research Ethics Committee of Arag&#243;n &#40;PI13&#47;0019&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">A total of 204 patients were included&#46; The mean age was 81 years &#40;interquartile range &#40;IQR&#41; 76&#8211;85 years&#41;&#44; 50&#46;5&#37; were men&#44; and the mean hospital stay was eight days &#40;IQR 7&#8211;14 days&#41;&#46; The most frequent etiology of HF was hypertensive cardiomyopathy &#40;39&#46;2&#37;&#41;&#44; followed by ischemic heart disease &#40;28&#46;9&#37;&#41;&#46; The baseline NYHA functional class prior to admission was i or ii in 172 patients &#40;83&#46;7&#37;&#41;&#46; No patients in class iv were included&#46; At admission&#44; 93&#37; of patients were taking loop diuretics&#44; 76&#46;5&#37; an angiotensin-converting enzyme inhibitors or angiotensin receptor blockers&#44; 56&#46;3&#37; a beta blocker&#44; 33&#46;7&#37; antimineralocorticoids&#44; and 63&#46;5&#37; anticoagulant therapy&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The most frequent comorbidities were hypertension &#40;84&#46;3&#37;&#41;&#44; atrial fibrillation &#40;57&#46;8&#37;&#41;&#44; type 2 diabetes mellitus &#40;39&#46;6&#37;&#41;&#44; ischemic heart disease &#40;36&#46;6&#37;&#41;&#44; anemia &#40;19&#46;3&#37;&#41;&#44; and chronic obstructive pulmonary disease &#40;18&#46;8&#37;&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">One hundred six patients &#40;57&#37;&#41; had HF with preserved ejection fraction &#40;EF&#41; &#40;EF<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>50&#37;&#41;&#44; 19&#46;3&#37; had HF with an intermediate EF &#40;EF 40-49&#37;&#41;&#44; and 24&#46;1&#37; had HF with diminished EF &#40;EF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40&#37;&#41;&#46; Systolic pulmonary artery pressure above 30<span class="elsevierStyleHsp" style=""></span>mmHg was found in 77&#37; of patients&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Renal function evaluation</span><p id="par0110" class="elsevierStylePara elsevierViewall">Fifty-four patients &#40;26&#46;7&#37;&#41; had a history of CKD on their medical record&#46; However&#44; 50-80&#37; &#40;depending on the formula used&#41; presented with an eGFR below 60<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> during hospitalization &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Compared to equations based on cystatin C&#44; the creatinine-based MDRD-4 overestimated eGFR&#46; Approximately 30&#37; more patients had a creatinine clearance level above 60<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> when GFR was estimated using the creatinine-based MDRD-4 formula&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The development of AKI during hospitalization was determined according to the RIFLE or the AKIN criteria&#46; Incidence of AKI was 17&#46;2&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>35&#41; or 24&#46;5&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41; according to the RIFLE and AKIN criteria&#44; respectively&#46; As per the most recent KDIGO guidelines and according to whether patients met at least one of the two sets of criteria&#44; we considered the incidence of AKI during hospitalization to be 28&#46;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&#46; In order to define the characteristics related to kidney function deterioration with greater precision&#44; the demographic characteristics and comorbidities of two groups were analyzed&#58; those who developed AKI during hospitalization and those who did not &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">A timeline of serum creatinine changes during hospitalization was also recorded&#46; Mean baseline creatinine in the entire sample was 1&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Creatinine concentration at admission to the emergency department was already higher &#40;1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; among patients who would later develop AKI during hospitalization compared to those who would not &#40;1&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;000&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Serum creatinine concentrations peaked on the fifth day of hospitalization&#44; reaching a concentration of 1&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL among patients with AKI&#44; whereas patients without AKI maintained their baseline values &#40;1&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;000&#41;&#46; Creatinine concentrations during hospitalization correlated with the measurements taken in the follow-up visit one month following discharge&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Using the last creatinine concentration measured during the 3 months prior to admission as a reference&#44; patients who did not develop AKI during hospitalization had a 4&#37; increase in creatinine levels one month after discharge &#40;mean increase of 0&#46;068<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; whereas those who presented with AKI in the hospital had increases of up to 20&#37; during the same time period &#40;mean increase of 0&#46;247&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;013&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Mortality</span><p id="par0135" class="elsevierStylePara elsevierViewall">Ten patients &#40;5&#37;&#41; died during hospitalization &#40;70&#37; due to HF&#41;&#46; During follow-up&#44; six more patients died &#40;cumulative mortality of 8&#37;&#41; in the first month following discharge&#46; At the end of the 12 months of follow-up&#44; mortality was 23&#46;5&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>48&#59; 81&#37; due to HF&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Mortality was associated with age &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#59; length of hospital stay &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;027&#41;&#59; and admission concentrations of serum urea &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;000&#41;&#44; creatinine &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41;&#44; cystatin C &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;014&#41;&#44; and NT-proBNP &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;000&#41;&#46; There were no significant differences related to EF phenotype&#46; In terms of comorbidities&#44; only CKD &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;005&#41; and anemia &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;038&#41; were associated with death&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The mortality rate differed greatly according to whether AKI was developed or not&#46; Among the 58 patients with AKI&#44; the cumulative mortality rate was 15&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41; from admission to the first month following discharge &#40;all cases were due to HF&#41; and reached 44&#46;8&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41; at 12 months&#46; On the contrary&#44; in patients without AKI&#44; the mortality rates were 5&#46;5&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41; and 15&#46;5&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41; for the same follow-up periods &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0019 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;000&#44; respectively&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">It should be underscored that the mortality rates in all periods studied differed according to the equation used to define AKI&#46; Specifically&#44; 14&#37; vs&#46; 22&#46;9&#37; at one month of discharge and 44&#37; vs&#46; 54&#46;3&#37; at one year if the AKIN or RIFLE criteria were used&#44; respectively&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Small increases in creatinine concentration&#8212;on the order of just 20&#37; or 0&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#8212;during hospitalization were associated with lower long-term survival &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;033 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;019 for relative and absolute increases in creatinine&#44; respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#59; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">Variations in creatinine over a longer period of time&#44; i&#46;e&#46; between the baseline concentrations three months before admission and at one month from discharge in the follow-up visit&#44; were also significant&#46; Mortality rose with serum creatinine increases of 10&#37; or greater &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#59; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Regardless of the moment creatinine was measured&#44; all later increases in its concentration were associated with a proportional decrease in survival&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">The multivariate analysis showed that developing AKI was the strongest predictor of death at 12 months&#44; with five times greater risk &#8210;Exp&#40;B&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;34&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#8210;&#46; Other classic markers&#44; such as NT-proBNP&#44; hematocrit&#44; and cystatin C&#44; also continued to be independently correlated with a poor prognosis &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0170" class="elsevierStylePara elsevierViewall">Worsening of renal function is a frequent phenomenon during hospitalization for decompensated HF&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> It was present in a third of our patients and was associated with higher mortality&#46; Nearly half of patients who developed AKI during hospitalization died within a year of discharge&#44; a rate three times higher than among those who did not develop AKI&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">We found an overall mortality rate at one year that was similar to what has been published in other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> with HF being the main cause of mortality in up to 80&#37; of patients&#46; In our series&#44; the development of AKI was the most powerful independent predictor of death&#44; with a 5-fold increase in risk if it was present&#46; The risk factors associated with developing AKI were HF with preserved EF&#44; worse NYHA functional class&#44; and prior CKD&#46; It is well known that a prior reduction in the GFR is a predisposing factor for greater renal function deterioration during episodes of cardiac decompensation&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> It has also been hypothesized that the degree of cardiac and renal stress&#8212;calculated based on natriuretic peptide and uric nitrogen concentrations in the blood&#8212;during acute HF episodes may be more relevant than baseline GFR&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In accordance with this observation&#44; our results demonstrate that patients who developed AKI already presented with higher concentrations of urea&#44; creatinine&#44; and cystatin C at