Chronic kidney disease is associated with significant physical and psychological impact, requiring an adaptation process by the patient. Peer mentoring has proven effective in managing chronic illnesses. This study aims to assess the impact of a Mentoring programme to improve patient adaptation to advanced chronic kidney disease.
Materials and methodsA mixed-methods (quantitative and qualitative) quasi-experimental, multicentre, hospital-based, non-controlled study was conducted in Spain with patients aged ≥ 18 years suffering from advanced chronic kidney disease. Mentor patients and incident patients in advanced chronic kidney disease units ("mentees") were recruited from 21 hospitals. The impact of the programme was assessed on self-care ability, treatment adherence and compliance, and emotional status of patients through ad-hoc self-report measures and focus groups.
ResultsA total of 142 mentors were trained and 315 mentees participated. Quantitative evaluation showed that most mutual support sessions were held in person (72.8%), with high satisfaction reported with the programme: 96.1% of mentees rated the sessions positively, and 91.1% felt they helped them manage the disease better. Furthermore, 89.4% felt more at ease about the future of their condition, and 79.3% reported reduced sadness. Qualitative analysis highlighted that the programme enhanced disease coping ability, reducing anxiety and increasing decision-making confidence. Mentors reported personal and professional growth, improving their communication and empathy, while mentees experienced reduced anxiety (90%) and increased confidence in managing their condition (85%). An improvement in treatment adherence and compliance, and strengthened relationships between the interdisciplinary team and patients were observed. Areas for improvement included the need for ongoing training for mentors and session flexibility, including the possibility of extending follow-up in cases requiring it.
ConclusionsThe Mentoring programme has a positive impact on patients with advanced chronic kidney disease, improving their coping with the illness, relationships with healthcare professionals, and the humanisation of healthcare in hospital units. Future research with more robust designs is needed to confirm these findings and evaluate the long-term effectiveness of the Mentoring programme, as well as the use of standardised instruments in the assessment.
La enfermedad renal crónica está acompañada de un fuerte impacto físico, así como psicológico, requiriendo un proceso de adaptación por parte del paciente. La mentoría entre pares ha demostrado ser efectiva en el manejo de enfermedades crónicas. Este estudio tiene como objetivo evaluar el impacto de un programa de Mentoring para mejorar la adaptación de los pacientes a la enfermedad renal crónica avanzada.
Materiales y métodosDiseño mixto (cuantitativo y cualitativo) cuasi-experimental multicéntrico de base hospitalaria, no controlado en pacientes ≥ 18 años con enfermedad renal crónica avanzada en España. Se reclutaron pacientes mentores y pacientes incidentes en las Unidades de enfermedad renal crónica avanzada ("mentees") en 21 centros hospitalarios. Se evaluó el impacto del programa en la capacidad de autocuidado, la adhesión al tratamiento y el estado emocional de los pacientes a través de medidas de autoinforme elaboradas ad-hoc y grupos focales.
ResultadosSe formaron 142 mentores y participaron 315 pacientes mentees. La evaluación cuantitativa mostró que la mayoría de las sesiones de apoyo mutuo se realizaron de forma presencial (72,8%) e indicó una alta satisfacción con el programa: el 96,1% de los mentees valoraron positivamente las sesiones, y el 91,1% consideraron que les ayudaron a manejar mejor la enfermedad. Además, el 89,4% se sintieron más tranquilos respecto al futuro de su enfermedad y el 79,3% reportaron menor tristeza. El análisis cualitativo destacó que el programa mejoró la capacidad de afrontamiento de la enfermedad, reduciendo la ansiedad y aumentando la confianza en la toma de decisiones. Los mentores reportaron un crecimiento personal y profesional, mejorando su comunicación y empatía, mientras que los mentees experimentaron una reducción de la ansiedad (90%) y un aumento en la confianza para gestionar la enfermedad (85%). Se observó una mejora en la adhesión al tratamiento y un fortalecimiento de la relación entre el equipo interdisciplinar y pacientes. Se identificaron áreas de mejora como la necesidad de mayor formación continua para mentores y la flexibilidad de las sesiones, incluyendo la posibilidad de prolongar el seguimiento en casos que lo requieran.
