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a single-lung transplant recipient 6 years previously due to emphysema&#44; was admitted due to <span class="elsevierStyleItalic">Nocardia</span> myositis that had formed an abscess in his right leg&#46; Initial post-transplant immune suppressive treatment had included tacrolimus&#44; mofetil mycophenolate and corticosteroids&#46; He presented deteriorating renal function&#44; with creatinine levels of 7&#46;92<span class="elsevierStyleHsp" style=""></span>mg&#47;dl compared with baseline admission levels of 3&#46;26<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; He developed anemia&#44; with hemoglobin 7&#46;92<span class="elsevierStyleHsp" style=""></span>g&#47;dl &#40;12&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dl on admission&#41;&#44; and thrombocytopenia 72<span class="elsevierStyleHsp" style=""></span>000&#47;&#956;l&#46; LDH was 794<span class="elsevierStyleHsp" style=""></span>U&#47;l&#46; The myositis abscess was successfully treated&#44; but there was no improvement in renal function&#44; anemia or thrombocytopenia&#44; and schistocytes were detected in peripheral blood&#46; In view of suspected TMA&#44; bone marrow aspirate was obtained&#44; showing predominant erythroid cell series&#44; with fragmented forms suggestive of microangiopathic anemia&#46; Tacrolimus was thought to be the probable cause&#44; so it was switched to everolimus&#46; In subsequent tests&#44; creatinine figures fell to 5&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl in 1 week and returned to baseline in following check-ups&#46; Platelets and hemoglobin levels recovered gradually &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 61-year-old woman&#44; a double-lung transplant recipient 6 months previously for idiopathic pulmonary fibrosis&#44; was admitted due to left lower lobe pneumonia&#44; weakness and deteriorating renal function&#46; Creatinine levels&#44; previously normal&#44; had risen to 2&#46;22<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; The patient also presented anemia 7&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dl &#40;initially 10&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41; and thrombocytopenia 68<span class="elsevierStyleHsp" style=""></span>000&#47;&#956;l&#44; so a platelet transfusion was administered&#44; but the thrombocytopenia could not be permanently reversed&#46; Intensive immunosuppressive therapy continued with tacrolimus&#44; mycophenolate and corticosteroids&#46; During admission&#44; she received antibiotic and antifungal treatment&#46; Radiological improvement was seen&#44; but altered renal function&#44; anemia and LDH of 847<span class="elsevierStyleHsp" style=""></span>U&#47;l persisted&#46; A morphological study of the blood revealed some very isolated schistocytes and low haptoglobin levels&#44; so the calcineurin inhibitor tacrolimus was switched to everolimus&#44; while the other immunosuppressive agents were continued unchanged&#46; This led to a progressive fall in LDH&#44; platelets normalized and creatinine levels fell to 1&#46;35<span class="elsevierStyleHsp" style=""></span>mg&#47;dl within 1 week &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Hemoglobin stabilized at 11&#46;0<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 3</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 21-year-old woman had received a double-lung transplant 4 months previously for cystic fibrosis&#46; She was receiving immunosuppressive therapy with tacrolimus&#44; mofetil mycophenolate and corticosteroids&#46; The patient was admitted with a febrile syndrome and an abscess in the area of the lower jaw&#46; <span class="elsevierStyleItalic">Candida glabrata</span> was isolated from the abscess&#44; but there was no hematogenous spread&#46; Creatinine levels deteriorated&#44; falling to 3&#46;92<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;0&#46;73<span class="elsevierStyleHsp" style=""></span>mg&#47;dl on admission&#41;&#44; hematocrit fell to 22&#46;6&#37; and thrombocytopenia to 18<span class="elsevierStyleHsp" style=""></span>000&#47;&#956;l&#44; causing repeated epistaxis&#46; A platelet transfusion was administered but the situation could not be completely reversed&#46; The abscess was successfully treated&#44; but no improvements were found on clinical laboratory results&#44; with persistent altered renal function&#44; anemia&#44; low-grade fever and low haptoglobin levels&#44; suggestive of hemolysis&#46; Tacrolimus was switched to everolimus&#44; and the dose of corticosteroids was increased&#44; leading to gradual return of creatinine levels to normal &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Hemoglobin rose to 11&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and platelets to 145<span class="elsevierStyleHsp" style=""></span>000&#47;&#956;l&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Tacrolimus is a metabolite extracted from the fungus <span class="elsevierStyleItalic">Streptomyces tsukubaensis</span>&#46; It is a potent immunosuppressive agent widely used in transplant procedures&#46; Tacrolimus-associated TMA is a rare&#44; but potentially fatal&#44; complication in solid organ and bone marrow transplantation&#44; with an estimated incidence of 