admission&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The incidence of AKI varied depending on the criteria used to define it&#46; Both the RIFLE and AKIN criteria are based on changes in serum creatinine and on diuresis&#46; The AKIN formula&#44; with a shorter interval of time&#44; includes cases in which there is a faster deterioration in renal function&#44; thus omitting cases in which an increase in creatinine occurs later&#46; In our cohort&#44; incidence of AKI ranged from 17&#37; to 24&#46;5&#37; depending on whether the RIFLE or AKIN criteria were used&#44; respectively&#46; This disparity may distort perception of the real risk&#44; leading to an erroneous classification of patients which could result in inadequate treatment or follow-up programs&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The decision to use one set of criteria or the other is of maximum importance&#46; Incidence of AKI was 30&#37; higher when AKIN criteria were used instead of RIFLE criteria&#46; However&#44; mortality was significantly higher among patients diagnosed with AKI using the RIFLE criteria&#46; The lack of a well-established cutoff point for a diagnosis of AKI makes it difficult to determine a precise diagnosis of AKI in the specific context of HF&#44; a premise that has recently been recognized by Kwong and Liu&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Given that the RIFLE criteria require higher elevations of creatinine concentration&#44; but consider a longer period of time&#44; it would be reasonable to expect a higher number of AKI cases detected&#46; On the contrary&#44; the AKIN criteria are less demanding in terms of creatinine concentration&#44; but the period of time needed to reach them is shorter and&#44; in consequence&#44; they would allow for detecting cases in which renal function deterioration was milder but had a more abrupt onset&#46; This apparent contradiction in our results underscores the importance of two factors in determining prognosis in ADHF&#46; First&#44; the intensity of kidney injury and second&#44; the period of time when it occurs&#46; Unfortunately&#44; neither of the two can easily be measured in the clinical setting&#59; at best they can be estimated&#46; Therefore&#44; estimating the prognosis of patients with HF is a very delicate clinical challenge&#46; In the specific context of ADHF&#44; the lack of precision in measuring the intensity of kidney injury and the time that has passed since it was triggered makes it extremely difficult to define it the terms of AKI or WRF&#46; It seems very reasonable to include the time frame in which the changes occurred&#44; as Damman and Testani propose&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> in order to make a correct interpretation&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Other aspects also merit discussion&#46; First&#44; onset of AKI occurred soon after admission in our patients&#46; Indeed&#44; the first blood test performed during the initial care provided in the emergency department already showed a significant difference in serum creatinine levels between patients who would later meet the standard for AKI according to either set of criteria and those who would not &#40;1&#46;50 vs&#46; 1&#46;12<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41;&#46; The differences in creatinine concentrations were maintained during the hospital stay&#46; On the fifth day&#44; creatinine peaked&#44; with a later progressive decline as patients became decongested and dyspnea was relieved&#46; This pattern of changes shows that&#44; among the different physiopathological mechanisms involved in kidney injury&#44; systemic congestion plays a significant role&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;23</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Second&#44; a point of interest is that&#8212;regardless of baseline renal function&#8212;developing AKI may confer a certain degree of functional deterioration&#46; Creatinine levels returned to baseline in 80&#37; of patients who presented with AKI and 96&#37; of patients who did not develop it&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">More important is the fact that a continuous relationship was found between serum creatinine and risk of mortality&#46; There was a linear relationship between the increase in creatinine and a worse prognosis&#44; with no threshold effect&#46; Furthermore&#44; the increase in mortality risk is already significant when there are small increases in creatinine concentrations&#44; even below the threshold that defines AKI&#46; An increase in creatinine of less than 20&#37; or 0&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;mL during hospitalization is associated with nearly double the risk of death within one year&#46; Moreover&#44; each successive increase in creatinine is followed by a significant increase in mortality&#46; This finding clearly calls into question the suitability of the RIFLE or AKIN criteria for defining kidney function deterioration in the specific context of ADHF&#46; A recent study supports the diagnostic significance of an increase in creatinine below the cutoff points proposed by the RIFLE and AKIN criteria&#46; In a study of 12&#44;000 unselected hospitalized patients&#44; Losito et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> found that an increase in creatinine of between 1&#46;2 and 1&#46;5 times the admission value was associated with long-term mortality due to HF and ischemic heart disease&#46; Small increases in creatinine concentrations were especially frequent among patients with HF &#40;36&#37;&#41;&#44; in which a 20&#37; increase above baseline concentration elevated the overall mortality risk by more than 57&#37;&#46; Therefore&#44; as our data show&#44; small increases in creatinine concentration below the threshold of AKI during hospitalization due to HF &#40;increase of 20&#37;&#41; or during the stable phase &#40;increase of 10&#37;&#41; are significant in terms of mortality and must be taken into account when adjusting medications and planning follow-up&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Limitations</span><p id="par0210" class="elsevierStylePara elsevierViewall">Our data were from a study conducted in a single center&#44; which limits the ability to extrapolate them&#46; The sample size was relatively small&#46; As patients with a creatinine clearance below 30<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> were excluded&#44; we cannot assume that our conclusions about the predictive value of small increases in creatinine are equally applicable to other populations&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusions</span><p id="par0215" class="elsevierStylePara elsevierViewall">Deterioration in kidney function during episodes of ADHF is frequent&#44; occurs soon after admission&#44; and is indicative of a worse prognosis&#46; Small increases in creatinine concentration below the currently accepted threshold for defining AKI are associated with significant linear increases in mortality both in ADHF and in outpatients&#46; Therefore&#44; it may be advisable to redefine the currently accepted criteria for the diagnosis of AKI in the specific context of HF&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Financing</span><p id="par0220" class="elsevierStylePara elsevierViewall">This study was funded by a grant &#40;Research Support Program PI12&#47;00694&#41; from the Carlos III Institute of Health &#40;Ministry of Economy and Competitiveness&#41; of Spain&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2019-08-10"
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            0 => "Heart failure"
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            2 => "Acute kidney injury"
            3 => "Renal dysfunction&#46;"
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            0 => "Insuficiencia card&#237;aca"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Diagnosis of acute kidney injury &#40;AKI&#41; during acute decompensations of heart failure &#40;ADHF&#41; remain challenging&#46; We analysed the incidence and prognosis of AKI&#44; and the significance of small increases of creatinine&#44; during ADHF and after stabilization&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patients admitted for ADHF were prospectively included&#46; Creatinine was measured at admission&#44; 48<span class="elsevierStyleHsp" style=""></span>h thereafter and 24<span class="elsevierStyleHsp" style=""></span>h before discharge&#46; AKI was diagnosed when creatinine increased &#8805;50&#37; in seven days &#40;RIFLE criteria&#41; or &#8805; 0&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in 48<span class="elsevierStyleHsp" style=""></span>h &#40;AKIN criteria&#41;&#44; during admission&#46; Changes between baseline creatinine &#40;measured within 3-month before admission&#41; and one month after discharge were assessed&#44; to seek for residual impairment of renal function and its significance&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Two hundred and four patients were included&#46; Incidence of AKI was 28&#46;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&#46; Creatinine peaked by day five in patients with AKI vs&#46; non-AKI &#40;1&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL vs&#46; 1&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;000&#41; and remained significantly higher among patients with AKI three months after discharge &#40;increase of 20&#37; vs&#46; 4&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;013&#41;&#46; Twelve-months mortality was associated with increases in cystatin C&#44; NT-proBNP and AKI &#40;15&#46;5&#37; vs&#46; 44&#46;8&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;000&#41;&#44; being the latter the most powerful independent predictor of death &#91;Exp&#40;B&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;34&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#93;&#46; Minor increases in creatinine &#40;20&#37; or 0&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; during admission&#44; associated lesser 12-months survival &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;033 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;019 respectively&#41;&#46; Increases in creatinine &#8805;10&#37; between baseline and one month after discharge are associated with higher mortality &#40;12&#46;6&#37; vs&#46; 22&#46;5&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;044&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">AKI is a strong predictor of mortality after ADHF&#46; Minor increments in creatinine concentrations&#44; below the accepted threshold for AKI definition&#44; are prognostically meaningful&#46;</p></span>"
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          2 => array:2 [