ConclusionesEl programa de Mentoring tiene un impacto positivo en los pacientes con enfermedad renal crónica avanzada, mejorando su afrontamiento de la enfermedad, la relación con los profesionales sanitarios, así como la humanización de la atención sanitaria en las unidades hospitalarias. Son necesarias futuras investigaciones con diseños más robustos para confirmar estos hallazgos y evaluar la efectividad del programa de Mentoring a largo plazo, así como el empleo de instrumentos estandarizados en la evaluación.
Chronic kidney disease (CKD) is a public health condition affecting 15% of the Spanish population, one of the highest prevalences in Europe.1,2 This disease generates a wide range of stressful situations for patients and their environment, causing both physical and psychological disorders in patients who must cope with a progressive and incurable condition that limits their daily activities and quality of life.3,4 Previous studies have shown that, in addition to medical treatment, emotional support is essential to improve patients’ adaptation process and reduce the adverse effects of the disease.5 The incorporation of peer support programs, such as Mentoring, emerges as a strategy to improve patient coping with advanced CKD (ACKD) in a threatening context such as the initiation of kidney replacement therapy (KRT). This type of structured intervention, led by an interdisciplinary team (nephrologist, nursing staff, and psychologist), is based on creating a mutual support space between patients with experience in disease management (mentors) and recently diagnosed patients and/or those with adaptation difficulties (mentees).5,6
The Mentoring program offers a space for emotional support, self-care education, and promotion of treatment adherence, key aspects for the comprehensive management of ACKD.7,8 Furthermore, it aligns with strategic line no. 3 of the Framework Document on CKD of the Spanish National Health System (SNS), which advocates for active patient participation in disease management,9 and with the first quality accreditation model for ACKD units, a pioneer worldwide, called ACERCA, created in 2019 by the Spanish Society of Nephrology (SEN), in collaboration with the National ALCER Federation, the Spanish Society of Nephrology Nursing (SEDEN), and the National Transplant Organization (ONT), which establishes a set of standards that provide transparency and help define/evaluate the work carried out in ACKD units, placing high value on patient orientation and highlighting the inclusion of key criteria for excellence in the service provided by the units, regarding equal access to treatments, patient decision-making rights, patient/family information, and the empowerment of patient autonomy and co-responsibility in the management of their condition.10 However, the use of Mentoring programs in the field of ACKD is still limited, and few studies have evaluated their impact on this specific population.6,7
To address this need in the care of patients with CKD, a hospital-based Mentoring program led by mentor patients was developed and implemented in ACKD units in Spain. This program was designed to provide a mutual support space where patients could share experiences, coping strategies, and strengthen their self-care capacity. The overall objective of this study is to evaluate the impact of implementing a Mentoring program in ACKD units to help diagnosed patients adequately cope with their disease.
Materials and methodsA non-controlled, multicenter, hospital-based quasi-experimental study was conducted in patients ≥ 18 years with a diagnosis of ACKD, residing in Spain, during the period from February 1, 2021, to October 4, 2024. The study was conducted in the ACKD units of specialized care services at 21 hospitals nationwide.
A mixed-methods approach was employed to obtain a comprehensive and multifaceted understanding of the program’s impact. The choice of a mixed-methods design is justified by the need to capture both quantifiable changes in the perception of self-care and treatment adherence, and the subjective and emotional experiences of patients, which enrich the quantitative findings.