1&#46;0&#37;&#8211;4&#46;7&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;3</span></a> Early diagnosis is essential for improving treatment outcomes&#44; but is difficult to achieve due to the existence&#44; on occasions&#44; of previous chronic renal failure &#40;CRF&#41; secondary to calcineurin inhibition&#46; A definitive diagnosis is obtained from the renal biopsy finding of thrombi in the glomerular capillary loops&#46; Treatment of drug-associated TMA is not well defined&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Recommendations in the literature are conventionally based on switching the causative medication to sirolimus&#44; everolimus or cyclosporin&#46; If diagnosis is early&#44; effective treatment is available&#44; for example&#44; the antibody eculizumab&#44; or plasmapheresis&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3&#44;4</span></a> No cases of tacrolimus-associated TMA in lung transplant have been published in the Spanish literature&#44; and few have been reported in the international literature&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> However&#44; this entity may be underdiagnosed&#44; and it should be considered in transplant patients receiving calcineurin inhibitors with deteriorating renal function and unexplained anemia&#46; In our opinion&#44; a kidney biopsy can be avoided if schistocytes are observed in peripheral blood along with low serum haptoglobin levels&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of Interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare they have no conflict of interests&#46;</p></span></span>"
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              "identificador" => "abst0005"
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        1 => array:2 [
          "identificador" => "xpalclavsec506934"
          "titulo" => "Keywords"
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          "titulo" => "Resumen"
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              "identificador" => "abst0010"
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        3 => array:2 [
          "identificador" => "xpalclavsec506935"
          "titulo" => "Palabras clave"
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        4 => array:3 [
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          "titulo" => "Presentation"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0010"
              "titulo" => "Case 1"
            ]
            1 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Case 2"
            ]
            2 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Case 3"
            ]
          ]
        ]
        5 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Discussion"
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        6 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Conflict of Interests"
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        7 => array:1 [
          "titulo" => "References"
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      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-05-26"
    "fechaAceptado" => "2014-07-07"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec506934"
          "palabras" => array:4 [
            0 => "Thrombotic microangiopathy"
            1 => "Lung transplantation"
            2 => "Tacrolimus"
            3 => "Hemolytic uremic syndrome"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec506935"
          "palabras" => array:4 [
            0 => "Microangiopat&#237;a tromb&#243;tica"
            1 => "Trasplante pulmonar"
            2 => "Tacrolimus"
            3 => "S&#237;ndrome hemol&#237;tico ur&#233;mico"
          ]
        ]
      ]
    ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Thrombotic microangiopathy &#40;TMA&#41; is a rare complication associated with the use of calcineurin inhibitors in lung transplantation&#44; irrespective of the underlying disease of the graft recipient&#46; It usually occurs in incomplete forms&#44; complicating and delaying diagnosis until damage is already irreversible&#46; It is unrelated to time from transplantation and often presents with concomitant infection&#44; which tends to confound diagnosis&#46; The cases discussed here have a common causative agent and all present with concomitant infection&#46; Treatment recommendations have changed in recent years with the introduction of plasmapheresis or&#44; more recently&#44; the availability of the antibody eculizumab&#46; Notwithstanding&#44; the most cost-effective measure is withdrawal or switching of the calcineurin inhibitor&#46; TMA is an underdiagnosed clinical entity that should be considered in the management of transplantation patients&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La microangiopat&#237;a tromb&#243;tica &#40;MAT&#41; es una complicaci&#243;n infrecuente asociada a los anticalcineur&#237;nicos en el trasplante pulmonar&#44; independiente de la enfermedad de base de los pacientes trasplantados&#46; Habitualmente se presenta como formas incompletas&#44; lo que dificulta el diagn&#243;stico&#44; que suele ser tard&#237;o&#44; provocando irreversibilidad de las lesiones&#46; Es independiente del tiempo de trasplante y en muchos casos existe infecci&#243;n concomitante&#44; lo que tiende a ocultar