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">El diagn&#243;stico de da&#241;o renal agudo &#40;DRA&#41; durante los episodios de insuficiencia card&#237;aca aguda &#40;ICA&#41; sigue siendo un desaf&#237;o&#46; Analizamos la incidencia y el pron&#243;stico del DRA&#44; y la importancia de aumentos peque&#241;os de creatinina&#44; durante los episodios de ICA y tras su estabilizaci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron prospectivamente pacientes ingresados &#8203;&#8203;por ICA&#46; La creatinina se midi&#243; al ingreso&#44; a las 48<span class="elsevierStyleHsp" style=""></span>h&#46; de este y 24<span class="elsevierStyleHsp" style=""></span>h&#46; antes del alta&#46; El DRA se diagnostic&#243; cuando la creatinina aument&#243; &#8805;50&#37; en siete d&#237;as &#40;criterio RIFLE&#41; o &#8805; 0&#44;3<span class="elsevierStyleHsp" style=""></span>mg &#47; dL en 48<span class="elsevierStyleHsp" style=""></span>horas &#40;criterio AKIN&#41;&#44; durante el ingreso&#46; Se evaluaron los cambios entre la creatinina basal &#40;medida dentro de los 3 meses previos al ingreso&#41; y un mes despu&#233;s del alta&#44; para buscar el deterioro residual de la funci&#243;n renal y su importancia&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 204 pacientes&#46; La incidencia de DRA fue del 28&#44;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&#46; La creatinina alcanz&#243; su m&#225;xima concentraci&#243;n al quinto d&#237;a en pacientes con DRA vs&#46; no DRA &#40;1&#44;9<span class="elsevierStyleHsp" style=""></span>mg &#47; dL vs&#46; 1&#44;1<span class="elsevierStyleHsp" style=""></span>mg &#47; dL&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;000&#41; y tres meses despu&#233;s del alta permaneci&#243; significativamente m&#225;s alta entre los pacientes con DRA &#40;aumento del 20&#37; vs&#46; 4 &#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;013&#41;&#46; La mortalidad a los doce meses se asoci&#243; con aumentos en la cistatina C&#44; NT-proBNP y la presencia de DRA &#40;15&#44;5&#37; vs&#46; 44&#44;8&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#44; siendo este &#250;ltimo el predictor independiente de muerte m&#225;s potente &#91;Exp &#40;B&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#44;34&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;009&#93;&#46; Aumentos menores de creatinina &#40;20&#37; o 0&#44;2<span class="elsevierStyleHsp" style=""></span>mg &#47; dL&#41;&#44; durante el ingreso&#44; asociaron una menor supervivencia a los 12 meses &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;033 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;019 respectivamente&#41;&#46; Los aumentos de creatinina &#8805;10&#37; entre la basal y un mes despu&#233;s del alta se tambi&#233;n se asociaron con una mayor mortalidad &#40;12&#44;6&#37; vs&#46; 22&#44;5&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;044&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">La presencia de DRA es un potente predictor de mortalidad en las ICA&#46; Peque&#241;os incrementos en las concentraciones de creatinina&#44; por debajo del umbral aceptado para la definici&#243;n de DRA&#44; tienen pron&#243;stico significativo&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Josa-Laorden C&#44; Gim&#233;nez-L&#243;pez I&#44; Rubio-Gracia J&#44; Garc&#233;s Horna V&#44; S&#225;nchez-Marteles M&#44; P&#233;rez-Calvo JI&#46; Importancia pron&#243;stica del da&#241;o renal agudo y de los peque&#241;os aumentos de la concentraci&#243;n de creatinina durante la descompensaci&#243;n aguda de la insuficiencia card&#237;aca&#46; Rev Clin Esp&#46; 2020&#59;220&#58;561&#8211;568&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">CKD-EPI Cyst&#58; Chronic Kidney Disease Epidemiology Collaboration&#44; based on cystatin C&#59; CKD-EPI Creat&#58; Chronic Kidney Disease Epidemiology Collaboration&#44; based on creatinine&#59; MDRD&#58; Modification of Diet in Renal Disease-4 formula&#59; eGFR&#58; estimated glomerular filtration rate&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">eGFR &#40;mL&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CKD-EPI Cyst&#58; Chronic Kidney Disease Epidemiology Collaboration&#44; based on cystatin C&#59; CKD-EPI Creat&#58; Chronic Kidney Disease Epidemiology Collaboration&#44; based on creatinine&#59; SD&#58; standard deviation&#59; AKI&#58; acute kidney injury&#59; LVEF&#58; left ventricle ejection fraction&#59; NT-proBNP&#58; n-terminal fragment of the prohormone brain-type natriuretic peptide&#59; eGFR&#58; estimated glomerular filtration rate&#46;</p>"
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                  \t\t\t\t">106 &#40;56&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Urea &#40;mg&#47;dL&#41;&#44; mean &#40;SD&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;55 &#40;0&#46;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;5 &#40;0&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;7 &#40;0&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Creatinine &#40;mg&#47;dL&#41;&#44; mean &#40;SD&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;1 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;1 &#40;0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;3 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cystatin C &#40;mg&#47;L&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;45 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;4 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;7 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">eGFR CKD-EPI Creat &#40;mL&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#41;&#44; mean &#40;SD&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&#46;8 &#40;32&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;2 &#40;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#46;7 &#40;21&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">eGFR CKD-EPI Cyst &#40;mL&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#41;&#44; mean &#40;SD&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#46;5 &#40;27&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;1 &#40;28&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;3 &#40;15&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">NT-proBNP &#40;pg&#47;mL&#41;&#44; mean &#40;SD&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;306 &#40;5&#44;388&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;142 &#40;5&#44;050&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;262 &#40;5&#44;611&#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">&#46;151&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbidities&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypertension&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">172 &#40;84&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">122 &#40;84&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;84&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;788&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ischemic heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74 &#40;36&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55 &#40;38&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;32&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;468&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Atrial fibrillation&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">118 &#40;57&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87 &#40;60&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;53&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;363&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54 &#40;26&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;22&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;37&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80 &#40;39&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58 &#40;40&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;37&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;758&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anemia&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">39 &#40;19&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;17&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;24&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Congestive signs&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kerley B lines positive on lung ultrasound&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">104 &#40;51&#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">68 &#40;46&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;62&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;046&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Interstitial pulmonary edema&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">147 &#40;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">110 &#40;75&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;58&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Jugular venous distention&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">115 &#40;56&#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">66 &#40;45&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;64&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;025&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hepatomegaly&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">45 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;18&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Relative change &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mortality &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;10 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>10&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">15&#46;3 vs&#46; 22&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;221&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;20 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 vs&#46; 26&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;033&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;30 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>30&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">15&#46;3 vs&#46; 28&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;032&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;40 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;9 vs&#46; 24&#46;8&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">&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;50 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>50&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">16&#46;1 vs&#46; 37&#46;5&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">&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;60 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16&#46;1 vs&#46; 42&#46;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">&#46;002&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Absolute change &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#60;0&#46;10 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;7 vs&#46; 22&#46;7&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">&#46;187&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;15 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;9 