The research team, composed of 63 healthcare professionals, served as trainers and advisors for the program. Within the research team, clinical psychologists from hospitals, patient associations, and foundations selected, trained, and advised mentor patients throughout the program phases. Role-playing methodology was used for training. The training content was organized into two modules: “Counselling to help a peer” and “Promoting self-care in ACKD.” Two types of participants were recruited with the following inclusion and exclusion criteria: 1) Mentor patients: patients with a diagnosis of and experience with ACKD, selected for their positive attitude, listening and communication skills, empathy, ability not to pressure toward change, experience in coping with and self-managing the disease, and willingness to lead support groups. Patients with any type of cognitive and/or emotional limitation that would hinder their training by psychology specialists and participation in mutual support sessions were excluded. 2) Mentee patients (program recipients): patients with a diagnosis of ACKD, with recent onset and/or difficulty adapting to any KRT modality and expressed desire to participate in the Mentoring program. Patients with any type of significant cognitive and/or emotional limitation that could hinder their participation in mutual support sessions and/or completion of the program evaluation questionnaire were excluded.
Collaborating investigators introduced the Mentoring program to ACKD unit patients with indicators of emotional impact amenable to peer-to-peer intervention, through in-person or telephone consultation. Once patients willing to voluntarily participate in the program were identified, each ACKD unit recruited a minimum of 3 mentor patients and between 15 and 28 mentee patients for the formation of the different Mentoring groups. Both profiles were selected by the ACKD unit principal investigator, taking into account the selection criteria, and each unit defined the format (online or in-person) and intervention modality (group or individual) most appropriate for their specific work setting.
The Mentoring program was divided into the following methodological phases:
- •
Phase 0. Training of psychologists affiliated with ACKD units.
- •
Phase 1. Design and validation of program content and selection of mentor patients.
- •
Phase 2. Training of mentors.
- •
Phase 3. Implementation of mutual support sessions between mentors and mentees, which were conducted in person or online, in individual or group modality.
- •
Phase 4. Evaluation and analysis of the Mentoring program results.
To conduct the training of psychologists and mentor patients, the following educational resources were used: 1) a train-the-trainer workshop for mentoring programs in ACKD units, and 2) a guide for accompanying patients with chronic kidney disease, to facilitate the transmission of knowledge and skills.11,12
For data collection, a structured questionnaire with open and closed questions was used, coded and self-completed in printed and online format through the SurveyMonkey platform, to evaluate the program’s impact on mentee patients after the intervention (post-test). The investigator at each unit provided the printed questionnaire for participation to patients with a diagnosis of ACKD, and subsequently, the unit digitized the questionnaire through the platform.
Two types of data were used: 1) Quantitative: evaluated variables included age; sex; hospital of origin; number and modality of sessions; marital status; current employment status; year of diagnosis and time in ACKD consultation; perception of the cause of CKD; number of pills/day; overall rating of sessions and mentor communication skills; perception of met expectations, self-care, anxiety level, sadness, and session recommendation. 2) Qualitative: evaluated variables included positive aspects and areas for improvement of Mentoring sessions and intention for life change as a consequence of participation. Additionally, two focus groups were conducted, one with 10 healthcare professionals and another with 7 participating mentors. Furthermore, 6 in-depth interviews were conducted with mentee patients. Focus group sessions and in-depth interviews were conducted online.
The collected data were exported by the external company Nephila Health Partnership, S.L. A descriptive statistical analysis of quantitative variables was performed using SPSS v.25 for Windows, employing descriptive statistics (mean, standard deviation, minimum, maximum, and percentiles), while categorical variables were described using frequencies and percentages. Additionally, a thematic analysis of qualitative data obtained from focus groups and in-depth interviews was performed, categorizing responses into key themes to identify patterns in the different perspectives and experiences of participants.
The study was approved by the Research Ethics Committee of Hospital Universitari Germans Trias i Pujol, in compliance with the Declaration of Helsinki and current European and national data protection regulations. All participants were provided with an information sheet for mentors/mentees and informed consent before inclusion in the study, and data confidentiality was ensured through pseudoanonymization.