el diagn&#243;stico&#46; Los casos presentados comparten el agente causal y la presencia de infecci&#243;n concomitante&#46; El tratamiento ha variado en los &#250;ltimos a&#241;os&#44; recomend&#225;ndose la plasmaf&#233;resis o&#44; m&#225;s recientemente&#44; el anticuerpo eculizumab&#46; No obstante&#44; la retirada o cambio del anticalcineur&#237;nico causante es la medida m&#225;s coste-efectiva&#46; La MAT podr&#237;a tratarse de una entidad infradiagnosticada a tener en cuenta en pacientes trasplantados&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Reig Mezquida JP&#44; Sol&#233; Jover A&#44; Ans&#243;tegui Barrera E&#44; Escriv&#225; Peir&#243; J&#44; Pastor Colom MD&#44; Pastor Guillem J&#46; Microangiopat&#237;a tromb&#243;tica asociada a tacrolimus en trasplante pulmonar&#46; Arch Bronconeumol&#46; 2015&#59;51&#58;e23&#8211;e24&#46;</p>"
      ]
    ]
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Creat&#46;&#58; creatinine&#59; Schist&#46; PB&#58; schistocytes in peripheral blood&#59; Hb&#58; hemoglobin&#59; LDH&#58; lactate dehydrogenate&#59; TMA&#58; thrombotic microangiopathy&#59; 1<span class="elsevierStyleHsp" style=""></span>m&#47;post&#58; one month after diagnosis of thrombotic microangiopathy&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial Hb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TMA Hb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hb 1<span class="elsevierStyleHsp" style=""></span>m&#47;post&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Schist&#46; PB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial creat&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TMA creat&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Creat&#46; 1<span class="elsevierStyleHsp" style=""></span>m&#47;post&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial LDH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TMA LDH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LDH 1<span class="elsevierStyleHsp" style=""></span>m&#47;post&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Case 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;26<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;92<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;93<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">389<span class="elsevierStyleHsp" style=""></span>U&#47;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">794<span class="elsevierStyleHsp" style=""></span>U&#47;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">569<span class="elsevierStyleHsp" style=""></span>U&#47;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Case 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11<span class="elsevierStyleHsp" style=""></span>g&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;82<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;22<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;35<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">562<span class="elsevierStyleHsp" style=""></span>U&#47;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">847<span class="elsevierStyleHsp" style=""></span>U&#47;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">568<span class="elsevierStyleHsp" style=""></span>U&#47;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Case 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;0<span class="elsevierStyleHsp" style=""></span>g&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12<span class="elsevierStyleHsp" style=""></span>g&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;73<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;92<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;59<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Summary of Changes in Hemoglobin&#44; Creatinine and LDH in the 3 Cases&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:5 [
            0 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Thrombotic microangiopathies"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Radhi"
                            1 => "S&#46;L&#46; Carpenter"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5402/2012/310596"
                      "Revista" => array:5 [
                        "tituloSerie" => "ISRN Hematol"
                        "fecha" => "2012"
                        "volumen" => "2012"
                        "paginaInicial" => "310596"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22888446"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Thrombotic microangiopathy and associated renal disorders"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "T&#46; Barbour"
                            1 => "S&#46; Johnson"
                            2 => "S&#46; Cohney"
                            3 => "P&#46; Hughes"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/ndt/gfs279"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nephrol Dial Transplant"
                        "fecha" => "2012"
                        "volumen" => "27"
                        "paginaInicial" => "2673"
                        "paginaFinal" => "2685"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22802583"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0040"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
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