vs&#46; 24&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">&#46;121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;20 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;6 vs&#46; 27&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;25 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;6 vs&#46; 30&#46;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">&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;30 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;1 vs&#46; 34&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Increase in creatinine &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mortality &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;10 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;6 vs&#46; 22&#46;5&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">&#46;044&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;20 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;2 vs&#46; 28&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">&#46;027&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;30 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;6 vs&#46; 35&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">&#46;012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;40 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;3 vs&#46; 39&#46;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">&#46;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;50 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;7 vs&#46; 53&#46;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">&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;60 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;9 vs&#46; 71&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2463170.png"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Change in creatinine concentration between baseline value<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> and one month following discharge and mortality&#46;</p>"
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            "identificador" => "at0035"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">AKI&#58; acute kidney injury&#59; Exp&#40;B&#41;&#58; exponent of the B coefficient&#59; LVEF&#58; left ventricular ejection fraction&#59; 95&#37; CI&#58; 95&#37; confidence interval&#59; KBL&#58; Kerley B lines&#59; NT-proBNP&#58; n-terminal fragment of the prohormone brain-type natriuretic peptide&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Mortality at 12 months&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cox regression</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Univariate</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Multivariate</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Exp&#40;B&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Exp&#40;B&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;56&#8722;2&#46;02&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">&#46;863&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;38&#8722;3&#46;06&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">&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital stay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;07&#8722;1&#46;65&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">&#46;010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LVEF &#60;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">1&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;18&#8722;1&#46;72&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">&#46;003&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">&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">&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">History of chronic kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;20&#8722;3&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">KBL positive on lung ultrasound&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">AKI&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">2&#46;04&#8722;6&#46;35&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">&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;52&#8722;18&#46;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2463168.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Multivariate analysis&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:24 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Renal function&#44; neurohormonal activation&#44; and survival in patients with chronic heart failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;L&#46; Hillege"
                            1 => "A&#46;R&#46; Girbes"
                            2 => "P&#46;J&#46; de Kam"
                            3 => "F&#46; Boomsma"
                            4 => "D&#46; de Zeeuw"
                            5 => "A&#46; Charlesworth"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/01.cir.102.2.203"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2000"
                        "volumen" => "102"
                        "paginaInicial" => "203"
                        "paginaFinal" => "210"
                        "link" => array:1 [
                          0 => array:2 [
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Original article
Prognostic significance of acute kidney injury and small increases in creatinine concentration during acute decompensation of heart failure
Importancia pronóstica del daño renal agudo y de los pequeños aumentos de la concentración de creatinina durante la descompensación aguda de la insuficiencia cardíaca
C. Josa-Laordena, I. Giménez-Lópezb, J. Rubio-Graciaa, V. Garcés Hornaa, M. Sánchez-Martelesa, J.I. Pérez-Calvoc,
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jiperez@unizar.es

Corresponding author.
a Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Instituto de Investigación Sanitaria de Aragón (IIS-A), Zaragoza, Spain
b Instituto de Investigación Sanitaria de Aragón (IIS-A), Faculta de Medicina, Universidad de Zaragoza, Zaragoza, Spain
c Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Instituto de Investigación Sanitaria de Aragón (IIS-A), Faculta de Medicina, Universidad de Zaragoza, Zaragoza, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Renal function is a powerful predictor of prognosis in patients with chronic<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and acute<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> heart failure &#40;HF&#41;&#46; In acute decompensated heart failure episodes&#44; a decrease in glomerular filtration rate &#40;GFR&#41; is frequently observed&#44; which confers a worse prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> The definition and diagnostic criteria of acute kidney injury &#40;AKI&#41; and worsening renal function &#40;WRF&#41; are subject to debate&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Some experts believe that the period of time it takes for creatinine concentrations to increase must be taken into account in order to classify it as AKI or WRF&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> When creatinine increases above certain limits soon before or during hospitalization&#44; the term used to define this scenario is AKI&#46; On the contrary&#44; when the increase in more prolonged&#8212;over weeks or months&#8212;and occurs in patients with chronic HF&#44; it is more appropriate to call it WRF&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Currently&#44; there are two sets of criteria used to define AKI&#46; The <span class="elsevierStyleItalic">Risk&#44; Injury&#44; Failure&#44; Loss</span>&#44; <span class="elsevierStyleItalic">End-stage</span> &#40;RIFLE&#41; functional criteria<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> evaluate changes in serum creatinine and&#47;or diuresis&#46; The RIFLE criteria include a decrease in GFR &#40;&#62;50&#37;&#41;&#44; a relative increase in serum creatinine with respect to baseline levels &#40;&#62;50&#37;&#41;&#44; and an absolute reduction in diuresis &#40;&#60;0&#46;5<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;hour for more than six hours&#41; for seven days&#46; The Acute Kidney Injury Network &#40;AKIN&#41; criteria<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> arose as an adaptation of the RIFLE criteria due to evidence that small increases in serum creatinine concentrations greater than 26<span class="elsevierStyleHsp" style=""></span>mmol&#47;L &#40;0&#46;29<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; during the first 48<span class="elsevierStyleHsp" style=""></span>h of hospitalization have been associated with an 80&#37; increase in mortality&#46; However&#44; both sets of criteria are mostly based on studies specifically on kidney injury &#40;for example&#44; contrast toxicity or surgical bypass&#41; in which the intensity of the aggression and&#44; especially&#44; the moment when it begins are easily recognizable&#44; which simplifies diagnosis of AKI&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In the specific context of HF&#44; these two aspects are neither explicit nor measurable&#44; which explains why the outcomes of studies on the incidence or prognostic impact of AKI are more heterogeneous and not always definitive&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;9&#44;10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Some studies show that in the specific context of decompensated HF&#44; the relationship between renal function and prognosis is more complex than previously thought&#46; It has been found that small increases in creatinine concentration during hospitalization for any cause can affect long-term prognosis&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> that small variations &#40;trajectories&#41; in creatinine in the short-term during hospitalization for HF are associated with differences in risk of death&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and that the role and prognostic data provided by renal function differ among subjects in the community and patients hospitalized for HF&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this study&#44; we aimed to analyze the validity of the AKIN and RIFLE criteria for the diagnosis of AKI in the specific context of patients hospitalized for HF&#44; the relationship of the criteria to prognosis&#44; and the significance of small increases in creatinine concentration and its residual elevation following discharge&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0025" class="elsevierStylePara elsevierViewall">Between February 2013 and December 2014&#44; 204 patients who were consecutively admitted to the Internal Medicine Department of a tertiary university hospital for acute decompensated heart failure &#40;ADHF&#41; were selected&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The inclusion criteria were&#58; 1&#41; patients admitted with a diagnosis of ADHF &#40;defined as rapid or gradual onset of the signs and symptoms of HF leading to an unplanned hospitalization&#41;&#59; 2&#41; patients over 18 years of age&#59; 3&#41; dyspnea