ResultsQuantitative resultsThe final sample included 457 patients with a diagnosis of ACKD from 21 participating ACKD units, of whom 142 patients were selected as mentors and 315 as mentee patients. The distribution of mentors by center is shown in Table 1, and the descriptive results on the mentee patient profile are shown in Table 2.
Distribution of mentor patients by hospital and province.
| Hospital | Province | No. of mentors |
|---|---|---|
| Hospital Clínico Universitario Virgen de la Arrixaca | Murcia | 3 |
| Hospital Comarcal Francesc de Borja, Gandía | Valencia | 7 |
| Hospital de La Línea de La Concepción | Cádiz | 10 |
| Hospital del Mar | Barcelona | 7 |
| Hospital La Mancha-Centro | Ciudad Real | 4 |
| Hospital General Universitario de Elche | Alicante | 8 |
| Hospital Regional Universitario de Málaga | Málaga | 4 |
| Hospital Universitario 12 de Octubre | Madrid | 7 |
| Hospital Universitario de Girona Doctor Josep Trueta | Girona | 16 |
| Hospital Universitario de Jaén | Jaén | 5 |
| Hospital Universitario de Torrevieja | Alicante | 8 |
| Hospital Universitario Germans Trias i Pujol, Badalona | Barcelona | 3 |
| Hospital Universitario Infanta Leonor | Madrid | 10 |
| Hospital Universitario Infanta Sofía | Madrid | 5 |
| Hospital Universitario Insular de Gran Canaria | Gran Canaria | 10 |
| Hospital Universitario Lucus Augusti | Lugo | 6 |
| Hospital Universitario Marqués de Valdecilla | Cantabria | 5 |
| Hospital Universitario Nuestra Señora de Candelaria | Tenerife | 3 |
| Hospital Universitario Punta de Europa | Cádiz | 5 |
| Hospital Universitario Virgen de las Nieves | Granada | 6 |
| Hospital Virgen del Rocío | Seville | 10 |
| Total | 142 |
Descriptive statistics of mentee patient profile.
| Interval/category | % | x̄ (SD) | |
|---|---|---|---|
| Age (years) | 20–85 | – | 60.0 (15.0) |
| Sex | Women | 46.9 | – |
| Men | 53.1 | ||
| Marital status | Single | 16.9 | |
| Married/domestic partner | 65.7 | ||
| Divorced/separated | 11.2 | ||
| Widowed | 6.2 | ||
| Employment status | Unemployed | 79.9 | |
| Employed | 20.1 | ||
| Time since ACKD diagnosis | < 1 year | 16.8 | |
| ≥ 1–< 5 years | 43.0 | ||
| ≥ 5–≤ 10 years | 26.8 | ||
| > 10 years | 13.4 | ||
| Time in ACKD consultation | < 6 months | 18.4 | |
| ≥ 6 months–< 1 year | 19.6 | ||
| ≥ 1–< 5 years | 46.4 | ||
| ≥ 5–≤ 10 years | 10.0 | ||
| > 10 years | 5.6 | ||
| Perceived cause of CKD | Unknown | 25.7 | |
| Hypertension | 15.1 | ||
| Diabetes mellitus | 14.5 | ||
| Obstructive nephropathy | 2.8 | ||
| Glomerulonephritis | 5.6 | ||
| Hereditary kidney disease | 17.9 | ||
| Other | 18.4 | ||
| Number of pills/day | < 5 | 15.1 | |
| ≥ 5–≤ 10 | 58.7 | ||
| ≥ 11–≤ 15 | 18.4 | ||
| ≥ 16–≤ 20 | 6.1 | ||
| > 20 | 1.7 |
x̄: mean; SD: standard deviation.
Of the mutual support sessions, 72.8% were held in person and 22.2% online. Regarding intervention modality, 50.6% of mentees received individual in-person sessions and 22.2% received group in-person sessions. The majority of mentees (70.5%) received a single mutual support session.
Post-test questionnaire results showed high satisfaction with the Mentoring program. Of mentees, 96.1% rated the session as well or very well rated overall, and 91.1% considered the session fairly or very useful for managing their disease better.
Of mentees, 89.4% reported that the session had helped them feel more at ease about the future of their disease; 79.3% reported feeling less sad; and 96.1% would recommend the program to others in the same circumstances. Furthermore, 90.5% of participants indicated that the session met their expectations very positively, and 97.8% rated the mentor’s communication skills fairly or very positively. Fig. 1 shows the distribution of responses to the program evaluation questions.
Qualitative results
The results of the 2 focus groups and 6 in-depth interviews identified the following key themes regarding the overall impact of the program: 1) both mentors and mentees reported greater ability to emotionally manage the disease, reducing anxiety and improving confidence in treatment decision-making; 2) an improvement was observed in adherence to nutritional recommendations, fluid management, and KRT modality choice; and 3) the relationship between interdisciplinary teams and patients (mentors and mentees) was strengthened, fostering a supportive and trusting environment.
Regarding the impact on ACKD units and healthcare professionals: 1) the program contributed to humanizing healthcare by providing a space for active listening and emotional support for patients with ACKD, and 2) it fostered a closer and more trusting relationship between healthcare professionals and patients, both mentors and mentees.
Patients who served as mentors expressed overall satisfaction with the program and described it as an experience of personal and professional growth that enabled them to develop communication and empathy skills. Ninety percent considered the program highly effective for improving communication and empathy with mentee patients. Patients felt part of the ACKD unit team, which strengthened interaction and trust with the healthcare team. This sense of belonging allowed them to assume an active role in accompanying the fear and uncertainty of mentee patients, sharing their experiences and coping strategies. Additionally, they perceived a positive impact on mentee treatment adherence, especially in dialysis and personal self-care.
In turn, mentee patients positively valued the experience of sharing with a peer who understood their situation, expressing that being able to talk to someone who “has been through the same thing” provided them with security and confidence to manage the disease. Mentors became trusted figures, which facilitated adaptation to the disease. Mentees reported significant emotional benefits, including improved emotional stability and disease coping ability. Ninety percent reported a significant reduction in anxiety thanks to mentor accompaniment. Furthermore, 85% reported an increase in confidence for managing their disease after program participation, and 75% indicated that sessions with their mentors helped them make more informed treatment decisions.
Despite the success of the Mentoring program in ACKD units, healthcare professionals, mentor patients, and mentees identified areas that could be optimized to further improve its impact. In the area of self-care, an improvement in adherence to nutritional recommendations was evidenced. Implementation of a more robust, long-term follow-up system to comprehensively evaluate changes in patient self-care is suggested.Regarding participation barriers, it was observed that some patients, initially reluctant to join the program, changed their stance after the first session. This finding underscores the importance of strengthening communication and motivation strategies for program presentation, ensuring that patients understand the potential benefits of their participation from the outset.
Mentor patients, for their part, expressed the need for access to continuing education programs to strengthen their accompaniment capacity, especially in the emotional management of complex situations that may arise during interactions with mentees.
Finally, some mentees suggested that sessions should be more flexible to optimally adapt to individual needs, including the possibility of extending follow-up in cases that require it. Implementation of these improvements will optimize the Mentoring program, maximizing its positive impact on unit dynamics and on the experience of patients with ACKD.
DiscussionThe present study addresses a critical issue in nephrology: psychosocial adaptation and the promotion of self-care in patients with ACKD. Through the implementation of a Mentoring program led by patients themselves, the aim is to provide emotional support and practical tools to cope with a disease that, in addition to being progressive and incurable, significantly affects the quality of life of patients and their family environment.5
The results obtained suggest that the Mentoring program has a positive impact on patients with ACKD. Both quantitative and qualitative data converge in showing high satisfaction with the program, improved disease coping, greater treatment adherence, and strengthened relationships between healthcare professionals and patients. These results are consistent with previous research that has highlighted the positive impact of psychosocial support in patients with chronic diseases and align with the prior literature supporting the effectiveness of peer support in chronic disease management,13–17 while also supporting the hypothesis that patient-led Mentoring programs can significantly improve adaptation to ACKD. The reduction in anxiety and sadness levels, together with the increase in perceived self-care, suggest that the program can serve as an effective tool to support comprehensive management of chronic diseases such as ACKD.