and presence of the Framingham criteria&#59;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> 4&#41; an N-amino terminal fragment of the prohormone B-type natriuretic peptide &#40;NT-proBNP&#41; level over 300<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#59; and 5&#41; clinical signs and x-ray findings compatible with a diagnosis of HF&#46; Patients with either new-onset ADHF or acute decompensation of chronic HF were eligible for inclusion&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The exclusion criteria were&#58; 1&#41; patients who did not wish to participate in the study&#59; 2&#41; patients with stage 4&#8211;5 chronic kidney disease &#40;CKD&#41;&#59; 3&#41; patients with cardiogenic shock&#59; 4&#41; need for inotropic agents during the hospitalization&#59; 5&#41; patients with a life expectancy of less than three months&#59; 6&#41; advanced dementia&#59; and 7&#41; allergy or intolerance to diuretics&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Laboratory measurements</span><p id="par0040" class="elsevierStylePara elsevierViewall">During the first two hours after the initial evaluation in the Emergency Department&#44; a blood test was performed that included urea&#44; creatinine&#44; and electrolytes&#46; Then&#44; another blood test was performed during the first 48<span class="elsevierStyleHsp" style=""></span>h from admission and again 24<span class="elsevierStyleHsp" style=""></span>h prior to discharge&#46; It included urea&#44; creatinine&#44; cystatin C&#44; and NT-proBNP &#40;Elecsys&#174;&#44; Roche Diagnostics GmbH&#44; Mannheim&#44; Germany&#41;&#46; Other additional blood tests were performed during the hospitalization as per the judgment of the attending physician&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The estimated glomerular filtration rate &#40;eGFR&#41; was calculated using equations based on creatinine&#58; Modification of Diet in Renal Disease-4 &#40;MDRD-4&#41; and Chronic Kidney Disease Epidemiology Collaboration &#40;CKD-EPI&#41;&#44; including cystatin C concentrations as well&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">AKI was diagnosed when serum creatinine levels increased at least 50&#37; above baseline in seven days &#40;RIFLE criteria&#41; or increased &#62;0&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in 48<span class="elsevierStyleHsp" style=""></span>h &#40;AKIN criteria&#41;&#44; both during the hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Pursuant to the criteria proposed by Sheerin et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> we also compared baseline serum creatinine &#40;measured within the three months prior to the ADHF episode&#41; with its concentration one month after discharge in order to search for potential residual worsening in renal function after the ADHF episode&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The relationship between changes in creatinine concentration and the appearance of end points was also analyzed&#46; The primary endpoints were all-cause mortality and mortality due to HF that occurred during follow-up&#46; Two periods of time were considered in order to observe creatinine variations during the hospitalization and&#44; secondly&#44; changes in creatinine values between the last available record in the three months prior to admission and the first visit one month after discharge&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Follow-up</span><p id="par0065" class="elsevierStylePara elsevierViewall">Patient follow-up took place in a specialized HF clinic and lasted 12 months&#46; All patients had an appointment scheduled for one month after discharge&#46; At that time&#44; another blood test was performed&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">An echocardiogram was performed on all patients prior to discharge from the hospital or in the first outpatient visit&#46; In patients who were readmitted&#44; the discharge summaries were carefully reviewed in order to identify causes of the readmission&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">Descriptive statistics&#58; the distribution frequency of qualitative variables was calculated for each category&#46; Quantitative variables were analyzed for normal distribution using the Kolmogorov-Smirnov test&#46; In terms of normality&#44; indicators of central tendency &#40;mean or median&#41; and dispersion &#40;standard deviation or interquartile range&#41; were determined&#46; A two-tailed <span class="elsevierStyleItalic">p</span> value of &#46;05 was considered statistically significant&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Comparisons were made using a contrast hypothesis&#44; comparing the percentages of qualitative variables &#40;chi-square test&#44; Fisher&#8217;s exact test&#41; or using a comparison of means of quantitative variables &#40;Student&#8217;s <span class="elsevierStyleItalic">t</span>-test or ANOVA&#41;&#46; The Mann-Whitney U test or the Kruskal-Wallis test were used for comparisons between groups when distribution was not normal&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The analysis was completed with a linear regression model &#40;for continuous variables&#41; or a logistic regression model &#40;for categorical variables&#41;&#46; To evaluate cumulative survival&#44; the Kaplan-Meier method was used without events with a log-rank test at 12 months of follow-up&#46; The all-cause total mortality and 12-month mortality study was carried out using a multivariate Cox regression model&#46; Once the initially identified predictors of all-cause mortality were corrected&#44; the multivariate-adjusted hazard ratios for mortality were calculated in terms of exponentiation of the B coefficient &#40;Exp&#40;B&#41;&#41; and odds ratio &#40;OR&#41;&#46; Variables regarding the candidate were selected based on clinical relevance and the available literature and included&#58; age&#44; sex&#44; length of hospital stay&#44; ejection fraction &#40;EF&#41;&#44; plasma urea and creatinine&#44; NT-proBNP&#44; cystatin C&#44; and well-known risk factors &#40;hypertension&#44; ischemia&#44; cardiomyopathy&#44; diabetes mellitus&#44; CKD&#44; and anemia&#41;&#46; Variables that were not normal were included in the multivariate regression expressed in logarithmic form &#40;Ln&#41;&#46; The analysis was carried out using the SPSS&#174; statistical software package&#44; version 22&#46;0 &#40;IBM&#44; Chicago&#44; Illinois&#44; USA&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical considerations</span><p id="par0090" class="elsevierStylePara elsevierViewall">All patients who agreed to participate in the study signed an informed consent form&#46; The study was approved by the Clinical Research Ethics Committee of Arag&#243;n &#40;PI13&#47;0019&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">A total of 204 patients were included&#46; The mean age was 81 years &#40;interquartile range &#40;IQR&#41; 76&#8211;85 years&#41;&#44; 50&#46;5&#37; were men&#44; and the mean hospital stay was eight days &#40;IQR 7&#8211;14 days&#41;&#46; The most frequent etiology of HF was hypertensive cardiomyopathy &#40;39&#46;2&#37;&#41;&#44; followed by ischemic heart disease &#40;28&#46;9&#37;&#41;&#46; The baseline NYHA functional class prior to admission was i or ii in 172 patients &#40;83&#46;7&#37;&#41;&#46; No patients in class iv were included&#46; At admission&#44; 93&#37; of patients were taking loop diuretics&#44; 76&#46;5&#37; an angiotensin-converting enzyme inhibitors or angiotensin receptor blockers&#44; 56&#46;3&#37; a beta blocker&#44; 33&#46;7&#37; antimineralocorticoids&#44; and 63&#46;5&#37; anticoagulant therapy&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The most frequent comorbidities were hypertension &#40;84&#46;3&#37;&#41;&#44; atrial fibrillation &#40;57&#46;8&#37;&#41;&#44; type 2 diabetes mellitus &#40;39&#46;6&#37;&#41;&#44; ischemic heart disease &#40;36&#46;6&#37;&#41;&#44; anemia &#40;19&#46;3&#37;&#41;&#44; and chronic obstructive pulmonary disease &#40;18&#46;8&#37;&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">One hundred six patients &#40;57&#37;&#41; had HF with preserved ejection fraction &#40;EF&#41; &#40;EF<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>50&#37;&#41;&#44; 19&#46;3&#37; had HF with an intermediate EF &#40;EF 40-49&#37;&#41;&#44; and 24&#46;1&#37; had HF with diminished EF &#40;EF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40&#37;&#41;&#46; Systolic pulmonary artery pressure above 30<span class="elsevierStyleHsp" style=""></span>mmHg was found in 77&#37; of patients&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Renal function evaluation</span><p id="par0110" class="elsevierStylePara elsevierViewall">Fifty-four patients &#40;26&#46;7&#37;&#41; had a history of CKD on their medical record&#46; However&#44; 50-80&#37; &#40;depending on the formula used&#41; presented with an eGFR below 60<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> during hospitalization &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Compared to equations based on cystatin C&#44; the creatinine-based MDRD-4 overestimated eGFR&#46; Approximately 30&#37; more patients had a creatinine clearance level above 60<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> when GFR was estimated using the creatinine-based MDRD-4 formula&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The development of AKI during hospitalization was determined according to the RIFLE or the AKIN criteria&#46; Incidence of AKI was 17&#46;2&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>35&#41; or 24&#46;5&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41; according to the RIFLE and AKIN criteria&#44; respectively&#46; As per the most recent KDIGO guidelines and according to whether patients met at least one of the two sets of criteria&#44; we considered the incidence of AKI during hospitalization to be 28&#46;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&#46; In order to define the characteristics related to kidney function deterioration with greater precision&#44; the demographic characteristics and comorbidities of two groups were analyzed&#58; those who developed AKI during hospitalization and those who did not &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">A timeline of serum creatinine changes during hospitalization was also recorded&#46; Mean baseline creatinine in the entire sample was 1&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Creatinine concentration at admission to the emergency department was already higher &#40;1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; among patients who would later develop AKI during hospitalization compared to those who would not &#40;1&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;000&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Serum creatinine concentrations peaked on the fifth day of hospitalization&#44; reaching a concentration of 1&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL among patients with