The integration of quantitative and qualitative methodologies has enabled a deeper understanding of the program’s impact. While quantitative data provide an overview of mentee patient satisfaction and perception, qualitative analysis enriches the understanding of the experiences and meanings that participants attribute to the program.
The areas for improvement identified by participants are crucial for optimizing the program and ensuring its long-term sustainability. Ongoing mentor training, session flexibility, and the implementation of strategies to overcome participation barriers are key aspects to consider in future program editions. Another relevant aspect is the duration and continuity of accompaniment. In most cases, the intervention consisted of a single meeting between mentor and mentee. Although this was positively valued, its effect could be limited over time. It would be desirable to promote more sustained follow-up, adapted to the needs of each patient, to increase the program’s impact and strengthen the therapeutic bond generated.
Despite the positive results, the study has some limitations to consider.Regarding the characteristics of the study population, it should be noted that no information was collected on patients who declined to participate in the program, nor on their origin in terms of rural or urban setting. The specific clinical stage of chronic kidney disease was also not included, although all participants came from ACKD units, implying an advanced stage (4–5). This information could be relevant to better characterize the target population and identify possible differences in the perception of accompaniment depending on the clinical stage, and it could be of interest to incorporate in future evaluations. No analysis was performed to determine homogeneity between groups. Likewise, no data were available regarding the dialysis modality chosen by patients, nor was it analyzed whether proximity to KRT initiation increased satisfaction perception with the intervention, relevant information that should be considered in future studies to better understand its impact on the valuation and benefit of the Mentoring program.
An important limitation is the absence of a control group, making it impossible to determine with certainty the causality between the Mentoring program and the observed results. Changes in the composition of ACKD unit teams, due to staff rotations or changes, may have disrupted program development and continuity of participant support. Nevertheless, variability in the availability and involvement of teams from different ACKD units may generate differences in program implementation and reach. Additionally, variability in intervention formats (mentors, content, modality, and number of sessions) may have influenced the results, and the limitation of resources needed to sustain the program long-term could compromise its continuity. Subsequent impact evaluation studies should include standardized instruments in their assessment.
Of the 21 centers participating in this pilot experience, 17 continue to implement the program. In the remaining 4, peer accompaniment is temporarily paused, mainly due to organizational issues related to the rotation of reference professionals, although all have expressed interest in resuming the activity as soon as possible.
To optimize the efficacy and sustainability of the Mentoring program, a structured scheme is recommended that includes regular sessions, combining in-person and online modalities to promote accessibility and adaptability. Furthermore, it is essential to incorporate a continuing education plan for mentors, focused especially on communication skills training and emotional management, addressing the difficulties reported by mentors themselves in their training process. Regarding mentee participants, flexibility in session duration and format and personalized follow-up, adjusted to individual patient needs, should be promoted to maximize results.
Future studies including a control group design with a larger sample size are needed to confirm the program’s efficacy and generalize results to the ACKD patient population, as well as to explore the effectiveness of different Mentoring formats to optimize program implementation in different hospital units. To ensure the involvement and commitment of ACKD unit teams for long-term program sustainability, it is essential to implement training, motivation, and communication strategies aimed at healthcare professionals, with the objective of increasing understanding of the program’s benefits and strengthening their commitment to its implementation. Finally, it is necessary to advocate for greater investment in support programs for ACKD patients, highlighting the positive impact of Mentoring on patient quality of life and its contribution to healthcare system efficiency. Although the choice of KRT modality was a topic present in conversations between mentors and mentees, no data were collected to assess whether the program influenced the final decision regarding the choice of home-based therapies, such as peritoneal dialysis or home hemodialysis. This aspect could be explored in future program editions, incorporating specific indicators to measure such impact.