AKI&#44; whereas patients without AKI maintained their baseline values &#40;1&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;000&#41;&#46; Creatinine concentrations during hospitalization correlated with the measurements taken in the follow-up visit one month following discharge&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Using the last creatinine concentration measured during the 3 months prior to admission as a reference&#44; patients who did not develop AKI during hospitalization had a 4&#37; increase in creatinine levels one month after discharge &#40;mean increase of 0&#46;068<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; whereas those who presented with AKI in the hospital had increases of up to 20&#37; during the same time period &#40;mean increase of 0&#46;247&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;013&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Mortality</span><p id="par0135" class="elsevierStylePara elsevierViewall">Ten patients &#40;5&#37;&#41; died during hospitalization &#40;70&#37; due to HF&#41;&#46; During follow-up&#44; six more patients died &#40;cumulative mortality of 8&#37;&#41; in the first month following discharge&#46; At the end of the 12 months of follow-up&#44; mortality was 23&#46;5&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>48&#59; 81&#37; due to HF&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Mortality was associated with age &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#59; length of hospital stay &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;027&#41;&#59; and admission concentrations of serum urea &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;000&#41;&#44; creatinine &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41;&#44; cystatin C &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;014&#41;&#44; and NT-proBNP &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;000&#41;&#46; There were no significant differences related to EF phenotype&#46; In terms of comorbidities&#44; only CKD &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;005&#41; and anemia &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;038&#41; were associated with death&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The mortality rate differed greatly according to whether AKI was developed or not&#46; Among the 58 patients with AKI&#44; the cumulative mortality rate was 15&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41; from admission to the first month following discharge &#40;all cases were due to HF&#41; and reached 44&#46;8&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41; at 12 months&#46; On the contrary&#44; in patients without AKI&#44; the mortality rates were 5&#46;5&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41; and 15&#46;5&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41; for the same follow-up periods &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0019 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;000&#44; respectively&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">It should be underscored that the mortality rates in all periods studied differed according to the equation used to define AKI&#46; Specifically&#44; 14&#37; vs&#46; 22&#46;9&#37; at one month of discharge and 44&#37; vs&#46; 54&#46;3&#37; at one year if the AKIN or RIFLE criteria were used&#44; respectively&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Small increases in creatinine concentration&#8212;on the order of just 20&#37; or 0&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#8212;during hospitalization were associated with lower long-term survival &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;033 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;019 for relative and absolute increases in creatinine&#44; respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#59; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">Variations in creatinine over a longer period of time&#44; i&#46;e&#46; between the baseline concentrations three months before admission and at one month from discharge in the follow-up visit&#44; were also significant&#46; Mortality rose with serum creatinine increases of 10&#37; or greater &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#59; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Regardless of the moment creatinine was measured&#44; all later increases in its concentration were associated with a proportional decrease in survival&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">The multivariate analysis showed that developing AKI was the strongest predictor of death at 12 months&#44; with five times greater risk &#8210;Exp&#40;B&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;34&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#8210;&#46; Other classic markers&#44; such as NT-proBNP&#44; hematocrit&#44; and cystatin C&#44; also continued to be independently correlated with a poor prognosis &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0170" class="elsevierStylePara elsevierViewall">Worsening of renal function is a frequent phenomenon during hospitalization for decompensated HF&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> It was present in a third of our patients and was associated with higher mortality&#46; Nearly half of patients who developed AKI during hospitalization died within a year of discharge&#44; a rate three times higher than among those who did not develop AKI&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">We found an overall mortality rate at one year that was similar to what has been published in other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> with HF being the main cause of mortality in up to 80&#37; of patients&#46; In our series&#44; the development of AKI was the most powerful independent predictor of death&#44; with a 5-fold increase in risk if it was present&#46; The risk factors associated with developing AKI were HF with preserved EF&#44; worse NYHA functional class&#44; and prior CKD&#46; It is well known that a prior reduction in the GFR is a predisposing factor for greater renal function deterioration during episodes of cardiac decompensation&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> It has also been hypothesized that the degree of cardiac and renal stress&#8212;calculated based on natriuretic peptide and uric nitrogen concentrations in the blood&#8212;during acute HF episodes may be more relevant than baseline GFR&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In accordance with this observation&#44; our results demonstrate that patients who developed AKI already presented with higher concentrations of urea&#44; creatinine&#44; and cystatin C at admission&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The incidence of AKI varied depending on the criteria used to define it&#46; Both the RIFLE and AKIN criteria are based on changes in serum creatinine and on diuresis&#46; The AKIN formula&#44; with a shorter interval of time&#44; includes cases in which there is a faster deterioration in renal function&#44; thus omitting cases in which an increase in creatinine occurs later&#46; In our cohort&#44; incidence of AKI ranged from 17&#37; to 24&#46;5&#37; depending on whether the RIFLE or AKIN criteria were used&#44; respectively&#46; This disparity may distort perception of the real risk&#44; leading to an erroneous classification of patients which could result in inadequate treatment or follow-up programs&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The decision to use one set of criteria or the other is of maximum importance&#46; Incidence of AKI was 30&#37; higher when AKIN criteria were used instead of RIFLE criteria&#46; However&#44; mortality was significantly higher among patients diagnosed with AKI using the RIFLE criteria&#46; The lack of a well-established cutoff point for a diagnosis of AKI makes it difficult to determine a precise diagnosis of AKI in the specific context of HF&#44; a premise that has recently been recognized by Kwong and Liu&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Given that the RIFLE criteria require higher elevations of creatinine concentration&#44; but consider a longer period of time&#44; it would be reasonable to expect a higher number of AKI cases detected&#46; On the contrary&#44; the AKIN criteria are less demanding in terms of creatinine concentration&#44; but the period of time needed to reach them is shorter and&#44; in consequence&#44; they would allow for detecting cases in which renal function deterioration was milder but had a more abrupt onset&#46; This apparent contradiction in our results underscores the importance of two factors in determining prognosis in ADHF&#46; First&#44; the intensity of kidney injury and second&#44; the period of time when it occurs&#46; Unfortunately&#44; neither of the two can easily be measured in the clinical setting&#59; at best they can be estimated&#46; Therefore&#44; estimating the prognosis of patients with HF is a very delicate clinical challenge&#46; In the specific context of ADHF&#44; the lack of precision in measuring the intensity of kidney injury and the time that has passed since it was triggered makes it extremely difficult to define it the terms of AKI or WRF&#46; It seems very reasonable to include the time frame in which the changes occurred&#44; as Damman and Testani propose&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> in order to make a correct interpretation&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Other aspects also merit discussion&#46; First&#44; onset of AKI occurred soon after admission in our patients&#46; Indeed&#44; the first blood test performed during the initial care provided in the emergency department already showed a significant difference in serum creatinine levels between patients who would later meet the standard for AKI according to either set of criteria and those who would not &#40;1&#46;50 vs&#46; 1&#46;12<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41;&#46; The differences in creatinine concentrations were maintained during the hospital stay&#46; On the fifth day&#44; creatinine peaked&#44; with a later progressive decline as patients became decongested and dyspnea was relieved&#46; This pattern of changes shows that&#44; among the different physiopathological mechanisms involved in kidney injury&#44; systemic congestion plays a significant role&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;23</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Second&#44; a point of interest is that&#8212;regardless of baseline renal function&#8212;developing AKI may confer a certain degree of functional deterioration&#46; Creatinine levels returned to baseline in 80&#37; of patients who presented with AKI and 96&#37; of patients who did not develop it&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">More important is the fact that a continuous relationship was found between serum creatinine and risk of mortality&#46; There was a linear relationship