ConclusionsThe Mentoring program for patients with ACKD has been evaluated as a valuable tool for improving disease coping, strengthening the relationship between patients and healthcare professionals, and humanizing care in ACKD units. Implementing improvements in the identified areas will contribute to optimizing the program and ensuring its sustainability over time. Future research with more robust designs is required to confirm these findings and evaluate the long-term effectiveness of the Mentoring program on quality of life, treatment adherence, and disease progression in patients with ACKD.
This type of patient support program is further evidence of the multidimensionality of ACKD, the plurality of approaches, the relevance of teamwork, and the enormous richness of moving forward together. Ultimately, a benefit for patients, mentors and mentees alike, and greater satisfaction for professionals.
FundingThe project for this study was promoted by the ACKD Working Group of the Spanish Society of Nephrology (SEN) and the SENEFRO Foundation. Unconditional funding was received from CSL Vifor, which did not participate in any phase of the project, including the selection of hospitals, mentors, mentees, or the intervention protocol. The funding covered the technical direction and secretariat services for coordination and monitoring.
No conflicts of interest related to the authors or the conduct of this study are reported.
Dr. Rebeca García Agudo, Dr. Marina Méndez Molina, and Dr. Sara Piqueras, Hospital La Mancha-Centro, Ciudad Real. Dr. Collado, Hospital del Mar, Barcelona. Dr. Fredzzia Graterol Torres, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona. Dr. Francisco José Toro Prieto, Hospital Virgen del Rocío, Seville. Dr. Isabel Millán del Valle, Hospital General Universitario de Elche, Alicante. Dr. Marta Puerta Carretero, Hospital Universitario Infanta Leonor, Madrid. Dr. María Luisa García Merino, Hospital Universitario Lucus Augusti, Lugo. Dr. Tamara Jiménez Salcedo, Hospital Regional Universitario de Málaga, Málaga. Dr. Carmen Patricia Gutiérrez Rivas, Hospital Universitario de Torrevieja, Alicante. Dr. Lucía Rodríguez Gayo, Hospital Universitario 12 de Octubre, Madrid. Dr. Florentina Rosique López, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia. Dr. Marta Cufí, Hospital Universitario de Girona Doctor Josep Trueta, Girona. Dr. María Covadonga Hevia Ojanguren, Hospital Universitario Infanta Sofía, Madrid. Dr. José Manuel Gil Cunquero, Hospital Universitario de Jaén. Dr. Celia Climent Codina, Hospital Comarcal Francesc de Borja, Gandía, Valencia. Dr. Almudena Pérez Marfil, Hospital Universitario Virgen de las Nieves, Granada. Dr. Yaiza María Rivero Viera and Dr. Selene González Nuez, Hospital Universitario Insular de Gran Canaria, Canary Islands. Dr. Gema Rangel Hidalgo, Hospital Universitario Punta de Europa, Cádiz. Dr. Esther Rubio Martín, Hospital de La Línea de La Concepción, Cádiz. Dr. Eduardo Gallego, Hospital Universitario Nuestra Señora de Candelaria, Canary Islands. Dr. María Valentín and Dr. María Kislikova, Hospital Universitario Marqués de Valdecilla, Santander.