between the increase in creatinine and a worse prognosis&#44; with no threshold effect&#46; Furthermore&#44; the increase in mortality risk is already significant when there are small increases in creatinine concentrations&#44; even below the threshold that defines AKI&#46; An increase in creatinine of less than 20&#37; or 0&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;mL during hospitalization is associated with nearly double the risk of death within one year&#46; Moreover&#44; each successive increase in creatinine is followed by a significant increase in mortality&#46; This finding clearly calls into question the suitability of the RIFLE or AKIN criteria for defining kidney function deterioration in the specific context of ADHF&#46; A recent study supports the diagnostic significance of an increase in creatinine below the cutoff points proposed by the RIFLE and AKIN criteria&#46; In a study of 12&#44;000 unselected hospitalized patients&#44; Losito et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> found that an increase in creatinine of between 1&#46;2 and 1&#46;5 times the admission value was associated with long-term mortality due to HF and ischemic heart disease&#46; Small increases in creatinine concentrations were especially frequent among patients with HF &#40;36&#37;&#41;&#44; in which a 20&#37; increase above baseline concentration elevated the overall mortality risk by more than 57&#37;&#46; Therefore&#44; as our data show&#44; small increases in creatinine concentration below the threshold of AKI during hospitalization due to HF &#40;increase of 20&#37;&#41; or during the stable phase &#40;increase of 10&#37;&#41; are significant in terms of mortality and must be taken into account when adjusting medications and planning follow-up&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Limitations</span><p id="par0210" class="elsevierStylePara elsevierViewall">Our data were from a study conducted in a single center&#44; which limits the ability to extrapolate them&#46; The sample size was relatively small&#46; As patients with a creatinine clearance below 30<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> were excluded&#44; we cannot assume that our conclusions about the predictive value of small increases in creatinine are equally applicable to other populations&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusions</span><p id="par0215" class="elsevierStylePara elsevierViewall">Deterioration in kidney function during episodes of ADHF is frequent&#44; occurs soon after admission&#44; and is indicative of a worse prognosis&#46; Small increases in creatinine concentration below the currently accepted threshold for defining AKI are associated with significant linear increases in mortality both in ADHF and in outpatients&#46; Therefore&#44; it may be advisable to redefine the currently accepted criteria for the diagnosis of AKI in the specific context of HF&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Financing</span><p id="par0220" class="elsevierStylePara elsevierViewall">This study was funded by a grant &#40;Research Support Program PI12&#47;00694&#41; from the Carlos III Institute of Health &#40;Ministry of Economy and Competitiveness&#41; of Spain&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Diagnosis of acute kidney injury &#40;AKI&#41; during acute decompensations of heart failure &#40;ADHF&#41; remain challenging&#46; We analysed the incidence and prognosis of AKI&#44; and the significance of small increases of creatinine&#44; during ADHF and after stabilization&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patients admitted for ADHF were prospectively included&#46; Creatinine was measured at admission&#44; 48<span class="elsevierStyleHsp" style=""></span>h thereafter and 24<span class="elsevierStyleHsp" style=""></span>h before discharge&#46; AKI was diagnosed when creatinine increased &#8805;50&#37; in seven days &#40;RIFLE criteria&#41; or &#8805; 0&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in 48<span class="elsevierStyleHsp" style=""></span>h &#40;AKIN criteria&#41;&#44; during admission&#46; Changes between baseline creatinine &#40;measured within 3-month before admission&#41; and one month after discharge were assessed&#44; to seek for residual impairment of renal function and its significance&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Two hundred and four patients were included&#46; Incidence of AKI was 28&#46;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&#46; Creatinine peaked by day five in patients with AKI vs&#46; non-AKI &#40;1&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL vs&#46; 1&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;000&#41; and remained significantly higher among patients with AKI three months after discharge &#40;increase of 20&#37; vs&#46; 4&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;013&#41;&#46; Twelve-months mortality was associated with increases in cystatin C&#44; NT-proBNP and AKI &#40;15&#46;5&#37; vs&#46; 44&#46;8&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;000&#41;&#44; being the latter the most powerful independent predictor of death &#91;Exp&#40;B&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;34&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#93;&#46; Minor increases in creatinine &#40;20&#37; or 0&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; during admission&#44; associated lesser 12-months survival &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;033 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;019 respectively&#41;&#46; Increases in creatinine &#8805;10&#37; between baseline and one month after discharge are associated with higher mortality &#40;12&#46;6&#37; vs&#46; 22&#46;5&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;044&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">AKI is a strong predictor of mortality after ADHF&#46; Minor increments in creatinine concentrations&#44; below the accepted threshold for AKI definition&#44; are prognostically meaningful&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">El diagn&#243;stico de da&#241;o renal agudo &#40;DRA&#41; durante los episodios de insuficiencia card&#237;aca aguda &#40;ICA&#41; sigue siendo un desaf&#237;o&#46; Analizamos la incidencia y el pron&#243;stico del DRA&#44; y la importancia de aumentos peque&#241;os de creatinina&#44; durante los episodios de ICA y tras su estabilizaci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron prospectivamente pacientes ingresados &#8203;&#8203;por ICA&#46; La creatinina se midi&#243; al ingreso&#44; a las 48<span class="elsevierStyleHsp" style=""></span>h&#46; de este y 24<span class="elsevierStyleHsp" style=""></span>h&#46; antes del alta&#46; El DRA se diagnostic&#243; cuando la creatinina aument&#243; &#8805;50&#37; en siete d&#237;as &#40;criterio RIFLE&#41; o &#8805; 0&#44;3<span class="elsevierStyleHsp" style=""></span>mg &#47; dL en 48<span class="elsevierStyleHsp" style=""></span>horas &#40;criterio AKIN&#41;&#44; durante el ingreso&#46; Se evaluaron los cambios entre la creatinina basal &#40;medida dentro de los 3 meses previos al ingreso&#41; y un mes despu&#233;s del alta&#44; para buscar el deterioro residual de la funci&#243;n renal y su importancia&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 204 pacientes&#46; La incidencia de DRA fue del 28&#44;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&#46; La creatinina alcanz&#243; su m&#225;xima concentraci&#243;n al quinto d&#237;a en pacientes con DRA vs&#46; no DRA &#40;1&#44;9<span class="elsevierStyleHsp" style=""></span>mg &#47; dL vs&#46; 1&#44;1<span class="elsevierStyleHsp" style=""></span>mg &#47; dL&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;000&#41; y tres meses despu&#233;s del alta permaneci&#243; significativamente m&#225;s alta entre los pacientes con DRA &#40;aumento del 20&#37; vs&#46; 4 &#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;013&#41;&#46; La mortalidad a los doce meses se asoci&#243; con aumentos en la cistatina C&#44; NT-proBNP y la presencia de DRA &#40;15&#44;5&#37; vs&#46; 44&#44;8&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#44; siendo este &#250;ltimo el predictor independiente de muerte m&#225;s potente &#91;Exp &#40;B&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#44;34&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;009&#93;&#46; Aumentos menores de creatinina &#40;20&#37; o 0&#44;2<span class="elsevierStyleHsp" style=""></span>mg &#47; dL&#41;&#44; durante el ingreso&#44; asociaron una menor supervivencia a los 12 meses &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;033 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;019 respectivamente&#41;&#46; Los aumentos de creatinina &#8805;10&#37; entre la basal y un mes despu&#233;s del alta se tambi&#233;n se asociaron con una mayor mortalidad &#40;12&#44;6&#37; vs&#46; 22&#44;5&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;044&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">La presencia de DRA es un potente predictor de mortalidad en las ICA&#46; Peque&#241;os incrementos en las concentraciones de creatinina&#44; por debajo del umbral aceptado para la definici&#243;n de DRA&#44; tienen pron&#243;stico significativo&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Antecedentes"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Pacientes y m&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Josa-Laorden C&#44; Gim&#233;nez-L&#243;pez I&#44; Rubio-Gracia J&#44; Garc&#233;s Horna V&#44; S&#225;nchez-Marteles M&#44; P&#233;rez-Calvo JI&#46; Importancia pron&#243;stica del da&#241;o renal agudo y de los peque&#241;os aumentos de la concentraci&#243;n de creatinina durante la descompensaci&#243;n aguda de la insuficiencia card&#237;aca&#46; Rev Clin Esp&#46; 2020&#59;220&#58;561&#8211;568&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mortality according to the relative increase in creatinine concentration during hospitalization&#46; The results are expressed in percentages&#46;</p>"
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        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Mortality according to the relative increase in creatinine concentration between baseline and at one month following discharge &#40;see text&#41;&#46; The results are expressed in percentages&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">CKD-EPI Cyst&#58; Chronic Kidney Disease Epidemiology Collaboration&#44; based on cystatin C&#59; CKD-EPI Creat&#58; Chronic Kidney Disease Epidemiology Collaboration&#44; based on creatinine&#59; MDRD&#58; Modification of Diet in Renal Disease-4 formula&#59; eGFR&#58; estimated glomerular filtration rate&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estimated glomerular filtration rate according to the equation used&#46;</p>"
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      3 => array:8 [
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CKD-EPI Cyst&#58; Chronic Kidney Disease Epidemiology Collaboration&#44; based on cystatin C&#59; CKD-EPI Creat&#58; Chronic Kidney Disease Epidemiology Collaboration&#44; based on creatinine&#59; SD&#58; standard deviation&#59; AKI&#58; acute kidney injury&#59; LVEF&#58; left ventricle ejection fraction&#59; NT-proBNP&#58; n-terminal fragment of the prohormone brain-type natriuretic peptide&#59; eGFR&#58; estimated glomerular filtration rate&#46;</p>"
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                  \t\t\t\t">&#46;690&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">82 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;324&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;007&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">106 &#40;56&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">72 &#40;52&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">34 &#40;66&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Creatinine &#40;mg&#47;dL&#41;&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;1 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;1 &#40;0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">eGFR CKD-EPI Creat &#40;mL&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#41;&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">eGFR CKD-EPI Cyst &#40;mL&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#41;&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">45&#46;1 &#40;28&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">NT-proBNP &#40;pg&#47;mL&#41;&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypertension&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">172 &#40;84&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">122 &#40;84&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;84&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;788&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ischemic heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74 &#40;36&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55 &#40;38&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;32&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;468&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Atrial fibrillation&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">118 &#40;57&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87 &#40;60&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;53&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;363&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54 &#40;26&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;22&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;37&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80 &#40;39&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58 &#40;40&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;37&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;758&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anemia&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">39 &#40;19&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;17&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;24&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Congestive signs&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kerley B lines positive on lung ultrasound&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">104 &#40;51&#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">68 &#40;46&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;62&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;046&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Interstitial pulmonary edema&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">147 &#40;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">110 &#40;75&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;58&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Jugular venous distention&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">115 &#40;56&#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">66 &#40;45&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;64&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;025&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hepatomegaly&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">45 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;18&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;019&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Relative change &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#46;221&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#60;20 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>20&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">14 vs&#46; 26&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;033&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15&#46;3 vs&#46; 28&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;9 vs&#46; 24&#46;8&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">&#46;003&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;50 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>50&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">16&#46;1 vs&#46; 37&#46;5&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">&#46;006&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;60 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>60&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">16&#46;1 vs&#46; 42&#46;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">&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Absolute change &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;7 vs&#46; 22&#46;7&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">&#46;187&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;15 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;9 vs&#46; 24&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">&#46;121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;20 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;6 vs&#46; 27&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;019&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;6 vs&#46; 30&#46;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">&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#60;0&#46;30 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;1 vs&#46; 34&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#46;000&nbsp;\t\t\t\t\t\t\n
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                0 => """
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                  \t\t\t\t">12&#46;6 vs&#46; 22&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;044&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;20 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;2 vs&#46; 28&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">&#46;027&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;30 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;6 vs&#46; 35&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">&#46;012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;40 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;3 vs&#46; 39&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;50 vs&#46;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;7 vs&#46; 53&#46;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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;9 vs&#46; 71&#46;4&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">&#46;001&nbsp;\t\t\t\t\t\t\n
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Change in creatinine concentration between baseline value<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> and one month following discharge and mortality&#46;</p>"
        ]
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">AKI&#58; acute kidney injury&#59; Exp&#40;B&#41;&#58; exponent of the B coefficient&#59; LVEF&#58; left ventricular ejection fraction&#59; 95&#37; CI&#58; 95&#37; confidence interval&#59; KBL&#58; Kerley B lines&#59; NT-proBNP&#58; n-terminal fragment of the prohormone brain-type natriuretic peptide&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Mortality at 12 months&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cox regression</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Univariate</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Multivariate</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Exp&#40;B&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Exp&#40;B&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;56&#8722;2&#46;02&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">&#46;863&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;38&#8722;3&#46;06&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">&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital stay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;07&#8722;1&#46;65&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">&#46;010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LVEF &#60;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">1&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;18&#8722;1&#46;72&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">&#46;003&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">&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">&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">History of chronic kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;20&#8722;3&#46;82&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">&#46;010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic anemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;07&#8722;3&#46;77&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">&#46;028&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;08&#8722;12&#46;88&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">&#46;039&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NT-proBNP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;32&#8722;1&#46;80&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">&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;06&#8722;1&#46;89&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">&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;89&#8722;1&#46;28&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">&#46;484&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">&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">&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Creatinine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;97&#8722;1&#46;52&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">&#46;091&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">&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">&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cystatin C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;08&#8722;1&#46;76&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">&#46;010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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Article information
ISSN: 22548874
Original language: English
DOI:10.1016/j.rceng.2019.11.015
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