Dña. Yolanda Carbayo de Gracia, Hospital La Mancha-Centro, Ciudad Real. Dña. Marisol Fernández Chamorro, Hospital del Mar, Barcelona. Dña. María Vicenta Ruíz Carbonell, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona. Dña. María Luisa Vera Gómez, Dña. Ana Belén Guillén and Dña. Cristina Peral, Hospital Virgen del Rocío, Seville. Dña. Mercedes Calatayud Sánchez, Hospital General Universitario de Elche, Alicante. Dña. Gemma Vinagre and Dña. Sonia García, Hospital Universitario Infanta Leonor, Madrid. Dña. Eva Carballo Aira, Hospital Universitario Lucus Augusti, Lugo. Dña. Ana Rebollo Rubio and Dña. Elia Ruiz, Hospital Regional Universitario de Málaga. Dña. María del Mar Baeza Valero and Dña. Elena Gisbert, Hospital Universitario de Torrevieja, Alicante. Dña. Maria del Carmen Coca García, Hospital Universitario 12 de Octubre, Madrid. Dña. Leonor Andújar Rocamora, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia. D. David Gil Nieto, Hospital Universitario de Girona Doctor Josep Trueta, Girona. Dña. Mónica García Garrido, Hospital Universitario Infanta Sofía, Madrid. Dña. Mercedes Marchal Ocaña, Hospital Universitario de Jaén. Dña. Lara Avellà Terenti, Hospital Comarcal Francesc de Borja, Gandía, Valencia. Dña. Marís Nuria Montes Martínez, Hospital Universitario Virgen de las Nieves, Granada. Dña. Sonia Guinea Solorzano, Hospital Universitario Insular de Gran Canaria, Canary Islands. Dña. Beatriz Julia Martín García and Dña. María del Carmen González Ortega, Hospital Universitario Punta de Europa, Cádiz. D. Juan Antonio Servan Sánchez, Hospital de La Línea de La Concepción, Cádiz. Dña. María Arantxa Sánchez Laguna, Hospital Universitario Nuestra Señora de Candelaria, Canary Islands. Dña. Rosana Sainz Alonso, Hospital Universitario Marqués de Valdecilla, Santander.
Dña. Raquel Arellano Díaz, Hospital La Mancha-Centro, Ciudad Real. Dña. Noelia Fernández, Hospital del Mar, Barcelona. Dña. Teresa Rangil, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona. Dña. Carmen Rosendo Vázquez, Hospital Virgen del Rocío, Seville. Dña. Josefa Dolores Palacios Payá and Dña. Inmaculada Lara Espejo, Hospital General Universitario de Elche, Alicante. Dña. Eva Rodríguez Pedraza, Hospital Universitario Infanta Leonor, Madrid. Dña. Patricia Casal Vázquez, Hospital Universitario Lucus Augusti, Lugo. Dña. María Cristina Sánchez Moreno and Dña. Laura Gómez, Hospital Regional Universitario de Málaga, Málaga. Dña. Cristina Borrego Honrubia, Hospital Universitario de Torrevieja, Alicante. Dña. Irene Rodrigo Holgado, Hospital Universitario 12 de Octubre, Madrid. Dña. Amparo Martínez Moya and Dña. Govinda López Vidaurre, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia. D. Guillem Adarve and Dña. Sonia Valentí, Hospital Universitario de Girona Doctor Josep Trueta, Girona. Dña. Ángela Fresnillo Alonso, Hospital Universitario Infanta Sofía, Madrid. Dña. María del Rocío Gay Pérez, Hospital Universitario de Jaén. Dña. Elga Mas Martinez, Hospital Comarcal Francesc de Borja, Gandía, Valencia. Dña. Sílvia Bolívar López, Hospital Universitario Virgen de las Nieves, Granada. Dña. María Dolores Santana Santana, Hospital Universitario Insular de Gran Canaria, Canary Islands. Dña. Miguel Ángel Diaz Sibaja and Dña. Ana Báez, Hospital Universitario Punta de Europa, Cádiz. D. Gustavo Camino Ordoñez, Hospital de La Línea de La Concepción, Cádiz. Dña. Gemma Roquerías Pruna, Hospital Universitario Nuestra Señora de Candelaria, Canary Islands. D. José Ramón Gómez Novo, Hospital Universitario Marqués de Valdecilla, Santander.
The following are Supplementary data to this article:
